Between a stone and a hard place-Mortality from conservative management of kidney stone disease: Systematic review of the literature from the European Association of Urology Section of Endourology.

Objective: The aim of this study was to provide information on the factors associated with mortality in conservative management of kidney stone disease (KSD). Secondary aims were to identify important risk factors and highlight key learning points to reduce mortality from conservatively managed KSD. Methods: A systematic literature review was conducted in Embase, MEDLINE, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature, in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, from the inception of the databases to 1 March 2025 (PROSPERO registration number: CRD420251013472). The Population, Intervention, Comparison, Outcome framework was used to define eligibility criteria, with the population comprising patients with KSD managed without procedural intervention, with mortality as the outcome. English-language articles involving adult or paediatric patients were included. Data extracted included demographics, comorbidities, stone characteristics, reasons for conservative management, complications, causes of death, and authors' learning points. Results: A total of 1301 articles were identified. After screening, 12 articles were eligible for analysis, which reported on 313 562 patients from 1955 to 2023. In 11 studies, a total of 119 deaths were recorded following conservative management, and an additional study of 147 600 conservatively managed cases reported a mortality rate of 1.7%. There were 38 deaths with reported causes, with renal failure being the most common, followed by sepsis and cardiac events. Key recommendations from the studies included prompt renal decompression in infected cases (as those without decompression had more than twice the mortality risk), surgical intervention for staghorn calculi, active stone removal in high-risk patients after thorough assessment, and prophylactic antibiotic use to reduce infection-related mortality. Conclusion: Renal failure appears to be a significant contributor to mortality in patients with conservatively managed KSD. Decisions regarding conservative management should be guided by the presence of infection, stone type, and the degree of renal impairment at presentation, as some cases may require timely renal decompression.