Development of Performance Metrics for Flexible Cystoscopy: Results from an In-Person Modified Delphi Consensus Meeting

BACKGROUND AND OBJECTIVE: Flexible cystoscopy is one of the most frequently performed diagnostic procedures in urology. Despite its routine nature, significant variability exists in how it is performed across institutions and countries, reflecting a lack of procedural standardization. Metric-based approaches have been effectively used in other surgical domains to characterize and objectively assess performance, but no such framework has previously been established for cystoscopy. The aim of the current study is to develop and achieve expert consensus on performance metrics for flexible cystoscopy through a modified Delphi consensus. METHODS: The study followed a validated methodological framework of metric-based performance analysis previously applied to an image-guided procedure. The study consisted of two phases: (1) procedure characterization and metrics development and (2) face and content validation through an in-person modified Delphi panel of 13 urologists, held at ORSI Academy (Melle, Belgium) on September 25, 2025. The preliminary metrics, comprising six procedural phases, 24 steps, 24 errors, and 16 critical errors (CEs), were developed through literature review, video analysis, and expert discussion. During the Delphi meeting, 14 international experts (urologists and one behavioral scientist) reviewed, discussed, and refined each metric element until ≥80% agreement was achieved. RESULTS: Consensus was unanimous (100%) for all procedural components. After editing, the final metrics include six phases, 24 steps, 25 errors, and 16 CEs. Beyond metric modifications and language refinements, discussions addressed the role of antibiotic prophylaxis, preprocedural urine cultures, patient positioning, and irrigation control. CONCLUSION: This Delphi consensus represents the first international, structured effort to define standardized, performance-based metrics for flexible cystoscopy. The resulting metrics provide an objective, reproducible framework for describing optimal and suboptimal performance and will serve as the foundation for future validation, educational implementation, and quality assurance initiatives in endourology.