Introduction: At one time, the standard treatment for patients with renal and ureteral calculi was open surgical lithotomy. Advances made in the past two decades have dramatically changed the way in which patients with urinary calculi are treated. In light of this present trend towards minimally invasive therapies, it is important to define which patients might be best served by undergoing an open surgical procedure for stone treatment. Materials and Methods: The authors review the current indications for open surgical removal of urinary calculi. Particular attention is paid to developments described in recent literature. Results: The development of percutaneous nephrostolithotomy, ureteroscopic stone removal, and extracorporeal shock wave lithotripsy has greatly diminished the role of open surgery in the treatment of urinary calculi. While most patients may be treated via these less invasive modalities, there are some patients to whom an open surgical procedure is the optimal therapy. Conclusions: There remains a role, albeit small, for open surgical stone removal. The patients who benefit from these procedures generally have extremely complex calculous disease with associated anatomic and physiologic derangements.