Contemporary surgical management of urolithiasis: a narrative review

Abstract

Urolithiasis is among the most prevalent urological conditions worldwide, with a rising incidence driven by obesity, metabolic syndrome, and climate-related factors, and an estimated global annual expenditure exceeding USD 5.3 billion. This is a narrative review of the literature. Relevant publications were identified through searches of PubMed/MEDLINE, EMBASE, and the Cochrane Library (last searched January 2025) using terms related to surgical management of kidney and ureteral stones, with priority given to systematic reviews, meta-analyses, randomized controlled trials, and current European Association of Urology (EAU) and American Urological Association (AUA) clinical practice guidelines. The review synthesizes current evidence on their surgical management, encompassing advances in laser lithotripsy technology, the evolving role of retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL) techniques, and management in special clinical situations including horseshoe kidney, pelvic ectopic kidney, and solitary kidney, pregnancy, and pediatric patients. Treatment selection is governed by stone size, location, composition, patient anatomy, comorbidities, and local surgical expertise, as outlined in current European Association of Urology (EAU) and American Urological Association (AUA) guidelines. Three key clinical messages emerge from the reviewed literature: (i) RIRS has become a widely adopted minimally invasive option for renal stones up to 20 mm as a primary indication, with selected larger stones in high-morbidity patients (stone-free rates [SFRs] consistently > 80% for 10–20 mm stones), though treatment should be individualized rather than modality-driven; (ii) PCNL remains the reference standard for large and staghorn stones (SFR up to 95% in a single session); (iii) newer laser platforms, particularly the thulium fiber laser (TFL), show promising technical advantages whose definitive clinical significance relative to modern holmium:YAG (Ho:YAG) systems requires confirmation through larger prospective comparative studies. In special clinical situations, RIRS is preferred in the solitary kidney and pregnancy (SFR 80–90%), while PCNL or RIRS are selected for horseshoe kidney according to stone burden (SFR 80–95% and 60–100%, respectively). Robust randomized trials and standardized outcome reporting remain necessary to guide future evidence-based practice.

Keywords: Urolithiasis, kidney stones, ureteroscopy, percutaneous nephrolithotomy, laser lithotripsy, horseshoe kidney