Renal cyst

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Renal cyst

Other names Kidney cysst

Renal cyst of the left kidney (hyperintense area) as shown on MRI.

Specialty Urology

Simple renal cyst

 A renal cyst is a fluid collection in or on the kidney. There are several types based on
the Bosniak classification. The majority are benign, simple cysts that can be monitored
and not intervened upon. However, some are cancerous or are suspicious for cancer
and are commonly removed in a surgical procedure called nephrectomy.
Numerous renal cysts are seen in the cystic kidney diseases, which include polycystic
kidney disease and medullary sponge kidney.

Contents

 1Classification
 2Diagnosis
 3Treatment
 4Peripelvic versus parapelvic cysts
 5Epidemiology
 6See also
 7References
 8External links

Classification[edit]
Renal cysts are classified by malignant risk using the Bosniak Classification System.
The system was created by Dr. Morton Bosniak, a faculty member at the New York
University Langone Medical Center in New York City.[1]
The Bosniak classification categorizes renal cysts into five groups. [2]
Category I
Benign simple cyst with thin wall without septa, calcifications, or solid
components, and has a density of 0–20 Hounsfield units (HU)[3] (about equal to
that of water). In such cases, a CT scan without intravenous contrast is enough
for classification.[4] Still, if a contrast CT is performed, a category I cyst should not
show significant enhancement,[4] which can be regarded as an increase of less
than 10HU.[5]
Category II
Benign cyst with a few thin septa, which may contain fine calcifications or a small
segment of mildly thickened calcification. This includes homogenous, high-
attenuation (60–70 Hounsfield units[3]) lesions less than 3 cm with sharp margins
but without enhancement. Hyperdense cysts must be exophytic with at least 75
percent of its wall outside the kidney to allow for appropriate assessment of
margins, otherwise they are categorized as IIF.[6]
 A Bosniak category IIF cyst. This one is 3 cm wide, with calcifications within its wall, seen as very
radiodense (white in this presentation) areas in its margins. There is also a septation which is
calcified. Yet, the cyst does not show enhancement (uptake of contrast).

Category IIF
This category includes renal cysts with multiple thin septa, a septum thicker than
hairline, slightly thick wall, or with calcification, which may be thick. It also
includes intrarenal cysts larger than 3 centimetres (1.2 inches) if:

 there is no contrast enhancement (otherwise category III).[7]

 there is high attenuation or there is a maximum 25% of their walls visible
outside the kidney (otherwise category II).[3]
Category IIF cysts have a 5–10% risk of being kidney cancer, and therefore
follow-up is recommended. However, there is no consensus recommendation on
the appropriate interval of follow up.[7]
Category III
Indeterminate cystic masses with thickened irregular septa with enhancement. 50
percent of these lesions are ultimately found to be malignant.
Category IV
Malignant cystic masses with all the characteristics of category III lesions but
also with enhancing soft tissue components independent of but adjacent to the
septa. 100 percent of these lesions are malignant.

Bosniak category

I II IIF III IV
 60–70
0–
Attenuation[3] Hounsfield
20 HU
units

Thick,
Thin Nodular or
Small and fine heterogeneous.
Walls[3] and irregular
calcifications Gross calcifications
smooth calcifications
with enhancement

Solid
No Yes
components[3]

Diagnosis[edit]
The complex cyst can be further evaluated with doppler ultrasonography,
and for Bosniak classification and follow-up of complex cysts,
either contrast-enhanced ultrasound (CEUS) or contrast CT is used.[8]

Renal ultrasonography of a simple renal cyst with posterior enhancement.

Advanced polycystic kidney disease with multiple cysts.[8]

Renal cyst as seen on abdominal ultrasound

 

Renal cyst as seen on abdominal ultrasound

Renal cyst as seen on abdominal ultrasound

Treatment[edit]
This system is more directly focused on the most appropriate
management. These alternatives are broadly to ignore the cyst, schedule
follow-up or perform a surgical excision of it. When a cyst shows
discrepancy in severity across categories, it is the most worrisome
feature that is used in deciding about management. There is no
established rule regarding the follow-up frequency, but one possibility is
after 6 months, which can later be doubled if unchanged.[5]

Recommended management[5]

Ignore Follow Excise

 Small, smooth
and liquid
(moves to
Calcification Thick, nodular
lowest point
when changing
position)
 Sharp margin,
< 3cm, not
completely  poorly
intrarenal and  totally defined
If radiodensity > homogenous intrarenal  heterogeneous
20 HU without radiocontrast
 Must also be  >3 cm  solid
clearly cystic if on ultrasound
seen
on ultrasound
 Slightly  thick
Septations Thin and smooth greater than  irregular
hairline  nodular
Enhancement (increase
< 10 HU 10–15 HU > 15 HU
with radiocontrast)
Multilocular If infection All others
Very small
Nodularity[5] and All others
nonenhancing
Wall thickening[5] If infection All others

Peripelvic versus parapelvic cysts[edit]

Non-contrast CT (at left) showing peripelvic fluid accumulations, which may

be hydronephrosis. CT urography (at right) reveals non-dilated calyces and pelvises. The
fluid accumulations are thus peripelvic cysts.

Parapelvic cysts originate from around the kidney at the adjacent renal
parenchyma, and plunge into the renal sinus. Peripelvic cysts are
contained entirely within the renal sinus, possibly related to dilated
lymphatic channels. When viewed on CT in absence of contrast, they can
mimic hydronephrosis.[9] If symptomatic, they can
be laparoscopically decorticated - removal of the outer layer or cortex.[10]

Epidemiology[edit]
Up to 27 percent of individuals older than 50 years may have simple renal
cysts that cause no symptoms.[11]