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INTRODUCTION: Renal nutcracker syndrome (RNS) is characterized by the compression of the left renal vein between the superior mesenteric artery (SMA) and the aorta or between the aorta and vertebral body. Most common symptoms are hematuria, pain, and severe pelvic congestion. However, RNS is often a diagnosis of exclusion. Several open and endovascular techniques have been described to treat this syndrome. We present a case report of a robotic assisted left renal vein transposition to treat a patient with NRS.
METHODS: A healthy 19 year old female with a BMI 19 presented with a 2 year history abdominal pain without a discernable etiology. She underwent an extensive work up including abdominal duplex ultrasound (US), computed tomography (CT), magnetic resonance imaging, endoscopy, and psychiatric evaluation due to discordance in her symptomatology and radiographic findings. A follow up CT later demonstrated worsening compression of her left renal vein by the superior mesenteric artery (SMA). A left renal venogram demonstrated a 70% stenosis, and a pressure gradient of 3mmHg. Multiple large venous lumbar collaterals were also seen. Intravascular US identified vascular webs and confirmed chronic venous compression.
RESULTS: After induction of general anesthesia, the patient was placed in a modified lithotomy position. Standard sterile prep and drape was performed. Six robotic ports were inserted in the bilateral lower abdomen (two 12mm, four 8mm). She was placed in steep Trendelenburg. The robotic surgical system was docked and connected to the ports. The small bowel was retracted cephalad and to the left upper quadrant. The base of the small bowel mesentery was incised. The retroperitoneal space was opened between the SMA and infrarenal abdominal aorta. The left renal vein was mobilized. The left adrenal and gonadal veins were divided with a vessel sealing device and a vascular stapler respectively. Vascular control of the suprarenal inferior vena cava (IVC), infrarenal IVC, and right renal vein were obtained with vessel loops. Lumbar veins were ligated and divided selectively. Intravenous heparin was given. The left renal vein was clamped near the hilum with a bulldog clamp. The renal vein was then transected at the confluence with the IVC with a small cuff of the IVC and closed with 5-0 prolene suture in running fashion. Vascular webs were excised from the intima of the renal vein. The left renal vein was then re-anastomosed to the IVC more distally in a tension free end-to-side fashion with a running 5-0 prolene suture. The patient was discharged on post-operative day 1. At her one week postoperative visit, she demonstrated a full recovery from her surgery and reported significant improvement in her abdominal pain.
CONCLUSIONS: Robotic assisted left renal vein transposition is a safe, effective and feasible surgical technique to treat patients with this condition.