Uncertainty During Ureteroscopy: Evaluating Surgeon Consensus on In Vivo Stone Dust After Laser Lithotripsy

OBJECTIVE: To evaluate surgeon consensus on stone dust quality and the ability to predict stone-free status based on intraoperative endoscopic appearance during ureteroscopy (URS) with laser lithotripsy. METHODS: Fifteen urologists (7 faculty, 8 trainees) reviewed 16 videos of ureteroscopic laser lithotripsy, blinded to clinical outcomes. Eight videos were from patients who were stone-free at 6-week postoperative computed tomography; eight had residual fragments. Reviewers rated stone dust quality on a 5-point Likert scale and predicted stone-free status. Inter-rater reliability was measured using the intraclass correlation coefficient (ICC). Accuracy of stone-free prediction was compared using a two-tailed t test. RESULTS: Inter-rater agreement on dust quality was poor (ICC = 0.41), with slightly higher agreement among faculty (ICC = 0.49) compared to trainees (ICC = 0.38). Mean accuracy of stone-free prediction was 63% (SD: 9%), with no significant difference between faculty and trainees (67% vs 58%, P = .05). Sensitivity and specificity of predicting residual fragments were 55% and 72%, respectively. Confidence in predictions did not differ between groups. Notably, three of eight cases with residual fragments resulted in significant clinical events (ICU admission, reintervention), with mean time to event of 221 days. In these, surgeon prediction accuracy remained modest (63%, SD: 14%). CONCLUSION: Surgeon assessment of stone dust quality is inconsistent, and predictive accuracy for stone-free status based on endoscopic appearance is limited. These findings underscore the need for standardized definitions and objective intraoperative tools to optimize outcomes in laser stone surgery.