Introduction: The imaging and evaluation of complex renal cystic lesions represent a major clinical problem as it is often difficult to exclude malignancy. The Bosniak classification system was developed to assist in categorizing and suggest the management of cystic lesions based on perceived malignant potential. Although it has been widely accepted by many radiologists and urologists, underutilization on imaging reports and lack of understanding by many providers undercuts the effectiveness of the system. The aim of this study was to evaluate the prevalence of the Bosniak classification system use in clinical practice and asses for means of improvement.
Methods: 500 patients with the diagnosis of renal cyst (ICD N28.1) who had been evaluated by the University of Kansas Department of Urology within the last 5 years were reviewed to assess the utilization of the Bosniak scoring system. Eligible patients must have undergone imaging with and without contrast enhancement (CT or MRI) during that time period. Additional information including indication for urology referral and patient disposition was also collected. 127 scans with the findings of “complex” lesions were retrospectively reviewed by an experienced GU radiologist and appropriate Bosniak scores were applied.
Results: The use of Bosniak classification was found in a total of 44 radiology reports (8.8%). Of these, Bosniak IIF was mostly commonly reported with 16 occurrences, followed by II (14), III (9), IV (3) and finally I (2). In total, 101 scans were ordered specifically for the evaluation of renal cysts and the Bosniak score was reported on 27 (26.7%) of these studies. Additionally, these scans generated 87 referrals to urology. Of those referred, 67 did not have a Bosniak score reported and 28 were released from urology care after initial consultation. Retrospective review revealed an additional 92 reports where Bosnaik scoring should have been included.
Conclusions: Despite the widespread acceptance of the Bosniak classification system, it was utilized less than 10% of the time for evaluation of renal cysts at our health system. Limited use of Bosniak scores on radiology reports and lack of understanding by physicians and advance practice providers contributes to increased patient anxiety, unnecessary repeat imaging, and referrals to urology for simple cysts that do not require follow up. We are working with our radiology colleagues to implement a standardized imaging report template to include Bosniak classification with all renal cysts in order to improve patient care, save hospital resources, and ultimately improve patient outcomes.
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