Introduction: Nutcracker syndrome is an uncommon clinical condition in which the left renal vein is compressed between the superior mesenteric artery and aorta. Patients most commonly present with hematuria or left flank pain, and a wide range of treatment modalities are available to treat symptomatic nutcracker syndrome. One such intervention is left renal vein transposition, which has produced excellent results when performed with an open approach. Minimally-invasive techniques have revolutionized how many surgical procedures are performed, but despite the increasing popularity of robotics, the literature on robotic-assisted left renal vein transposition remains limited. In this study, we describe our robotic left renal vein transposition technique in a patient with nutcracker syndrome.
Methods: The patient was a 19-year-old male with a 12-month history of left flank pain, gross hematuria, and early satiety. The patient had a thin body habitus, with a body mass index of 17.7 kg/m2. Physical examination was unremarkable. His baseline serum creatinine was 0.8 mg/dL, and urinalysis showed moderate blood and no proteinuria. The patient initially attempted conservative treatment options, including weight gain and acetaminophen for flank pain, which were unsuccessful. Computed tomography of the abdomen revealed a compressed left renal vein. In the context of his clinical presentation, laboratory reports and, and imaging findings, a presumptive diagnosis of nutcracker syndrome was made. The patient was counseled regarding the various treatment options for this condition and elected to proceed with robotic-assisted left renal vein transposition.
Results: The patient tolerated the procedure well. Total operative time was 152 minutes, there were no complications, and the patient was discharged home on postoperative day one. At his six-week follow-up visit, the patient reported resolution of left flank pain and hematuria, and ultrasound revealed no abnormalities.
Conclusions: Robotic-assisted left renal vein transposition is a safe and effective treatment for nutcracker syndrome. This approach to left renal vein transposition should be achievable for surgeons experienced with robotic retroperitoneal lymph node dissection and caval thrombectomy.
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