Extracorporeal shock wave lithotripsy in combination with transurethral surgery for management of large bladder calculi and moderate outlet obstruction. In 5 men evaluated for symptoms of obstructive voiding flexible cystoscopy revealed large or multiple bladder calculi along with small to moderate prostatic enlargement. All patients had successful localization and fragmentation of calculi with the Dornier HM3 lithotriptor. Of these patients 4 underwent transurethral resection or incision of the prostate under the same epidural anesthesia for moderate prostatic obstruction without complication and 1 subsequently required suprapubic prostatectomy of a gland with a large middle lobe that made a transurethral operation difficult. Extracorporeal shock wave lithotripsy should be considered for the primary management of large or hard bladder calculi and it is of particular value in combination with a transurethral operation for patients with small to moderate prostatic obstruction. 