Urethral calculi indications and outcomes of surgical management: a systematic review by EAU endourology.

PURPOSE: Urethral calculi account for fewer than 1% of urinary tract stones, yet they can present as acute emergencies requiring prompt intervention. Despite this clinical relevance, contemporary urological guidelines devote little attention to their surgical management. We undertook this systematic review to consolidate the available evidence on surgical indications and outcomes for urethral calculi. METHODS: MEDLINE (PubMed), Scopus and Google Scholar were searched from inception to January 2026 in accordance with PRISMA 2020 guidelines (PROSPERO: CRD420261305468). We included studies reporting surgical management of urethral calculi with extractable outcome data. Methodological quality was evaluated using the MINORS checklist, supplemented by RoB 2 and ROBINS-I for the two comparative studies. RESULTS: Nineteen studies published between 1976 and 2020, encompassing 689 patients, met the inclusion criteria. Acute urinary retention was the most common presentation. Retrograde manipulation with push back into the bladder was the most widely used initial approach, with holmium laser lithotripsy becoming the preferred energy source in more recent series. Stone free rates exceeded 94% across all modalities and no procedure related deaths were recorded. Coexisting urethral stricture was reported in 6-100% of patients, with prevalence closely reflecting each study's selection criteria. A stone diameter of approximately 20 mm emerged as a practical threshold separating cases suitable for minimally invasive management from those requiring open surgery. CONCLUSIONS: Surgical treatment of urethral calculi is safe and consistently effective. Stone size, anatomical location, and the presence of urethral stricture are the main drivers of treatment selection. Prospective multicentre trials with standardised definitions of treatment success are needed before formal management recommendations can be made.