Back-Table Stone Removal During Renal Transplantation: A Systematic Review

Nephrolithiasis was traditionally considered a relative contraindication to kidney donation; however, to combat ongoing donor kidney shortages, ex vivo stone management during renal transplantation has increasingly been adopted to expand the donor pool. This review aims to explore the current state of back-table ureteroscopy and other ex vivo techniques for the treatment of urolithiasis at the time of transplantation. Existing literature was reviewed to summarize the available evidence on safety, feasibility, stone characteristics and location, as well as the techniques used for stone removal. A Literature search was conducted using PubMed, Scopus, Web of Science, and LILACS. All English- and Spanish-language studies reporting cases of back-table stone removal were included. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools. A total of 40 manuscripts comprising 371 cases of ex vivo stone removal were included. The available evidence demonstrates a high overall procedural success rate with low recurrence and complication rates. Mean back-table procedure time was 19.8 min, with minimal impact on allograft function. A size-dependent management threshold was identified; stones <5 mm were typically managed endoscopically, while those >10 mm required incisions into the collecting system. Limitations include low certainty of evidence and potential publication bias, as most available studies are small retrospective case series. Overall findings suggest urolithiasis should not be considered a contraindication to donation, and back-table stone management appears safe and feasible. However, current evidence remains largely retrospective and of low methodological quality. Further studies are needed to standardize patient selection and operative techniques.