The Post-Ureteroscopic Lesion Scale (PULS): A multicenter video-based evaluation of inter-rater reliability

Martin Schoenthaler, Noor Buchholz, Erik Farin, Hammad Ather, Christian Bach, Thorsten Bach, John D. Denstedt, Hans Martin Fritsche, Michael Grasso, Oliver W. Hakenberg, Ralf Herwig, Thomas Knoll, Franklin Emmanuel Kuehhas, Evangelos Liatsikos, Peter Liske, Michael Marberger, Palle J.S. Osther, José Manuel Reis Santos, Kemal Sarica, Christian SeitzMichael Straub, Olivier Traxer, Alberto Trinchieri, Ben Turney, Arkadiusz Miernik

Research output: Contribution to journalArticlepeer-review

50 Citations (Scopus)


Abstract: Purpose: The Post-Ureteroscopic Lesion Scale (PULS) offers a simple grading system for the description of ureteral lesions after ureteroscopy. In this article, we present the results of a video-based multicenter evaluation of the inter-rater reliability of clinically important PULS grades 0-3. Methods: Video sequences at the end of ureteroscopy (final passage) were recorded for 100 consecutive patients at a single institution and assessed by experienced urologists (n = 20) and senior residents (n = 17) at 19 international centers. The cohort included only patients with lesions grades 0-3 (with grades 2 and 3 subsumed as 2 + since distinction is defined by an extravasation of contrast medium in fluoroscopy). The gradings were evaluated for inter-rater reliability and in terms of simplicity, validity, comprehensibility, reproducibility, and usefulness. Results: Overall, inter-rater reliability was high (Kendall's W = 0.69, p < 0.001) and was comparable between specialists (Kendall's W = 0.69, p < 0.001) and residents (Kendall's W = 0.71, p < 0.001). The matched ratings showed grade 0 in 43.0 % of patients and grades 1 or 2 + in 44.0 and 13.0 % of patients, respectively. Results of the questionnaires indicated a high degree of acceptance, with an overall rating of 1.76 (1.64-1.93 for different items, scale 1-6). Conclusions: Inter-rater reliability of the endoscopically assessable PULS was high among urologists with different levels of experience in different countries worldwide. The validated PULS system may be used for standardized reporting of ureteral lesions/injuries after ureteroscopy. In addition, PULS will enable more selective standardization of indications for postoperative DJ stenting based on the randomized controlled trials.

Original languageEnglish
Pages (from-to)1033-1040
Number of pages8
JournalWorld Journal of Urology
Issue number4
Publication statusPublished - Aug 2014


  • Classification
  • Complication
  • Injury
  • Inter-rater reliability
  • Lesion
  • Ureter
  • Ureteroscopy


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