Anatomical renal variants such as horseshoe kidney (HSK) and renal malrotation are associated with altered pelvicalyceal geometry, impaired urinary drainage, and increased risk of urolithiasis. The role of extracorporeal shock wave lithotripsy (ESWL) in these patients remains clinically relevant but technically nuanced. Published data suggest that ESWL is safe in anatomical variants; however, stone-free rates (SFR) are consistently lower compared to normal renal anatomy, primarily due to impaired fragment clearance rather than inadequate fragmentation. Evidence is derived predominantly from retrospective series and small comparative studies. This review synthesizes available literature regarding outcomes, complication profiles, patient selection, and technical modifications for ESWL in horseshoe kidney and renal malrotation. Practical decision-making frameworks are proposed for clinicians managing stone disease in this unique population.