Laser versus Mechanical Lithotripsy for Endourological Treatment of Bladder Stones: A Prospective Multicenter Analysis from the EAU-Endourology Bladder Lithiasis Assessment of Surgical Treatment (BLAST) registry.

We aim to compare perioperative outcomes, postoperative stone-free rate, complications, and predictors of treatment success in patients undergoing endourological treatment of bladder stones using laser versus mechanical energy. We performed a prospective multicenter analysis from the Bladder Lithiasis Assessment of Surgical Treatment (BLAST) registry. Patients undergoing endourological treatment for bladder stones between May 2025 and September 2025 were included and stratified according to the energy source used for stone fragmentation: laser or mechanical energy, reflecting a pragmatic, category-level comparison of heterogeneous device platforms rather than a device-specific efficacy analysis. Postoperative stone-free rate was assessed at 4-6 weeks and graded from A to D; Grade A indicated complete clearance, while Grade A and B were considered stone-free. Secondary outcomes included operative parameters, complications, hospital stay, and reintervention. Given the observational nature of the study and the observed baseline differences between groups, clinically relevant covariates were incorporated into multivariable regression model with center as a random effect to account for potential confounding. Multivariable logistic regression was used to identify predictors of Grade A stone-free status and 48-hour postoperative complications. Overall, 722 patients from 31 centers were included: 437 underwent laser lithotripsy and 285 mechanical lithotripsy. Patients in the laser group were older, had higher body mass index, more cardiovascular comorbidity, more frequent antithrombotic therapy, slightly larger stones, and more concomitant procedures. Mechanical energy was associated with shorter lithotripsy time (17 vs. 23 min, p < 0.001) and operative time for bladder stone treatment (30 vs. 50 min, p < 0.001). Final Grade A stone-free status was comparable between groups (95.8% vs. 95.2%), and overall stone-free rate exceeded 98% in both cohorts. Overall, 48-hour complications were more frequent in the mechanical group, whereas major early complications were more frequent in the laser group. In center-adjusted mixed-effects analysis, no significant differences were observed between mechanical and laser lithotripsy in stone-free status or postoperative complications. On multivariable analysis, mechanical energy was not independently associated with Grade A stone-free status, while mechanical energy and suction device use were independently associated with higher odds of 48-hour complications. In conclusion, laser and mechanical energy achieved similarly high postoperative stone-free rates. Mechanical energy improved operative efficiency but did not increase the rate of complete clearance. Energy selection should be individualized according to patient characteristics, stone burden, need for fragment evacuation, available technology, and surgeon experience.