Robotic-assisted left renal vein transposition as a novel surgical technique for the treatment of renal nutcracker syndrome.
ABSTRACT: Renal nutcracker syndrome is an anatomic anomaly characterized by the compression of the left renal vein between the superior mesenteric artery and the aorta or between the aorta and the vertebral body. Diagnosis is often challenging. Common presenting symptoms include hematuria, abdominal pain, and pelvic congestion. Several open and endovascular techniques have been described to treat this syndrome. We report a novel surgical technique with robotic-assisted left renal vein transposition to treat a 19-year-old woman with renal nutcracker syndrome. Robotic vascular surgery can be a safe and effective therapy for this condition.
Project description:Posterior nutcracker syndrome is caused by the compression of left renal vein between the abdominal aorta and the vertebral body. Most seen symptoms are haematuria, left flank pain, abdominal pain and varicocele. The nutcracker syndrome may lead to left renal vein thrombosis due to blood congestion within compression of the vessel. Both endovascular and open surgical interventions can relieve symptoms; however, traditional surgical repair is still considered as the gold standard. Here, we present the surgical treatment of a 36-year old female with complaints of hypertension, hyperaldosteronism and diagnosed with posterior nutcracker syndrome.
Project description:The Nutcracker Syndrome is manifest in the presence of a symptomatic entrapment of the left renal vein between the abdominal aorta and the superior mesenteric artery. In a more ephemeral variation of this disorder, called the Posterior Nutcracker Syndrome, the renal vein is not compressed anterior to the aorta, but posteriorly, between the artery and the spine. Although there are multiple treatment options, current techniques aim to relieve the symptoms and reduce venous pressure on the left renal vein. This report describes a case of Posterior Nutcracker Syndrome in which the management approach chosen was open surgery, transposing the gonadal vein distally, to the inferior cava vein.
Project description:To assess the detection rate of nutcracker syndrome in children with isolated hematuria, renal Doppler ultrasound examinations were routinely performed on 216 consecutive children (176 microscopic hematuria and 40 gross hematuria). Renal Doppler ultrasound was also performed on 32 healthy normal children. The peak velocity (PV) was measured at the hilar portion of the left renal vein (LRV) and at the LRV between the aorta and the superior mesenteric artery. The PV at the aortomesenteric portion (P=0.003) and the PV ratios of the LRV (P=0.003) were significantly higher in children with hematuria than in normal children, while the PV at the hilar portion was not different. If a PV ratio of the LRV of at least 4.1 (the cut-off level set at the mean +/-2 SD of the value for the normal children) was defined as abnormal, 72 cases (33.3%) in children with hematuria and no cases in normal children were diagnosed as having nutcracker syndrome. The prevalence of nutcracker syndrome is relatively high in children with isolated hematuria, and the inclusion of renal Doppler ultrasound as a screening examination has a substantial effect on the detection of nutcracker syndrome.
Project description:Posterior nutcracker syndrome is caused by compression of the left renal vein between the abdominal aorta and the vertebral column. We present the case of a 14-year-old girl with vague left loin pain, mild haematuria and proteinuria. Diagnosis of this rare syndrome was achieved using color Doppler US and multidetector computed tomography (MDCT) angiography.
Project description:The nutcracker syndrome is a rare clinical manifestation of symptoms caused by the compression of the left renal vein by an overriding superior mesenteric artery, an anatomical variant otherwise known as the nutcracker phenomenon. Usually present in women and children, when symptomatic, it commonly presents with hematuria, proteinuria, and chronic pelvic pain. Effective modalities of treatment apart from conservative management, include both invasive surgical procedures such as renal vein transposition and autotransplantation of the kidney and more popular recently, the less invasive endovascular stenting. Both options, however, are not without complications, such as, retroperitoneal hematomas or stent migration, thrombosis and restenosis. We now present a case of spontaneous renosplenic shunting in a 68-year-old lady of Chinese descent with the nutcracker syndrome-the first of such cases to be ever reported in a patient with no preexisting predilection for chronic liver disease and portosystemic shunting. Despite having significant pelvic venous congestion as evident on computed tomography scans, she remained asymptomatic. This may present a novel paradigm shift for the treatment of the nutcracker syndrome -surgical creation of a renosplenic bypass instead of current modalities, an alternative solution which can be performed laparoscopically and is without problems related to stent use. The creation of laparoscopic splenorenal bypass has been reported once thus far in Cleveland Ohio by Chung and Gill with good symptomatic improvement but no further studies since to validate its long-term effectiveness.
Project description:Median arcuate ligament syndrome and superior mesenteric artery syndrome are well-known abdominal compression syndromes, the coexistence of which is rarely described in literature. In addition, due to the common pathogenesis, anterior nutcracker syndrome may occur simultaneously to superior mesenteric artery syndrome. To our knowledge, this is the first case reporting combination of these 3 syndromes detected with ultrasound, Computed Tomography and upper gastrointestinal fluoroscopic exam. A 69-year-old man came to our attention for rapid weight loss, postprandial epigastric pain and recurrent vomiting for at least 6 months. Doppler ultrasound showed both celiac artery and left renal vein stenosis with simultaneous left varicocele. Computed tomography showed a reduction of aortomesenteric space causing both left renal vein and duodenal stenosis, this latter confirmed by upper gastrointestinal fluoroscopic exam. The diagnosis of these three vascular compression syndromes (MALS, SMAS, and anterior NCS) has been formulated, based on clinical and imaging findings. We assumed that the postprandial crises caused by median arcuate ligament syndrome may induce a reduction of meals consumption and progressive weight loss which can be a cause of anterior nutcracker syndrome and superior mesenteric artery syndrome onset. Doppler ultrasound, in expert hands, allows to accurately diagnosing these syndromes which are often underestimated. Failure to recognize it and inadequate treatment could have serious consequences for patients' health.
Project description:A 20-year-old man complained of debilitating left flank pain for 6 months with an episode of gross hematuria. Computed tomography showed compression of the left renal vein between the aorta and superior mesenteric artery with an aortomesenteric angle of 25 degrees. Venography showed a gradient of 3 mm Hg across the compression and 94.4% luminal compression of the left renal vein. After discussion of all surgical and endovascular options, robot-assisted laparoscopic placement of an extravascular cuff around the left renal vein was performed using the da Vinci X Surgical System (Intuitive Surgical, Sunnyvale, Calif). The patient did well with full resolution of the left flank pain.
Project description:Wilkie's Syndrome is a very rare disease caused by reduction of aorto-mesenteric space with consequent duodenum compression. It can combine with left renal vein stenosis which, when symptomatic, is known as "Nutcracker Syndrome". We describe a clinical onset case with epigastric pain without vomiting in a normal weight patient. 28-year-old woman who came to our observation for intense epigastric pain after a weight loss of 14 kg in 4 months. Multidetector Computed Tomography and Ultrasound revealed gastric and duodenal overdistension with hydro-air levels, severe duodenum stenosis, and left renal vein compression. Wilkie's Syndrome is common in anorexic individuals suffering from recurrent postprandial vomiting, onset with severe epigastric pain, without vomiting, is quite unusual. High-calorie diet must be first therapeutic approach, in case of failure treatment of first choice should be endovascular stenting and, only in selected cases, surgical treatment should be used because it is very invasive and burdened with numerous complications. Failure to diagnose this disease can expose patients to serious health risks.
Project description:Circumaortic right renal vein is an extremely rare finding and to our knowledge only 1 case has been reported in the literature so far. Its rareness, in contrast to left renal vein anomalies, is thought to be due to a relatively simple embryologic development of right renal vein compared with left renal vein. On the other hand, association of Circumaortic right renal vein with inferior vena cava agenesis and aortic coarctation is an extremely rare occurrence. Our aim is to introduce a case of Circumaortic right renal vein in a 3-month-old child with inferior vena cava agenesis and aortic coarctation. Discussion on the underlying embryology of Circumaortic right renal vein, its clinical importance and the association with other vascular anomalies, will be on our focus as well. Precise understanding of renal vein anomalies is important when planning retroperitoneal surgery or interventional vascular procedures. Awareness of such anomaly implies crucial knowledge for radiologists who should include it in the medical reports to aid future patient's management.
Project description:We hypothesized that the left renal vein pressure difference (ΔP) before and after the ligation can serve as an objective indicator for free of reconstruction after resection of a retroperitoneal tumor with renal segment of inferior vena cava and right kidney. After established a model of left renal vein compression, 45 miniature pigs were operated on experimental procedures including renal segment of inferior vena cava resection, right nephrectomy, and left renal vein ligation. The ΔPs of left renal vein before and after the ligation were measured. Safe ΔP variation without causing acute kidney injury was calculated using regression analysis. In human the safety range of ΔP before and after ligation of the left renal vein was calculated by diuretic response test. The safety range of ΔP in animals or human was 0-11.9 or 0-17.5 cm H2O, respectively. The renal function changed dramatically (p < 0.01), characterized by a significant increase in the rate of acute kidney injury when the ΔP was beyond the upper limit of the safety range. In conclusion, ΔP can predict free of reconstruction after resection of a retroperitoneal tumor with the renal segment of the inferior vena cava and the right kidney.