Renal Autotransplantation for Nutcracker Syndrome

  

This is the case of thirty-four-year-old woman who presented with a long-term history of left flank pain, groin pain, and proteinuria. She underwent a venography, angiography, and CT scan. The cause of her symptoms was identified as Nutcracker syndrome (left renal vein entrapment). 

The Surgery

The abdomen was entered via the laparoscopic approach. The dissection began by reflecting the left colon medially by excising the white line of Toldt. Colorenal attachments were then taken down, and the posterior peritoneum overlying the kidney's poles was opened. The adrenal gland was dissected off the renal hilum and upper pole. Then the lateral attachments were taken down. The gonadal vessels were identified at the lower poles. The cone of Gerota’s fascia was then elevated to include the ureter, which was then dropped, and the fascia was divided. The gonadal vessels were then separated, clipped, and divided. The ureter was divided at the level of the iliac vessels. The extraction incision was created in the infraumbilical area in the midline. The kidney was elevated. The renal artery, vein, and ureter were then divided. The kidney was extracted and brought to the back table.

The kidney was flushed with cold preservation solution and prepared in an iced preservation solution on the back table.

The patient was repositioned to supine. A curvilinear incision was made in the right lower quadrant, and the standard exposure of the external iliac artery and vein was performed. The kidney autotransplant was carried out by suturing the renal vein end-to-side to the external iliac vein. The two renal arteries were similarly sutured separately to the external iliac artery. The ureter was reimplanted to the bladder. The kidney was immediately well perfused, and the urine output was appropriate.

At the three month follow-up, the patient was doing well and free of her Nutcracker pain.

References

1. Neglén, Peter, Tara L. Thrasher, and Seshadri Raju. "Venous outflow obstruction: an underestimated contributor to chronic venous disease." Journal of vascular surgery 38, no. 5 (2003): 879-885.Harvard

2. Ruel, Jennifer. "May-Thurner Syndrome: An often-missed cause of chronic pelvic pain." Journal of the American Association of Nurse Practitioners 31, no. 7 (2019): 388-390.

3. Salehipour, Mehdi, Alireza Rasekhi, Mehdi Shirazi, Abdolreza Haghpanah, Shahrokh Jahanbini, and Seyed Ali Eslahi. "The role of renal autotransplantation in treatment of nutcracker syndrome." Saudi Journal of Kidney Diseases and Transplantation 21, no. 2 (2010): 237.

4. Xu, Danfeng, Yushan Liu, Yi Gao, Lei Zhang, Junkai Wang, Jiangping Che, and Youhua Zhu. "Management of renal nutcracker syndrome by retroperitoneal laparoscopic nephrectomy with ex vivo autograft repair and autotransplantation: a case report and review of the literature." Journal of Medical Case Reports 3, no. 1 (2009): 1-6.