T he Bosniak classification of cystic renal masses (CRMs) has contributed substantially to the stratification of malignancy risk in the 3 decades since it was proposed (1). As a living system, refinements were made in 1993 and 2005 (version 2005) (2-4). With the current version of the Bosniak classification (version 2005), several shortcomings in both clinical practice and scientific research have been noted. A systematic review has suggested that interreader variability for the Bosniak classification is large, ranging from 6% to 75% (5), especially for Bosniak classes II, IIF, and III. This variability is partly explained by relatively subjective classification criteria. Moreover, the reported risk for malignancy of each class of CRM varies widely. For example, the likelihood for Bosniak classes II, IIF, III, and IV is, respectively, 9% (range, 5%-14%), 18% (range, 12%-26%), 51% (range, 42%-61%), and 86% (range, 81%-89%) (5). The high prevalence of a benign finding among Bosniak class III CRMs (approximately 49%) (6) is also a concern because unnecessary surgery may cause potential harm and present no clinical benefit.