Clinical Scorecard: Real-Time Tumor Grading in Upper Tract Urothelial Carcinoma Using Confocal Laser Endomicroscopy: Validation of Criteria and Introduction of a Scoring System

At a Glance

Key Highlights

• Histopathologic tumor grade is critical for risk stratification and treatment decisions in UTUC.
• CLE enables real-time intraoperative imaging with proposed criteria adapted from bladder urothelial carcinoma but requires validation for UTUC due to probe differences.
• Study validates CLE criteria prevalence, diagnostic accuracy, inter-rater agreement, and proposes a scoring system for CLE-based UTUC grading.

Guideline-Based Recommendations

Diagnosis

• Use ureteroscopic biopsy for histopathologic tumor grading as standard reference.
• Apply CLE imaging intraoperatively for real-time assessment of UTUC lesions using validated criteria.
• Exclude flat lesions from CLE-based grading analysis.

Management

• Perform endoscopic laser ablation for low-risk UTUC based on tumor grade.
• Indicate radical surgical resection for high-risk UTUC cases.
• Use CLE-based grading to support risk stratification and treatment planning.

Monitoring & Follow-up

• Conduct follow-up ureteroscopy with CLE imaging after kidney-sparing treatment to monitor for recurrence.
• Assess CLE image quality and diagnostic yield to ensure reliable grading.

Risks

• Consider fluorescein allergy and pregnancy as exclusion criteria for CLE imaging.
• Recognize 10–40% discordance between ureteroscopic biopsy grade and surgical specimen grade.
• Account for 10–20% non-diagnostic yield in ureteroscopic biopsies and CLE imaging.

Patient & Prescribing Data

Adults undergoing ureteroscopy for suspected or recurrent UTUC

CLE imaging provides real-time grading information to guide kidney-sparing versus radical treatment decisions, potentially improving risk stratification accuracy.

Clinical Best Practices

• Use a 2.7 Fr Uroflex-B CLE probe with 488-nm laser and fluorescein contrast for optimal imaging.
• Perform at least two 1-minute CLE recordings per lesion for adequate assessment.
• Ensure CLE raters are trained and blinded to clinical and histopathologic data for unbiased evaluation.
• Reach consensus on CLE criteria and grading to improve diagnostic accuracy.
• Exclude lesions with insufficient image quality from CLE-based grading.

References

• IDEAL Recommendations for Surgical Innovation
• WHO 2004 Classification of Urothelial Carcinoma
• ClinicalTrials.gov NCT03013920