Does bespoke metabolic investigation reduce urinary stone recurrence? A narrative review

To examine whether individualised ('bespoke') metabolic investigation and targeted dietary and medical therapy reduces urinary stone recurrence, and whether the approach also improves health-related quality of life (HRQOL) and lowers financial and environmental cost.

In this narrative review we searched PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), the Cochrane Library and Europe PubMed Central (PMC) (January 1980 to March 2026) for randomised trials, controlled cohorts and systematic reviews on metabolic assessment and stone recurrence prevention in adults, supplemented by European Association of Urology (EAU), American Urological Association (AUA), National Institute for Health and Care Excellence (NICE) and American College of Physicians (ACP) guidance and by hand-searching of reference lists.

Interventions that correct a defined urinary abnormality each reduce stone recurrence. Increased fluid intake approximately halves it (relative risk [RR] 0.45-0.55); a normal calcium, reduced sodium, reduced animal protein diet achieves a similar reduction in hypercalciuric calcium-oxalate formers (RR 0.49); and targeted pharmacotherapy lowers it further (potassium citrate RR approximately 0.25, thiazides 0.52, allopurinol 0.59), although the rigorous NOSTONE trial (ClinicalTrials.gov identifier: NCT03057431) found no significant thiazide benefit. After shockwave lithotripsy and percutaneous nephrolithotomy, medical therapy reduces stone formation and residual-fragment regrowth. Evidence that 24-h-urine-directed therapy outperforms empirical therapy is confined to high-risk patients, in whom selective treatment yields significantly fewer stone-related events. Stone disease impairs disease-specific quality of life and is costly, so preventing stone recurrence is cost-saving.

The case for bespoke prevention is strongest in recurrent, high-risk and post-procedural stone formers. Identifying the abnormality, correcting it, ensuring adherence and confirming the response by repeat testing offers the best chance to reduce stone recurrence and residual-stone growth, improve HRQOL, and lower financial cost.