Gout patients have an elevated risk of upper urinary tract urolithiasis, leading to the use of urate-lowering therapy (ULT) such as xanthine oxidase inhibitors and uricosuric agents to prevent disease progression. However, the association between ULT use and the risk of surgical intervention for urolithiasis remains unclear.

We conducted a retrospective cohort study using data from the Taiwan National Health Insurance Research Database (2000–2019). Patients diagnosed with gout were categorized into ULT users and non-users and followed until urolithiasis surgery, death, or December 31, 2020. Cox regression models estimated adjusted hazard ratios (aHRs), and Kaplan-Meier survival analysis assessed cumulative incidence.

Among 28,017 patients (19,115 ULT users, 8,902 non-users), 60% were aged 40-64 years, and 77% were male. Urolithiasis requiring surgery occurred in 27% of non-users and 31.2% of ULT users. Xanthine oxidase inhibitors (aHR = 1.29, 95% CI: 1.18–1.41) and uricosuric agents (aHR = 1.31, 95% CI: 1.24–1.38) were associated with increased surgical risk. Conversely, Thiazide, Furosemide, Corticosteroids, and Statins were linked to reduced risk (aHRs: 0.39–0.75). Hypertension significantly increased urolithiasis risk (aHR = 1.18, 95% CI: 1.11–1.26).

ULT does not prevent the need for surgical intervention in gout patients with urolithiasis. Effective hypertension management may reduce risk, and adequate hydration and proactive monitoring remain crucial for ULT users.