Post-transplant urolithiasis, while relatively uncommon, poses unique challenges in renal allograft recipients, potentially leading to complications such as acute kidney injury, graft dysfunction, and infection. Despite the availability of various surgical and pharmacological forms of treatment, there remains no consensus on the optimal management strategy for this condition. This systematic review aimed to synthesize available evidence on the efficacy and safety of treatment modalities for urolithiasis in kidney transplant recipients, a patient profile common in our high-volume center.

A systematic search on PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Library for relevant studies published between 1990 and 2024 was conducted. Eligible studies include randomized controlled trials, cohort studies, and case-control studies assessing interventions for post-transplant urolithiasis. Primary outcomes included stone clearance rates and graft function, while secondary outcomes encompass complications, recurrence rates, and quality of life measures. Risk of bias (RoB) was assessed using the Cochrane RoB 2 tool for RCTs and ROBINS-I for observational studies. As meta-analysis was deemed impractical due to significant variability across the studies, a narrative synthesis was employed to summarize findings.

A total of 17 studies published between 1996 and 2024 were included, evaluating treatment modalities such as ESWL, Flexible URS, PCNL, open surgery, and pharmacological therapies. PCNL achieved the highest stone clearance rates (86–90%), particularly for larger or complex stones, while flexible URS was effective for mid-sized stones, with clearance rates up to 95% for proximal stones. ESWL showed variable success (70–81%), performing best for stones ≤12 mm. Complications were most common with PCNL, including bleeding and infection, whereas flexible URS and ESWL had fewer but included risks like ureteral perforation. Open surgery, though achieving clearance rates of up to 96%, was rarely performed due to high morbidity.

This systematic review highlights the variability in efficacy and safety of treatment modalities for post-transplant nephrolithiasis. While PCNL remains the gold standard for larger stones, less invasive options like URS and ESWL are effective for smaller stones with fewer complications. However, significant heterogeneity in study designs, outcome measures, and reporting limits the ability to recommend a definitive treatment pathway. Future studies should focus on standardizing protocols and long-term outcomes to optimize management strategies for this high-risk population.