Purpose of Review <p>This review evaluates the role of urine culture (UC) in preoperative assessment for endourological stone procedures. It addresses the optimal timing of UC, its predictive value compared to urinalysis, the interpretation of mixed flora, and the utility of repeat cultures after antibiotic treatment. In addition, it explores emerging molecular methods that may refine perioperative infection risk assessment.</p> Recent Findings <p>UC remains the gold standard for identifying infection risk, but several controversies persist. Studies suggest urine dipstick testing can complement or even outperform UC in certain contexts, while mixed flora results often do not justify antibiotic therapy. Evidence indicates that prolonged preoperative antibiotic prophylaxis reduces postoperative sepsis in high-risk patients, though repeat UC after treatment has limited predictive value. Novel approaches such as next-generation sequencing and molecular diagnostics offer higher sensitivity but risk overdiagnosis.</p> Summary <p>Preoperative UC remains indispensable for risk assessment in endourology, though its limitations demand a more nuanced, risk-adapted approach. Integration of urinalysis, selective repeat testing, and emerging molecular diagnostics could refine perioperative decision-making while supporting antimicrobial stewardship.</p>