A narrative review in BJU International gathered randomised trials, controlled cohorts, systematic reviews and guidance from the EAU, AUA, NICE and ACP on preventing stone recurrence in adults.
Increasing fluid intake roughly halves recurrence (RR about 0.45–0.55). In hypercalciuric calcium oxalate formers, a diet with normal calcium, less salt and less animal protein achieves a similar reduction (RR 0.49). Targeted drugs lower risk further: potassium citrate (RR about 0.25), allopurinol (0.59) and thiazides (0.52) — though the NOSTONE trial found no significant thiazide benefit. Medical therapy also reduces regrowth of residual fragments after lithotripsy or PCNL.
Evidence that tailoring therapy to a 24-hour urine beats general advice is limited to high-risk and recurrent stone formers. For first-time, low-risk patients, fluid and diet advice is the core.
India's stone belt makes this a high-volume question. Practical steps are to aim for about 2.5 litres of urine a day, avoid restricting dietary calcium, and reserve the full metabolic work-up for those it is likely to help.
- Advise every stone former to drink enough to pass about 2.5 litres of urine a day.
- Do not restrict dietary calcium; reduce salt and animal protein instead.
- Arrange 24-hour urine testing for recurrent, high-risk and post-procedure stone formers.
- Consider potassium citrate for hypocitraturia and allopurinol for hyperuricosuria.
- Repeat the urine test after starting treatment to confirm the abnormality has corrected.
Why it matters
It matches the intensity of investigation to the patients most likely to benefit.
Don't overread it
This is a narrative review, and thiazide benefit was not confirmed in the largest recent trial.
The statistics, in plain English
A relative risk of 0.5 means recurrence is about halved; how many stones that prevents depends on each patient's baseline risk, which is highest in recurrent formers.
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