Comprehensive Management of Complex and Refractory Urolithiasis: Minimally Invasive Techniques, Perioperative Optimisation, and Recurrence Prevention.

BACKGROUND: Complex and refractory urolithiasis represents a growing clinical challenge, characterised by a large stone burden, recurrent disease, anatomical abnormalities, infection, and metabolic risk factors, all of which complicate management and increase morbidity. Contemporary management has shifted toward risk-stratified, minimally invasive strategies supported by advances in endourology, perioperative optimisation, and individualised patient assessment. To synthesise current evidence on the diagnostic evaluation, risk stratification, minimally invasive management, perioperative optimisation, special population management, and emerging techniques relevant to complex and refractory urolithiasis. METHODS: A structured narrative review of the published literature and contemporary guideline recommendations was conducted, focusing on comparative outcomes of extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and endoscopic combined intrarenal surgery (ECIRS), along with perioperative care principles and technological innovations. Evidence from recent clinical studies, systematic reviews, and international guidelines was synthesised qualitatively. RESULTS: ESWL retains a limited role in carefully selected low-complexity stones, whereas URS provides effective management for ureteric and moderate sized renal calculi. PCNL-based approaches demonstrate the highest stone-free rates for stones >20 mm, staghorn calculi, and anatomically complex disease, with miniaturised techniques and ECIRS offering potential morbidity reduction in selected cases. This review integrates surgical, perioperative, and preventive strategies into a unified clinical framework for high-risk stone disease. Outcomes are strongly influenced by perioperative infection control, metabolic optimisation, anticoagulation management, and structured postoperative surveillance. Management of special populations including patients with a solitary kidney, chronic kidney disease (CKD), paediatric patients, pregnant women, anatomical abnormalities, and those receiving anticoagulant therapy, requires individualised multidisciplinary care. Emerging technologies such as artificial intelligence-assisted imaging, augmented-reality guidance, single-use URS, and advanced laser technologies remain promising but investigational due to limited prospective evidence. CONCLUSIONS: Optimal management of complex and refractory urolithiasis depends on accurate risk stratification, appropriate selection among minimally invasive modalities, comprehensive perioperative optimisation, and individualised care in vulnerable populations. Future progress requires prospective comparative studies, standardised outcome reporting, and patient-centred evaluation of emerging technologies to ensure evidence-based improvement in long-term renal outcomes and quality of life.