Management Of Complex Renal Cysts Research Articles

MP64-03 LOW METASTATIC POTENTIAL OF COMPLEX RENAL CYSTS: THE Case FOR ACTIVE SURVEILLANCE

You have accessJournal of UrologyCME1 Apr 2023MP64-03 LOW METASTATIC POTENTIAL OF COMPLEX RENAL CYSTS: THE Case FOR ACTIVE SURVEILLANCE Hannah Thomas, Shideh Abedi, Toronto, Canada, Thenappan Chandrasekar, PA Philadelphia, Kartik Jhaveri, Toronto, Canada, Johan Bjorklund, Stockholm, Sweden, Douglas Cheung, Michael Jewett, and Antonio Finelli Hannah ThomasHannah Thomas More articles by this author , Shideh AbediShideh Abedi More articles by this author , Toronto Toronto More articles by this author , Canada Canada More articles by this author , Thenappan ChandrasekarThenappan Chandrasekar More articles by this author , PA PhiladelphiaPA Philadelphia More articles by this author , Kartik JhaveriKartik Jhaveri More articles by this author , Toronto Toronto More articles by this author , Canada Canada More articles by this author , Johan BjorklundJohan Bjorklund More articles by this author , Stockholm Stockholm More articles by this author , Sweden Sweden More articles by this author , Douglas CheungDouglas Cheung More articles by this author , Michael JewettMichael Jewett More articles by this author , and Antonio FinelliAntonio Finelli More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003322.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The incidence of incidentally-detected renal cysts is high, ranging from 12% to 61%. While well-defined clinical consensus exists for Bosniak I and II renal cysts, our understanding of best practices for surveillance and management of complex renal cysts remains contended. This study aimed to evaluate key patient and disease-specific outcomes of complex renal cysts across an updated, twenty-year cohort. METHODS: We performed a retrospective chart review of patients diagnosed with Bosniak IIF, III and IV renal cysts from 2001-2013 across three tertiary academic hospitals. Data from date of diagnosis to June 2022 was extracted, including demographics, cyst characteristics, biopsy and surgical/ablative intervention. Primary endpoints were radiologic upgrading (i.e. formal Bosniak upgrading or subjective worsening of radiographic features in same Bosniak class) and cancer-specific mortality. RESULTS: A total of 332 patients with complex renal cysts were included: Bosniak IIF (55.4%, 184/332), Bosniak III (36.4%, 121/332), Bosniak IV (8.1%, 27/332). The majority of patients were male (63.3%, 210/332). Most patients were managed with active surveillance, except Bosniak IV patients where 66.7% (18/27) underwent upfront nephrectomy. Rates of biopsy were similar among Bosniak III and IV groups (22.3%, 27/121 and 22.2%, 6/27). Median follow-up for Bosniak IIF, III and Bosniak IV cysts on active surveillance was 7.8 years (IQR= 3.9-12.4 yrs), 6.6 years (IQR= 3.7-10.1 yrs) and 4.6 years (IQR=3.7-8.6 yrs), respectively. Twenty-eight percent of surgical patients (19/67) experienced peri-operative complications. The rate of radiologic upgrading for Bosniak IIF, III and IV was 7.1% (13/184), 4.9% (6/121) and 3.7% (1/27), respectively (Table 1). Cancer-specific mortality remained at 0.3% (1/332). CONCLUSIONS: Overall, despite lengthy follow-up, the rate of radiologic progression and cancer-specific mortality for complex renal cysts remains low. This analysis challenges conventional views of upfront intervention, particularly for Bosniak III cysts. It appears safe to de-intensify surveillance for complex renal cysts along with transfer of care to primary care providers (with appropriate direction and triggers for re-referral), especially for patients with compatible goals of care. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e881 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hannah Thomas More articles by this author Shideh Abedi More articles by this author Toronto More articles by this author Canada More articles by this author Thenappan Chandrasekar More articles by this author PA Philadelphia More articles by this author Kartik Jhaveri More articles by this author Toronto More articles by this author Canada More articles by this author Johan Bjorklund More articles by this author Stockholm More articles by this author Sweden More articles by this author Douglas Cheung More articles by this author Michael Jewett More articles by this author Antonio Finelli More articles by this author Expand All Advertisement PDF downloadLoading ...

Management of complex renal cysts in Canada: results of a survey study

BackgroundBosniak III and IV cysts have a high risk of malignancy and have traditionally been managed surgically. However, growing evidence suggests that many can be managed by active surveillance. The main objective of this study was to characterize the use of surveillance in the management of complex renal cysts.MethodsA web-based survey was sent to all registered, active members of the Canadian Urological Association (N = 583) in October 2018.ResultsThe survey response rate was 24.7%. Management of Bosniak III cysts varied considerably. A large proportion of respondents (33.1%) offered active surveillance in > 50% of cases. Only 13.7% of respondents reported never or rarely (< 5% of cases) offering surveillance. In contrast, for Bosniak IV cysts, 60.1% of urologists never or rarely offered surveillance, while only 10.1% offer it in > 50% of cases. A significantly greater proportion of academic urologists, compared to non-academic urologists, viewed surveillance as a management option for patients with a Bosniak III or IV cyst. The most commonly reported barriers to a greater adoption of surveillance were concerns regarding its oncologic safety, the lack of data to support surveillance in this population, and the lack of triggers for discontinuation of active surveillance and intervention.ConclusionsDespite active surveillance being included as a management option in guidelines, many Canadian urologists are reluctant to offer surveillance to patients with Bosniak III or IV cysts. Practice patterns are heterogeneous among those offering surveillance. High-quality studies are required to better define the benefits and risks of cystic renal mass surveillance.

797 - Comparison of computed tomography and contrast enhanced ultrasound for the management of complex renal cysts: A single-center experience

797 - Comparison of computed tomography and contrast enhanced ultrasound for the management of complex renal cysts: A single-center experience

P176 - Comparison of computed tomography (CT) and contrast enhanced ultrasound (CEUS) for the management of complex renal cysts: A single-center experience

P176 - Comparison of computed tomography (CT) and contrast enhanced ultrasound (CEUS) for the management of complex renal cysts: A single-center experience

VE13 - Robot-assisted surgical management of complex renal cysts

VE13 - Robot-assisted surgical management of complex renal cysts

The diagnosis and management of complex renal cysts

Cystic renal disease is very common and the detection of complex cystic masses in the kidney has increased dramatically over the last few decades with increased cross-sectional imaging. Cystic renal cell carcinoma represents 5-7% of all renal tumours. The ability to differentiate between those who are benign from those malignant represents a major challenge. The controversy and difficulty lies in those complex cystic renal masses that lie between Bosniak II and III. This review focuses on the diagnosis and management of complex renal cysts, examining the evidence for biopsy and looks at novel diagnostic techniques. There are varying results in interpretation of complex cysts and this is heavily dependent on interobserver variability. Bosniak classification is a valuable tool for the clinician. Computed tomography remains the gold standard, however, newer diagnostic imaging modalities such as contrast-enhanced ultrasonography is demonstrating promising results. Percutaneous biopsy of these complex lesions would appear to be well tolerated and adequate for diagnosis. The ability to accurately identify complex renal cysts that are malignant remains a major challenge to the clinician. Regularly there is no other way to identify malignant features than to biopsy or continue surveillance. Recent literature would suggest that percutaneous biopsy has a good yield and is accurate in the majority of cases. Current apprehension with regard to iatrogenic complications from percutaneous renal biopsy may be exaggerated, as complication rates are higher in patients with intrinsic real disease rather than this cohort of patients. The overlap in diagnosing Bosniak IIf versus III is heavily influenced by interobserver variability and this needs to be a significant factor in making any decision.

Risk Assessment of Incidentally Detected Complex Renal Cysts in Children: Potential Role for a Modification of the Bosniak Classification

Incidentally detected complex renal cysts in children are a rare but worrisome occurrence due to the perceived potential risk of malignancy. We examined the natural history of such cysts in a cohort of children. We obtained access to a database containing all radiology reports generated at a single institution from 1996 to 2004. We used key words to limit our search, subsequently reviewing charts and images to confirm the diagnosis of a complex renal cyst and to collect clinical data. Cases were categorized according to a modification of the Bosniak classification, using ultrasound in most patients and computerized tomography or magnetic resonance imaging when available. Complex renal cysts were identified in 39 children. Mean patient age at presentation was 7 years. Mean cyst size was 1.6 cm. A total of 18 cases diagnosed by ultrasound only were observed with serial imaging. Additional contrast enhanced computerized tomography or magnetic resonance imaging was performed in 21 of 39 patients (54%). Surgical resection was performed in 5 patients and pathological evaluation revealed benign cyst in 3 (modified Bosniak class II in 2 patients and class III in 1) and renal cell carcinoma in 2 (III in 1 and IV in 1). All other patients had modified Bosniak class II cysts, which remained essentially unchanged during a mean followup of 26.8 months (range 9 to 70). While not validated in children, our data suggest the modified Bosniak classification appears useful as a guideline to direct the management of complex renal cysts in the pediatric population.

CYSTIC RENAL CELL CARCINOMAS IN ADULTS. IS PREOPERATIVE RECOGNITION OF MULTILOCULAR CYSTIC RENAL CELL CARCINOMA POSSIBLE?

We correlated clinicopathological and imaging features of multilocular cystic renal cell carcinoma (MCRCC) to propose preoperative criteria for therapeutic modalities. A total of 24 RCCs with a chiefly cystic component were identified from 1993 to 2002. In each case histological slides and available imaging studies were retrieved. Two tumor groups were defined, namely MCRCC and clear RCC with cystic change (CRCC) by intrinsic growth or necrotic degeneration. Radiological correlation using computerized tomography and magnetic resonance imaging was performed considering criteria such as an expansile nodule, cyst wall thickness and septa. On imaging MCRCC presented as a multilocular cystic mass lacking an expansile nodule, and with regular thin cyst wall and septa. On pathological study MCRCC presented as complex, multilocular cystic carcinoma with septa covered by low nuclear grade clear renal tumor cells without a grossly expansile nodule. They were staged pT1 with a free clinical course. In contrast, CRCC was identified on imaging with an expansile nodule (5 mm or greater), thick, irregular cyst wall and septa. On pathological study CRCC was characterized by a grossly expansile nodule in the septa and/or cyst wall. Nuclear grade and TNM stage were higher in CRCC. Preoperative recognition of MCRCC is possible using strict computerized tomography and/or magnetic resonance imaging criteria. The current study confirms the low malignant potential of MCRCC. Nephron sparing surgery should be proposed when MCRCC is suspected.

An update of the Bosniak renal cyst classification system

w m s [ i s m t n he Bosniak renal cyst classification was first introduced in 19861 and has been accepted by rologists and radiologists as a way of diagnosing, iscussing, and determining the management aproach to cystic renal masses.2–4 Using the lesion’s orphology and enhancement characteristics, ach lesion can be categorized into one of five roups (categories I, II, IIF, III, and IV; Table I), ith associated recommendations for patient treatent. With additional experience during the past wo decades, the Bosniak renal cyst classification as been updated and refined.5,6 However, pubished reports have incorrectly described and aplied the classification system,7–10 leading to conusion in its use that could be detrimental to atient care. Therefore, the purpose of this comentary is to present an up-to-date version of the osniak renal cyst classification, point out potenial errors in its use, and present our approach to he evaluation of cystic lesions of the kidney. We elieve that this is particularly relevant in this age f laparoscopic surgery and ablative techniques. ecause these procedures are less invasive, there ay be a tendency to treat patients using these techiques on the basis of imaging studies that are not echnically adequate or have been interpreted incorectly. High-quality imaging studies are needed for ccurate characterization of renal masses to avoid unecessary surgery, even if it is minimally invasive. One of the major changes in the original classifiation was the introduction of category IIF (F for ollow-up), which was added to include cystic leions that are slightly more complex than category I, but not complex enough to fulfill the criteria for ategory III.6,11–13 This category was introduced on he basis of experience gained after the removal of enign category III cysts. Category IIF lesions are

Surgical Management of Complex Renal Cysts

Surgical Management of Complex Renal Cysts

Surgical Management of Complex Renal Cysts: A Series of 32 Cases

Purpose The differentiation between benign cysts of the kidney and those that require surgical exploration remains difficult. The accuracy of radiological techniques (ultrasound, computerized tomography [CT], angiography, magnetic resonance imaging, cyst puncture and intraoperative pathological examination) is analyzed. Materials and Methods Surgical exploration was performed in 30 patients with 32 asymptomatic renal cysts, and the pathological specimens were compared retrospectively to the radiological findings. The classification of Bosniak was used to categorize the ultrasound and CT findings. Results Of our complex renal cysts 41 percent proved to be malignant. Our results suggest that the radiological techniques are not well suited for characterization of these cysts. None of the Bosniak types was sufficiently predictive of the lesion. Only a Bosniak score of 4 (the sum of ultrasound and CT Bosniak types) was not associated with renal cell carcinoma. According to the radiological findings, 1 patient was under treated (recurrent renal cell carcinoma) and 4 were over treated (radical nephrectomy for benign lesions). Conclusions A practical therapeutic strategy is described in which radical nephrectomy is performed when malignant lesions are detected either by preoperative or intraoperative techniques. Conservative surgery is indicated for benign cysts according to the clinical status and risks of nephron sparing surgery.