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On first glance there might be concern for severe hydronephrosis in this left sided kidney. As the operator fans, however, it becomes clear that the anechoic area is not traversing the renal pelvis and collecting system. Instead, this rounded structure actually protrudes beyond the boundary of the renal cortex. This cyst is not reflective of an obstructive process. Differentiating simple cysts from complex ones like this is possible with ultrasound, but generally considered outside of the domain of the point of care sonologist.