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.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
El-Sadr AR, Mina E (1950) Anatomical and surgical aspects in the operative management of varicocele. Urol Cutaneous Rev 54(5):257–262
de Schepper A (1972) "Nutcracker" phenomenon of the renal vein and venous pathology of the left kidney. J Belg Radiol 55(5):507–511
Said SM, Gloviczki P, Kalra M, Oderich GS, Duncan AA, Felming M, Bower TC (2013) Renal nutcracker syndrome: surgical options. Semin Vasc Surg 26(1):35–42. https://doi.org/10.1053/j.semvascsurg.2013.04.006
Grimm LJ, Engstrom BI, Nelson RC, Kim CY (2013) Incidental detection of nutcracker phenomenon on multidetector CT in an asymptomatic population: prevalence and associated findings. J Comput Assist Tomogr 37(3):415–418. https://doi.org/10.1097/RCT.0b013e3182873235
Kurklinsky AK, Rooke TW (2010) Nutcracker phenomenon and nutcracker syndrome. Mayo Clin Proc 85(6):552–559. https://doi.org/10.4065/mcp.2009.0586
Rudloff U, Holmes RJ, Prem JT, Faust GR, Moldwin R, Siegel D (2006) Mesoaortic compression of the left renal vein (nutcracker syndrome): case reports and review of the literature. Ann Vasc Surg 20(1):120–129. https://doi.org/10.1007/s10016-005-5016-8
He Y, Wu Z, Chen S, Tian L, Li D, Li M, Jin W, Zhang H (2014) Nutcracker syndrome–how well do we know it? Urology 83(1):12–17. https://doi.org/10.1016/j.urology.2013.08.033
Barnes RW, Fleisher HL 3rd, Redman JF, Smith JW, Harshfield DL, Ferris EJ (1988) Mesoaortic compression of the left renal vein (the so-called nutcracker syndrome): repair by a new stenting procedure. J Vasc Surg 8(4):415–421
Zhang Q, Zhang Y, Lou S, Liu F, Ye Z, Zhang D (2010) Laparoscopic extravascular renal vein stent placement for nutcracker syndrome. J Endourol 24(10):1631–1635. https://doi.org/10.1089/end.2010.0001
Wang SZ, Zhang WX, Meng QJ, Zhang XP, Wei JX, Qiao BP (2015) Laparoscopic extravascular stent placement for nutcracker syndrome: a report of 13 cases. J Endourol 29(9):1025–1029. https://doi.org/10.1089/end.2014.0411
Guo YT, Wang H, Wang JP, Zhang B (2018) Two-year follow-up on laparoscopic three-dimensional printed extravascular stent placement for posterior nutcracker syndrome. Chin Med J (Engl) 131(23):2895–2896. https://doi.org/10.4103/0366-6999.246075
Chen FM, Chen XL, Jiang XN, Tang S, Shi JQ, Li DB, Zhong SW, Chen Y (2019) A new technique: laparoscopic resection of fibrous ring and placing extravascular stent in patients with nutcracker syndrome: a report of 5 cases. Urology. https://doi.org/10.1016/j.urology.2018.12.039
Scultetus AH, Villavicencio JL, Gillespie DL (2001) The nutcracker syndrome: its role in the pelvic venous disorders. J Vasc Surg 34(5):812–819
Sorokin I, Nelson J, Rectenwald JE, Cadeddu JA (2018) Robot-assisted laparoscopic extravascular stent for nutcracker syndrome. J Robot Surg 12(3):561–565. https://doi.org/10.1007/s11701-017-0744-7
Chau AH, Abdul-Muhsin H, Peng X, Davila VJ, Castle EP, Money SR (2018) Robotic-assisted left renal vein transposition as a novel surgical technique for the treatment of renal nutcracker syndrome. J Vasc Surg Cases Innov Tech 4(1):31–34. https://doi.org/10.1016/j.jvscit.2017.09.008
Hohenfellner M, D'Elia G, Hampel C, Dahms S, Thuroff JW (2002) Transposition of the left renal vein for treatment of the nutcracker phenomenon: long-term follow-up. Urology 59(3):354–357
Yu S, Hu H, Ding G (2019) Robot-assisted laparoscopic left renal vein transposition for the treatment of nutcracker syndrome: preliminary experience. Ann Vasc Surg. https://doi.org/10.1016/j.avsg.2018.09.039
Yang BZ, Li Z, Wang ZG (2012) Nutcracker syndrome due to left-sided inferior vena cava compression and treated with superior mesenteric artery transposition. J Vasc Surg 56(3):816–818. https://doi.org/10.1016/j.jvs.2012.03.021
Amaral J, Honjo O, Hannick JH, Rickard M, Lorenzo AJ (2019) In situ gonadal vein valvulotomy and side-to-side gonado-iliac bypass for the management of nutcracker syndrome in an adolescent with a solitary kidney and absence of pelvic congestion. Urology. https://doi.org/10.1016/j.urology.2018.12.033
Chung BI, Gill IS (2009) Laparoscopic splenorenal venous bypass for nutcracker syndrome. J Vasc Surg 49(5):1319–1323. https://doi.org/10.1016/j.jvs.2008.11.062
Zhang X, Wang S, Wei J (2015) Prosthetic left renocaval bypass for posterior nutcracker syndrome. Indian J Surg 77(Suppl 1):103–105. https://doi.org/10.1007/s12262-014-1180-9
Chen S, Zhang H, Shi H, Tian L, Jin W, Li M (2011) Endovascular stenting for treatment of Nutcracker syndrome: report of 61 cases with long-term followup. J Urol 186(2):570–575. https://doi.org/10.1016/j.juro.2011.03.135
Xu D, Liu Y, Gao Y, Zhang L, Wang J, Che J, Zhu Y (2009) Management of renal nutcracker syndrome by retroperitoneal laparoscopic nephrectomy with ex vivo autograft repair and autotransplantation: a case report and review of the literature. J Med Case Rep 3(1):82
Wu Z, Zheng X, He Y, Fang X, Li D, Tian L, Zhang H (2016) Stent migration after endovascular stenting in patients with nutcracker syndrome. J Vasc Surg 4(2):193–199
Tian L, Chen S, Zhang G, Zhang H, Jin W, Li M (2015) Extravascular stent management for migration of left renal vein endovascular stent in nutcracker syndrome. BMC Urol 15(1):73
Yau R, Haber G-P (2019) V03–03 Robotic extravascular graft placement for nutcracker syndrome. J Urol 201(Supplement 4):e399–e399
Conflict of interest
R. Steinberg, B. Johnson, and A. Garbens declare they have no conflict of interest; J. Cadeddu discloses an advisory board position and investment in Levita Magnetics.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.”
Informed consent was not obtained from individual participants included in this study given the retrospective nature of the study.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Steinberg, R.L., Johnson, B.A., Garbens, A. et al. Robotic assisted extravascular stent placement for nutcracker phenomenon of the left renal vein: a case series. J Robotic Surg 14, 781–788 (2020). https://doi.org/10.1007/s11701-020-01054-x
- Robotic surgical procedures
- Minimally invasive surgery
- Renal nutcracker syndrome