Key Points Of The 2023 Canadian Guidelines For The Management Of Cystic Renal Disease

Cystic disease of the kidney is usually found incidentally in routine imaging studies. With the increasing availability of abdominal imaging, more and more people are being diagnosed with cystic renal disease. This article is an update of the 2017 guidelines for the management of cystic renal disease, to provide a reference for physicians in the management of cystic renal disease.

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Recommendation 1:

For patients with complex renal cysts first detected on ultrasonography, enhanced cross-sectional imaging is recommended to better differentiate cysts further (moderate quality, strong recommendation).

Recommendation 2:

Patients identified as having renal cysts should be classified according to the 2019 Bosniak grading system (Expert Opinion).

Recommendation 3:

For patients with disagreements or doubts in the classification of complex renal cysts, this expert group believes that if these situations may affect the treatment plan, they should be submitted to the multidisciplinary meeting (MDT) for discussion (expert opinion).

Recommendation 4:

For patients with Bosniak grade I and II cysts, follow-up imaging is not recommended (moderate quality, strong recommendation).

Recommendation 5:

In patients with Bosniak grade I and II cysts, intervention is only required if the cyst is symptomatic (ie, bleeding, recurrent infection, or pain) (clinical principle).

Recommendation 6:

For patients with Bosniak grade IIF cysts, follow-up is recommended every 6–12 months for the first year and annually if the cyst is stable (expert opinion).

Recommendation 7:

For patients with Bosniak grade IIF cysts without radiographic progression, a 5-year follow-up is recommended (conditional recommendation, low-certainty evidence).

Recommendation 8:

For patients with Bosniak grade III or IV complex renal cysts ≤2 cm, active surveillance is recommended as the preferred option (conditional recommendation, low-certainty evidence).

Recommendation 9:

For Bosniak grade III and IV cysts with a diameter of 2-4 cm, active surveillance or surgical treatment is recommended as the first choice (conditional recommendation, low-certainty evidence).

Recommended 10:

For patients with Bosniak grade III or IV cysts >4 cm, surgical resection is recommended as the preferred option (conditional recommendation, low-certainty evidence).

Recommendation 11:

For patients with Bosniak grade III or IV complex renal cysts with significant comorbidities and/or limited life expectancy, observation (or watchful waiting) is recommended as the preferred option (conditional recommendation, low-certainty evidence).

Recommendation 12:

For patients with Bosniak grade III or IV cysts undergoing surgery, partial nephrectomy (rather than radical nephrectomy) is recommended when technically and oncologically feasible, especially for small complex cysts (conditional recommendation, low definitive evidence).

Recommendation 13:

For patients with Bosniak grade III or IV cysts on active surveillance, definitive treatment options should be offered when oncologic risk is increased or when the patient wishes to be treated for personal reasons. When competing risks outweigh treatment benefits, patients should switch to cautious observation (clinical principle).

Recommendation 14:

Patients with Bosniak grade III or IV cysts ≤3 cm who are being considered for thermal ablation should be informed of the high uncertainty in the efficacy and adverse effect data of percutaneous thermal ablation compared with surgery (Expert Opinion).

Recommendation 15:

A biopsy may be considered in patients with Bosniak grade IV cysts if they have a biopsy-viable significant solid component and the findings may alter treatment options. Renal masses without substantial components should not be biopsied due to low diagnostic yield (expert opinion).

Summarize:

Compared with the old CUA guidelines for the management of renal cystic diseases, the key updates of the 2023 guidelines lie in three aspects: (1) patients with renal cysts should be classified according to the 2019 Bosniak grading system; (2) Bosniak III and ≤2 cm For grade IV cysts, active surveillance is recommended as the preferred strategy; (3) For Bosniak grade III and IV cysts with a diameter of 2-4 cm, active surveillance or surgical treatment is recommended. The panel made these revisions to reduce the burden of treatment for patients but acknowledged that the quality of evidence supporting them was low. Therefore, clinicians need to fully communicate and share decisions with patients when choosing treatment options, and patients who choose non-surgical treatment strategies should be aware of the high uncertainty in the data supporting their treatment choices.

References:

[1] Richard PO, Violette PD, Bhindi B, et al. 2023 UPDATE – Canadian Urological Association guideline: Management of cystic renal lesions Can Urol Assoc J 2023;17(6):162-74.