Objectives: This study aimed to investigate whether metabolic dysfunction-associated steatotic liver disease (MASLD) is associated with an increased risk of urolithiasis compared with individuals without steatotic liver disease (SLD) and those with cardiometabolic risk factors (CMRFs) alone. Methods: We conducted a retrospective cohort study of 242,022 participants from the Korean National Health Insurance Service–National Health Screening Cohort. Participants were categorized into three groups: no SLD without CMRFs, no SLD with at least one CMRF, and MASLD. Urolithiasis incidence was identified using ICD-10 codes. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) for urolithiasis, adjusting for demographic, metabolic, and lifestyle factors. Results: During a median follow-up of 8.7 years, 8,907 participants (3.7%) developed urolithiasis. After multivariate adjustment, urolithiasis incidence was highest in the MASLD group (adjusted HR [aHR]. 1.45; 95% confidence interval [CI], 1.33–1.57; P<0.001), followed by the no SLD with CMRFs group (aHR. 1.25; 95% CI, 1.15–1.36; P<0.001), compared with the no SLD without CMRFs group. In addition, the number of CMRFs was a significant predictor of urolithiasis risk, with a stepwise increase in incidence observed with higher CMRF counts. Conclusion: MASLD significantly increases the risk of urolithiasis, independent of CMFRs. Furthermore, the risk of urolithiasis rises progressively with the number of CMRFs. Our findings support the recognition of MASLD as a systemic metabolic condition with renal implications, highlighting the need for integrated management strategies that address both hepatic and metabolic health to prevent stone formation.