Monday July 01, 2019 from 07:30 to 09:00
Management of complex cysts in Canada: Results of a survey study
Patrick Richard1, Amélie Tétu1, Luke T. Lavallée2, Philippe Violette3, Anil Kapoor4, Wassim Kassouf5, Antonio Finelli6.
1Division of Urology, Centre Hospitalier Universitaire de Sherbrooke , Sherbrooke, QC, Canada; 2Division of Urology, The Ottawa Hospital, Ottawa, ON, Canada; 3Division of Urology, Woodstock General Hospital, Woodstock, ON, Canada; 4Division of Urology, St. Joseph Healthare Centre, Hamilton, ON, Canada; 5Division of Urology, McGill University Health Network, Montréal, QC, Canada; 6Division of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
Introduction: Given their high-risk of malignancy (>50% risk), Bosniak III and IV cysts have traditionally been managed with surgical excision.1 There is growing evidence suggesting that many of these cysts behave in an indolent fashion.2 Therefore, active surveillance (AS) has been proposed as a possible treatment alternative.3-5 The objectives of this study were to characterize the use of AS in the management of complex renal cysts in Canada and to identify the perceived barriers to its greater adoption.
Methods: A web-based survey was sent to all practicing urologists (n=583) of the Canadian Urological Association (CUA) in October 2018. The survey examined the physician’s management of complex renal cysts and perceived barriers to adoption of AS. Chi-squared tests were used to assess for differences between respondents.
Results: The response rate was 24.7%. Of eligible respondents, 13.7% never or rarely offer AS (<5% of cases), while 33.1% offer AS in >50% of patients with a Bosniak III cysts in whom surgical extirpation is considered a viable treatment option. In contrast, for Bosniak IV cyst, 60.1% of urologists never or rarely offer AS, while only 10.1% offer it >50% of cases. A greater proportion of academic urologists compared to non-academic urologists viewed AS as a viable treatment option for patients with a Bosniak III (p=0.03) or IV (p=0.002) cysts. The most commonly reported barriers to greater adoption of AS were: concerns regarding the safety and/or benefits of AS, the lack of data to support AS in patients with Bosniak III–IV cyst and the lack of specific triggers for intervention for patient managed by AS.
Conclusions: Although AS is reported by the CUA guidelines as a possible treatment option for complex cysts, most urologists are still reluctant to offer this option to their patients, mostly due to the lack of data supporting its role. Thus, future studies are required to better define the role of AS in patients with Bosniak III or IV cysts.
 Schoots IG, Zaccai K, Hunink MG, et al. Bosniak classification for complex renal cysts re-evaluated: A systematic review. J Urol 2017;198:12-21. https://doi.org/10.1016/j.juro.2016.09.160
 Bhatt JR, Jewett M, Richard PO, et al. Multilocular cystic renal cell carcinoma: Results of a long-term, large population-level study: Pathologic T-staging makes no difference to favourable outcomes and should be reclassified. J Urol 2016;196:1350-5. https://doi.org/10.1016/j.juro.2016.05.118
 Chandrasekar T, Ahmad AE, Fadaak K, et al. Natural history of complex renal cysts: Clinical evidence supporting active surveillance. J Urol 2018:199:633-40. https://doi.org/10.1016/j.juro.2017.09.078
 Pruthi DK, Liu Q, Kirkpatrick IDC, et al. Long-term surveillance of complex cystic renal masses and heterogeneity of Bosniak 3 lesions. J Urol 2018;200:1192-9. https://doi.org/10.1016/j.juro.2018.07.063
 Richard PO, Violette PD, Jewett MAS, et al. CUA guideline on the management of cystic renal lesions. Can Urol Assoc J 2017;11:E66-73. https://doi.org/10.5489/cuaj.4484