Robotic assisted extravascular stent placement for nutcracker phenomenon of the left renal vein: a case series
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ORIGINAL ARTICLE
Robotic assisted extravascular stent placement for nutcracker phenomenon of the left renal vein: a case series Ryan L. Steinberg1 · Brett A. Johnson1 · Alaina Garbens1 · Jeffrey A. Cadeddu1,2 Received: 6 November 2019 / Accepted: 4 February 2020 © Springer-Verlag London Ltd., part of Springer Nature 2020
Abstract Nutcracker phenomenon of the left renal vein is a rare anatomic anomaly that can present with chronic flank/pelvic pain, pelvic congestion, and hematuria. Conventional treatment options (superior mesenteric artery transposition, endovascular stent placement, auto-transplantation) involve substantial risk, morbidity, or the need for chronic anti-coagulation. We now report our institution’s robotic experience with extravascular left renal vein stent placement. A retrospective, single surgeon series from December 2016 to May 2019 was reviewed. After positioning and port placement (three robotic ports, one assistant), the left renal vein was exposed and dissected free circumferentially down to the inferior vena cava insertion. The distance between the renal vein ostium and adrenal vein was measured and a 1 cm-diameter ringed polytetrafluoroethylene vascular stent of this length placed. The stent edges were secured to itself with 3–0 polyglactin sutures. Demographics, surgical, and functional outcomes were collected. Six patients with mean age of 45 ± 6 years and body mass index of 20.3 ± 3.3 g underwent the procedure. Mean operative time was 143 ± 20 min. Estimated blood loss was minimal. Mean graft length utilized was 2.25 ± 0.3 cm. Median day of discharge was 1.5 days (range 1–3). No high-grade complications occurred. All patients received immediate pain relief and 50% also saw other symptomatic improvements. Robotic assisted extravascular left renal vein stent placement appears safe and effective in a small cohort with short follow-up. Further long-term follow-up for pain relief and graft-related complications are needed. Keywords Robotic surgical procedures · Minimally invasive surgery · Renal nutcracker syndrome · Stents
Introduction Initially described anatomically by Grant in 1944, clinically by El-Sadr and Mina in 1950 [1], and terminology coined by De Schepper [2], nutcracker phenomenon of the left renal vein is the compression of the left renal vein leading to clinical symptoms. Venous compression typically occurs between the superior mesenteric artery (SMA) and aorta, but compression between the aorta and vertebral body in the case of a retroaortic vein (“posterior nutcracker phenomenon”) has been reported [3]. While symptomatic compression is considered a rare entity without a well-established occurrence, the prevalence of renal vein compression alone * Jeffrey A. Cadeddu [email protected] 1
Department of Urology, University of Texas Southwestern, Dallas, TX, USA
UT Southwestern Department of Urology, 2001 Inwood Dr. Urology 4th Floor, MC 9164, Dallas, TX 75390, USA
2
may be higher than initially thought [4]. Symptomatology varies but includes left fl
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