Context <p>Nephrolithiasis is increasingly recognized as a recurrent disorder that often coexists with broader metabolic vulnerability. Observational studies have also raised the possibility that stone disease may identify patients with a higher subsequent risk of upper tract urothelial carcinoma (UTUC) and, less consistently, renal cell carcinoma (RCC), particularly papillary RCC (pRCC).</p> Objective <p>To critically review the epidemiologic and mechanistic literature linking nephrolithiasis to UTUC and RCC, distinguish association from causation, and outline a clinically practical risk-stratified framework.</p> Evidence acquisition <p>This narrative review was informed by targeted searches of population-based cohort studies, meta-analyses, guideline documents, and mechanistic studies relevant to nephrolithiasis, UTUC, RCC, obstruction, infection, inflammation, and metabolic dysregulation. Greater weight was given to subtype-specific epidemiologic studies and directly relevant upper-tract biology, whereas indirect mechanistic data were interpreted as emerging or hypothesis-generating.</p> Evidence synthesis <p>The available literature supports three main conclusions. First, epidemiologic studies suggest an association between nephrolithiasis and increased risk of UTUC, with more limited and lower-specificity evidence for RCC, especially pRCC. Second, shared metabolic abnormalities—including obesity, diabetes, hypertension, dyslipidemia, smoking, and hyperuricemia—may contribute both to lithogenesis and to a pro-inflammatory milieu relevant to carcinogenesis. Third, mechanistic data support biologic plausibility through chronic obstruction, recurrent epithelial injury, crystal toxicity, inflammasome activation, and infection-related inflammation. However, surveillance bias, reverse causation, and heterogeneous endpoint definitions limit causal inference. Current evidence, therefore, supports nephrolithiasis as a clinically relevant marker of metabolic vulnerability and a possible biological contributor in selected contexts, rather than an established causal driver.</p> Conclusions <p>Current evidence does not support universal proactive intervention or routine oncologic surveillance for all stone formers. A more defensible clinical approach is risk stratification. Patients with recurrent, early-onset, infection-related, obstructive, or metabolically complicated stone disease may warrant intensified metabolic assessment, a lower threshold for selective stone-directed intervention in defined scenarios, and individualized follow-up. Dedicated cancer surveillance should remain selective and investigational pending prospective validation.</p> Graphical abstract <p></p>