+ MODEL

Journal of Pediatric Urology (2015) xx, 1.e1e1.e6

Ultrasound classification of solitary renal

cysts in children
B. Karmazyn a, A. Tawadros b, L.R. Delaney a, M.B. Marine a,
M.P. Cain c, R.C. Rink c, S.G. Jennings d, M. Kaefer c

a
Department of Radiology and Summary In 20.2% (18/89) of the children, the cysts
Imaging Sciences, Indiana increased in size.
University School of Medicine, Introduction A definitive diagnosis was obtained in 8.5% (18/
Riley Hospital for Children, 705 Solitary renal cysts are typically incidentally found 212) of the children. A cystic tumor (multilocular
Riley Hospital Drive, Room 1053, in children who have undergone renal ultrasound cystic nephroma) was found in one child (Figure)
Indianapolis, IN 46202, USA (US). The main concern is a cystic tumor. There is no with a complex cyst (graded III by both radiologists).
US-based grading system for children to guide
b
Department of Radiology, management. Discussion
Memorial Hospital of South The use of a modified Bosniak classification system
Bend, 615 N. Michigan Street, Objective to grade renal cysts was found to have good inter-
South Bend, IN 46601, USA
To evaluate a US-based, modified Bosniak grading observer variability (kappa Z 0.65) in differenti-
c
system in order to differentiate between simple ating between simple and complex renal cysts. Using
Department of Urology, Indiana (grade I or II) and complex (grade II or IV) renal cysts this classification, few (<4%) renal cysts were clas-
University School of Medicine,
and guide management in children. sified as complex. Cystic tumors are rare and the
Riley Hospital for Children, 705
Riley Hospital Drive, Room 4230,
only cystic tumor (multilocular cystic nephroma) was
Indianapolis, IN 46202, USA Study design classified as complex renal cysts by the two radiol-
This was a retrospective (2003e2011) study of 212 ogists. Growth of simple, solitary renal cyst is com-
d
Department of Radiology and
children (114 females), age range one day to 17 mon (20.2%) and, therefore, if not associated with
Imaging Sciences, Indiana years (mean 8.4 years), with solitary renal cysts other imaging findings, is not an indication for a
University School of Medicine, diagnosed by US. Two radiologists, who were inde- cystic tumor.
950 W. Walnut Street, Room pendent and blinded to clinical information, graded There were limitations inherent in the retro-
E124, Indianapolis, IN 46202, USA the cysts using the modified Bosniak classification spective nature of the study and because only one
system. In children with more than one year of child had a cystic tumor.
Correspondence to: B. Karmazyn, follow-up US, the change (>10%) in cyst diameter
Department of Radiology and was evaluated. Inter-observer variability (Kappa) Conclusion
Imaging Sciences, Indiana was calculated. The modified Bosniak classification system demon-
University School of Medicine, strated good inter-observer agreement, and identi-
Riley Hospital for Children, 705 Results fied the single tumor as a complex cyst. The vast
Riley Hospital Drive, Room 1053,
Radiologists one and two saw simple renal cysts in majority of solitary renal cysts in children are simple
Indianapolis, IN 46202, USA. Tel.:
317 948 6305
96.2e96.6% (204205/212) of the children. Ten and if asymptomatic, they require no other imaging
children had complex renal cysts, as rated by either evaluation. Complex renal cysts are uncommon and
bkarmazy@iupui.edu of the radiologists. There was good inter-observer should be evaluated with a pre-intravenous and
(B. Karmazyn) agreement (kappa Z 0.65) for simple versus com- postintravenous contrast CT scan to exclude a
tawadros.alex@gmail.com plex cysts. tumor.
(A. Tawadros)
ldelaney@iupui.edu
(L.R. Delaney)
mbshelto@iupui.edu
(M.B. Marine)
mpcain@iupui.edu (M.P. Cain)
rrink@iupui.edu (R.C. Rink)
sajennin@iupui.edu
(S.G. Jennings)
mkaefer@iupui.edu
(M. Kaefer)

Keywords
Ultrasound; Children; Solitary
renal cysts; Simple cysts; Com-
plex cysts

Received 15 January 2015

Accepted 9 March 2015
Available online xxx

http://dx.doi.org/10.1016/j.jpurol.2015.03.001
1477-5131/ 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Karmazyn B, et al., Ultrasound classification of solitary renal cysts in children, Journal of Pediatric
Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.001
 + MODEL
1.e2 B. Karmazyn et al.

Figure Longitudinal color doppler US of a complex (grade III by both radiologists) left renal cyst in a 7.2 year-old boy. The child
presented with gross hematuria. Ultrasound shows a septated cystic mass with vascularity of the septations (arrowheads) and cyst
wall (arrow). Radical nephrectomy was performed with pathologic diagnosis of multiloculated cystic nephroma.

Introduction abscess, prior renal tumor, or syndromes associated with

Only a few small series have evaluated solitary renal cysts
in children [1e5]. In adults, the Bosniak classification
system of renal cysts is used to assess cystic renal cell
carcinoma risk and to guide complex renal cyst manage-
ment [6e8]. This classification is based on computerized
tomography (CT) [8]; however, in children, most solitary
renal cysts are discovered using ultrasound (US), and
cystic renal tumors are rare [9e11].
A modified Bosniak classification system for renal cysts,
which is based on US, has been developed for children.
Solitary renal cysts have now been retrospectively classified
using the new system and its reproducibility and ability to
identify cystic tumors has been determined.
Material and methods
Patient population
The institutional review board approved this Health Insur-
ance Portability and Accountability Act compliant study
with waiver of informed consent. From the radiology in-
formation system at a tertiary care childrens hospital, all
children younger than 18 years, who underwent a renal US
study, with keyword of cyst on the report, between 2003
and 2011 were retrospectively identified.
Exclusion criteria were children with: multiple renal
cysts, previous renal surgery, a transplanted kidney, renal
renal cysts (polycystic kidney disease, tuberous sclerosis,
von Hippel-Lindau syndrome).
All follow-up renal US studies until December 2012 were
retrieved. Medical charts were reviewed for demographic
information, underlying urologic diseases, and symptoms.
Other available renal imaging studies, including CT, MRI,
and VCUG, were also reviewed. The VUR side was noted, as
was ureteral reimplant or Deflux injection side, if
performed.
Review of renal ultrasound
Two fellowship-trained pediatric radiologists, blinded to
the clinical information, independently reviewed the renal
US studies. One radiologist excluded children with multiple
cysts, and then measured the maximum cyst diameter on
the initial and available follow-up studies. Each radiologist
independently graded the renal cysts using a
US-based modification of the Bosniak classification system
(Table 1).
For children with follow-up studies, change in grading
and cyst size (either absolute size change or ratio of renal
cyst diameter to renal length) was evaluated. Any change
by at least 10% of the renal size was considered to be
positive.
For children with a modified Bosniak grade III or IV on
initial US, a different fellowship-trained pediatric radiolo-
gist graded their available CT, or MRI studies were graded
using the Bosniak classification system.

Table 1 The modified Bosniak classification system for renal cysts, based on ultrasound findings.
Grade Shape Wall Septations Calcification Content
Thickness Nodules Doppler flow Number Thickness Nodules Doppler flow
I Round 1 mm No No 0 N/A No No Noa Anechoic
II Lobulated 1 mm No No Few 1 mm No No No Debris
III N/A 1 mm No Yes Multiple 1 mm No Yes Yes N/A
IV N/A N/A Yes N/A N/A N/A Yes N/A N/A Soft tissue
a
Not including movable cyst stone.

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 + MODEL
Solitary renal cysts in children 1.e3

A definitive diagnosis of renal cysts was determined by Ultrasound findings

pathology reports, or imaging demonstrating a cyst
and collecting system communication (calyceal
diverticulum).
Statistics
Laterality of VUR and reimplant/Deflux injection was
compared with the presence of renal cysts by the Chi-
squared test. The grading system and each of the
morphological features of the renal cysts were examined as
a predictor of renal tumor or development of polycystic
renal disease during the follow-up period using Chi-squared
tests. Weighted kappa was calculated to assess inter-
observer agreement. Analyses were performed using SAS
version 9.3 (SAS Institute, Cary NC) and significance was
defined as P < 0.05.
Results
Patient population
A total of 212 (prevalence of 1.0%, 212/20,349) children
with solitary renal cysts were identified; 114 (54%) were
females and 98 (46%) were males, with a mean age of 8.4
years (range one day to 17 years, median 8.1 years). The
most common (>5% prevalence) indications for US
included: VUR (22.6%, 48/212); follow-up of known renal
cysts (14.2%, 30/212); dysfunctional voiding (13.2%, 28/
212); UTI (12.7%, 27/212); hydronephrosis (6.6%, 14/212);
neurogenic bladder (6.1%, 13/212); and abdominal pain
(5.7%, 12/212).
There was no statistical significance between side of
VUR and the presence of renal cysts (ipsilateral 62.5% (30/
48), contralateral 60.4% (29/48), P Z 0.83). Thirty-eight
children had a reimplant (n Z 16) or Deflux injection
(n Z 2) ipsilateral to the cysts; 20 children had a contra-
lateral reimplant (n Z 15) or Deflux injection (n Z 5). The
surgical procedure location and the presence of renal cysts
were not associated (P Z 0.56).
Renal cyst grades
Most cysts (96.2% and 96.7% by radiologists one and two,
respectively) were simple (grade I or II). Most simple cysts
were grade I: 86.3% (183/212) by radiologist one and 74.1%
(157/212) by radiologist two.
Complex renal cysts (grade III and IV) were seen in 3.8%
(8/212) and 3.3% (7/212) of children by radiologists one and
two, respectively (Fig. 1). Only radiologist one categorized
one cyst as grade IV. There were up to four septations in the
cysts that were classified by either of the two radiologists
as having few septations, and at least six in cysts classified
as having multiple septations.
Of the 10 renal cysts graded as grade III or IV by either
radiologist, three children had surgical resection of the
cysts (one multilocular cystic nephroma, two simple cysts),
five children had CT and one had an MRI that demonstrated
simple cysts (two grade I, three grade II, one grade IIF). The
child with the grade IIF cyst had a stable cyst on US at the
two-year follow-up. One child did not attend follow-up US.
Other findings in the ipsilateral kidney included hydro-
nephrosis in 8% (21/212) and parenchymal echogenicity in
10% (21/212) of children.
Inter-observer variability
Radiologists one and two agreed on the cyst grade classi-
fication (kappa Z 0.48) in 83% of children. When classifying
by simple (grades IeII) versus complex (grades IIIeIV)
cysts, the radiologists agreed in 98% of children
(kappa Z 0.65).
Follow-up renal ultrasound
Of the 212 children (42.0%), 89 had at least one year of
follow-up US. The cysts resolved (40.4%, 36/89) or
decreased in size (6.7%, 6/89) in 47.2% (42/89) of these
children. A total of 32.6% (29/89) of the cases had stable
cysts. In 20.2% (18/89) of the children, the cysts increased
in size; using the ratio of cyst to renal length, the relative
size increased in 15 (16.9%) children.

Figure 1 Images of a complex left renal cyst (grades IV by one radiologist and III by the other radiologist) in a 7.4 year-old boy.
The child presented with macroscopic hematuria. a) Transverese ultrasound view of the right kidney shows a complex cystic mass
with an echogenic material. b) An axial post-intravenous-contrast CT scan of the abdomen was performed that demonstrated a
right kidney lesion with high density thought to represent a solid mass. A non-contrast CT was not performed. Radical nephrectomy
was performed. Pathology diagnosis was epithelial cyst filled with blood.

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 + MODEL
1.e4 B. Karmazyn et al.

Four (three and one, by radiologists one and two, Discussion

respectively) simple cysts changed to complex cysts at
follow-up. In two of the four children, no long-term follow-
up was performed, as the cysts were reported as stable and
simple in the original report, one child had a CT scan
demonstrating simple (grade II) renal cysts and one other
child had a resection of the cysts, which were diagnosed as
benign on pathology.
In five of the 212 children (2.4%) there was an increase in
the number of renal cysts on follow-up. The additional cysts
appeared 1.6e6.8 years (mean 3.7 years) after the initial
study. In four of the five children, the number of cysts
increased to four. In one child with a single kidney following
resection of multicystic dysplastic kidney, follow-up US
demonstrated numerous (n Z 20) cysts in the kidney that
were compatible with polycystic renal disease.
Definitive diagnosis of the renal cysts
A definitive diagnosis was obtained in 18 of the 212 children
(8.5%, Table 2). Calyceal diverticulum was diagnosed in
nine children by delayed intravenous (IV) contrast abdom-
inal CT (n Z 7), retrograde nephrostogram (n Z 1), and
technetium 99m MAG3 scan (n Z 1).
Nine children had surgical resection of the cyst. In-
dications for surgical procedures included: complex cyst
(n Z 5), flank pain (n Z 2), and increased size of the cyst
(n Z 1). One child had end-stage renal disease and the right
lower pole artery was used for anastomosis of the trans-
planted kidney. The pathology diagnosis was benign renal
cysts in eight children; one had a cluster of cysts. One child
had multilocular cystic nephroma (MLCN). Overall, surgical
intervention for renal cysts was performed in thirteen
children (Table 2).
Solitary renal cysts are uncommon in children, with a re-
ported prevalence of 0.22e2% [1e5]. In the present series,
the prevalence was 1%. The true prevalence, however, may
be higher as asymptomatic children were not screened.
There is a challenge in providing imaging criteria to
consistently and reliably differentiate between simple and
complex renal cysts. When discovered, complex renal cysts
can pose a challenge to both the physician taking care of
the child and the radiologist [1,5]. In adults, the Bosniak
classification system is a well-established grading system
that guides management of renal cysts based on imaging
characteristics on CT scan [6,8].
However, there are several differences between chil-
dren and adults in the natural history of renal cysts. The
main risk in adults is cystic renal cell carcinoma (RCC)
[6,8,12e14]. Yet, malignant transformations of renal cysts
into renal cell carcinoma, Wilms tumor, or multilocular
cystic renal carcinoma are very rare in children. They have
been reported in a few case reports and in a small series of
complex renal cysts [9,10,14e17].
Prior reports of solitary renal cysts in children have been
from selected groups of children with either simple or
complex renal cysts [14,16]. The present study is the first to
evaluate all consecutive simple and complex solitary renal
cysts in children.
The CT-based Bosniak classification system for renal
cysts guides surgical treatment versus conservative man-
agement. Because approximately 25% of grade IIF or in-
termediate-grade cysts (multiple septa and/or minimal
septal thickening) found on CT scan are malignant [18,19],
these children require follow-up CT. However, US imaging

Table 2 Details of the children with a specific diagnosis of renal cysts (n Z 18).
Gender Age (years) Indicationa Diagnosis Cyst grade Procedure
(Radiologists 1 and 2)
Male 4.3 Complex cyst Benign cyst II, II Upper pole nephrectomy
Female 3.0 Flank pain Benign cyst II, II Fulguration
Female 8.7 Increased size Benign cyst II, II Fulguration
Female 11.8 Flank pain Epithelial cyst I, II Fulguration
Male 15.4 Complex cyst, HT Benign cyst II, II Partial nephrectomy
b
Male 2.3 Benign cyst I, I Nephrectomy
Male 7.4 Complex cyst Epithelial cyst with blood IV, III Radical nephrectomy
Female 7.2 Complex cyst A cluster of benign cysts III, III Upper pole nephrectomy
Male 7.2 Complex cyst MLCN III, III Radical nephrectomy
Male 12.8 Cyst CD I, I e
Male 4.7 UTI CD I, I e
Female 14.8 Cyst vs DK CD I, II e
Female 9.5 Stone, pain, UTI CD with stone I, II Fulguration
Male 2.1 Cyst vs DK CD I, II e
Female 4.7 Stone, UTI CD with stone I, II Excision of the cyst
Male 14.1 Stone, HT CD with stone I, I Fulguration
Male 1 day UTI CD I, I Fulguration
Female 8.6 Cyst vs DK CD I, I e
HT, hypertension; CD, calyceal diverticulum; MLCN, multilocular cystic nephroma; DK, hydronephrotic upper pole of a duplex kidney.
a
Indication for further imaging work-up or surgery of the cyst.
b
End-stage renal disease, right lower pole artery was used for anastomosis of the transplanted kidney.

Please cite this article in press as: Karmazyn B, et al., Ultrasound classification of solitary renal cysts in children, Journal of Pediatric
Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.001
 + MODEL
Solitary renal cysts in children
helps to select the few children with complex renal cysts
that require further evaluation with CT. Therefore, the
modified Bosniak classification system is for US, so that
imaging characteristics of CT-grade IIF cysts are included in
grade III. Only four categories (I to IV) of cysts are used that
define simple (grade I and II) and complex (grade III and IV)
cysts. Based on the present study results, it is suggested
that multiple septations be defined as >4 septations.
It was found that the vast majority of renal cysts were
simple and none of the children were found to have a renal
tumor. Very few children (3.8%, 8/212 and 3.3%, 7/212, by
radiologists 1 and 2, respectively) had complex (grade III or IV)
renal cysts. Only one of these complex renal cysts was found
to have a benign tumor (multilocular cystic nephroma, MLCN).
The Bosniak classification system has previously been
reported in children in two highly selective groups of chil-
dren [14,16]. One study included 22 children who had sur-
gical resection of their cystic masses [16] and the other
series included 39 children with complex renal cysts [14].
All children with malignant tumors had either Bosniak grade
III or IV. In these two studies, the authors included the US
characteristics of grade IIF in the grade II category. This
resulted in the inclusion of MLCN tumors as grade II and the
authors suggestion for follow-up of grade II cysts.
In the present study, inter-observer agreement of the
modified Bosniak classification system was 83%
(kappa Z 0.48). However, when the population was divided
into simple (grade I and II) and complex (grade III and IV)
cysts, there was better agreement (98% agreement,
kappa Z 0.65). In children, inter-observer variability has
been evaluated in one other study [17]. The authors found
higher inter-observer agreement on both CT and US
(kappa Z 0.86 and 0.83, respectively). However, this study
included a highly selective small series of children with
approximately 80% grade III or IV renal cysts [16]. In adults,
inter-observer agreement varied between studies [20,21].
The management of renal cysts in children depends on
the clinical presentation and imaging. The clinician may
decide to perform follow-up US, other imaging, or an inter-
vention. In the present study, 89 children had follow-up US
for more than a year later, 73 children had an abdominal CT,
and 14 had an MRI. Surgery was performed in 13 children.
A study on 41 children that were followed for at least
one year found that 49% (20/41) of the cysts grew in size
[4]. In the present study, the cysts increased in size in 18 of
the 89 children (20%). Using the ratio of cyst to renal
length, there was an increase in relative size in 17% (15/89)
of the children.
Very few (three and one, by radiologists one and two,
respectively) cysts progressed from simple to complex
cysts; none contained tumors.
The risk for development of polycystic kidney disease
(PCKD) is another concern in children with solitary renal
cysts. During the follow-up period of the present study, five
out of 89 (6%) children had an increase in the number of
renal cysts; four children had up to four cysts and only one
child with prior resection of multicystic kidney disease and
numerous (n Z 20) cysts was diagnosed with a polycystic
renal disease. However, to evaluate the long-term risk for
PCKD, follow-up is required until the fifth decade of life,
which is when most PCKDs are discovered; this is beyond
the scope of the present study.
Please cite this article in press as: Karmazyn B, et al., Ultrasound classification of solitary renal cysts in children, Journal of Pediatric
Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.001
1.e5
A definitive diagnosis of the renal cysts was obtained in
18/212 (8.5%) children; calyceal diverticulum was diag-
nosed in 50% (9/18), and benign renal cysts in 44% (8/18).
Only one child (6%, 1/18) had a tumor (MLCN).
The indications for intervention for renal cysts in chil-
dren include complications of simple renal cysts such as
bleeding, stone, superimposed infection, and/or pain [2].
In complex renal cysts, the indication for surgery is a risk of
tumor. In the present study, 12 children underwent surgical
intervention, five were due to complex renal cysts and risk
of tumor (one also had hypertension) and seven were due to
cyst stones (n Z 3), hypertension (n Z 1) and/or symptoms
(pain (n Z 3) and recurrent UTIs (n Z 3)). Another child had
the kidney removed at the time of renal transplant, but not
because of symptoms.
Based on experience, a management algorithm based on
clinical presentation and grade of the cyst is suggested. The
modified Bosniak classification system provides consistent
and well-defined criteria for simple (grade I and II) and
complex (grade II and IV) cysts. In asymptomatic simple renal
cysts, no other imaging workup is required. In symptomatic
children, if surgical intervention is considered, a single-
phase, delayed, post-contrast CT scan is suggested to
differentiate between calyceal diverticulum (potential for
either percutaneous or retrograde fulguration) and non-
communicating cysts. In complex cysts, a non-contrast CT of
the kidneys followed by IV CT scan in the corticomedullary
(arterial) and nephrographic phase (120 seconds) is sug-
gested. In one of the present cases, a radical nephrectomy
was performed in a child with hemorrhagic simple renal
cysts. The CT scan was performed as a single, post-contrast
phase and the high-density cyst appeared as a solid tumor.
The addition of a non-contrast phase may have shown non-
enhancement of the mass and suggested a high-density cyst.
Using this algorithm and US cyst grade, approximately 96% of
the present children would not have needed additional im-
aging. The other children would have needed a dedicated CT
scan for further characterization of the mass.
The present study had some limitations that were
inherent to the retrospective nature of the study. Only 42%
children had follow-up for more than a year. Additionally,
only one child was found to have a tumor, which limited the
evaluation of the grading of renal cysts to predict renal
tumors. However, this reflects the overall low risk of cystic
renal tumors in children.
Conclusions
The risk of a renal tumor in children with solitary renal cysts
is extremely low. No children with grade I and II cysts had a
renal tumor. The use of a modified Bosniak classification
system designed for US can save unnecessary imaging work-
up and lead to more consistent classification and manage-
ment of renal cysts. Prospective studies based on this
classification would be necessary to confirm these results.
Conflict of interest
None of the authors of this manuscript has a conflict of
interest related to this manuscript.
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1.e6 B. Karmazyn et al.

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Please cite this article in press as: Karmazyn B, et al., Ultrasound classification of solitary renal cysts in children, Journal of Pediatric
Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.03.001