Simultaneous outlet surgery for bladder stones and BPO: a scoping review from EAU endourology - challenging the traditional approach

Management of bladder stones in men with benign prostatic obstruction (BPO) conventionally assumes simultaneous outlet surgery is universally required. This scoping review evaluates evidence comparing simultaneous and staged strategies to establish rationale for selective management. The protocol was registered in the Open Science Framework (OSF: https://osf.io/egmz7 ). Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, PubMed, the Cochrane Library, and Web of Science were systematically searched for studies published up to September 18, 2025, Studies reporting outcomes of stone removal with or without concurrent outlet surgery in patients with bladder stones and BPO were included. Outcomes included stone-free rate (SFR), recurrence, voiding parameters (IPSS, Qmax, PVR), complications, and reintervention. Fifteen studies (six comparative) met criteria. Both approaches achieved high SFRs (> 90%). Recurrence was lower after combined procedures (≤ 5%) versus isolated stone removal (10–25%), diverging beyond 2–3 years; however, most men receiving stone removal alone did not require subsequent outlet surgery. Combined procedures produced greater LUTS improvement, particularly with prostate volumes > 100 mL or PVR > 90 mL. Early morbidity was higher with simultaneous surgery. No study incorporated urodynamic testing, limiting physiologic interpretation. Key functional domains (ejaculatory function, continence, patient-reported outcomes) and minimally invasive surgical therapies were rarely evaluated. Available evidence does not support routine simultaneous outlet surgery for all men with bladder stones. The presumed equivalence of stone presence with obstruction, and prostate size with surgical indication, lacks consistent validation. A selective strategy incorporating postoperative re-evaluation, risk stratification, and patient-centered priorities offers a more physiologic, evidence-aligned approach while avoiding overtreatment.