# External Validation and Comparative Performance of the T.O.HO. and S.T.O.N.E. Scoring Systems for Predicting Stone-Free Outcomes Following Flexible Ureteroscopy: Toward Personalized Preoperative Counseling

## TL;DR

This study compares two scoring systems for predicting successful outcomes after a kidney stone procedure, finding one to be more accurate and useful for personalized patient counseling.

## Contribution

The study provides external validation and threshold-based guidance for T.O.HO. and S.T.O.N.E. scores in a Japanese cohort for flexible ureteroscopy outcomes.

## Key findings

- T.O.HO. outperformed S.T.O.N.E. in predicting stone-free outcomes (AUC 0.86 vs. 0.77).
- Both scores showed acceptable calibration and provided useful clinical cut-offs for decision-making.
- Larger stone size, lower-pole location, and preoperative pyuria were significant predictors of residual fragments.

## Abstract

Background/Objectives: The attainment of a stone-free (SF) condition is a fundamental indicator of successful outcomes after flexible ureteroscopy (fURS) for urinary stone disease. External confirmations of preoperative scores remain limited. We externally validated the T.O.HO. and S.T.O.N.E. scores in an independent Japanese cohort and examined calibration, decision curve utility, and threshold-guided use to support personalized planning. Methods: We retrospectively analyzed 361 consecutive patients treated with fURS from March 2018 to August 2023. Postoperative SF status was defined as the absence of residual calculi greater than 2 mm on non-contrast computed tomography performed within three months of surgery. Independent determinants of SF were identified using multivariable logistic regression, predictive performance was quantified by receiver operating characteristic analyses with DeLong’s test, and model calibration and decision curve analysis were additionally assessed. Results: Among the 361 patients, 255 (70.6%) achieved an SF state. A larger stone diameter, the presence of lower-pole calculi, and preoperative pyuria (positive urine WBC) were significant independent predictors of residual fragments. T.O.HO. demonstrated superior discrimination (AUC 0.86) compared with S.T.O.N.E. (AUC 0.77; p < 0.01) and surpassed individual predictors. Both scores showed acceptable calibration. Decision curve analysis demonstrated higher net benefit for T.O.HO. across clinically relevant thresholds. We provide clinically useful cut-offs (e.g., T.O.HO. ≤5: high SF probability; 6: trade-off discussion; ≥7: higher residual risk) to align actions with patient priorities. Conclusions: Beyond discrimination, a calibrated, threshold-aware use of T.O.HO. enables personalized preoperative counseling and shared decision-making, potentially reducing unnecessary staging and enhancing routine fURS planning.