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We thank the reader [
The 401 cystoscopic images were curated from established educational and clinical sources, including reference atlases, PubMed-indexed articles and repositories, clinical websites, industry archives, and Creative Commons–licensed educational videos. These images were originally accompanied by source-provided diagnoses, educational labels, captions, or contextual information.
As stated in the Study Design section, “The reference standard diagnoses were determined through a multiphase, consensus-based process.” To further clarify how source-provided diagnostic information was incorporated, this process can be described in two key phases. In the initial independent review phase, source-provided diagnostic labels were withheld, and two urological experts independently inspected each image and answered the prespecified Q1 to Q5 framework, including anatomic site, cystoscopic findings, lesion detection, lesion reasoning, and final diagnosis. In the subsequent consensus phase, the available source-provided diagnoses or educational labels were disclosed to the experts and considered together with the cystoscopic appearance to resolve discrepancies and establish the final reference answers for Q1 to Q5.
Therefore, the final consensus diagnosis for each image was not based solely on independent visual inspection by two urologists. Rather, the reference standard was established through a source-informed expert consensus process, integrating source-provided diagnostic information with expert review of the cystoscopic appearance.
Thus, the reference standard in our study was designed to support the evaluation of model-generated cystoscopic interpretation and reasoning, rather than to independently re-establish or revalidate the original pathological diagnosis of each image. We agree that histopathology remains the definitive standard for pathological lesion classification, particularly for entities such as carcinoma in situ, papilloma, and papillary urothelial carcinoma. Accordingly, our study should be read as an image interpretation and reasoning benchmark based on images with pre-existing source-provided diagnostic or educational information, with final reference labels established through expert consensus after consideration of both the cystoscopic appearance and the diagnoses provided by the original educational or clinical sources.
Generative artificial intelligence assistance was used for language editing. The authors reviewed, revised, and approved the final content and take full responsibility for the submitted manuscript.
The authors declared no financial support was received for this work.
None declared.