Gonadal Vein Transposition in the Treatment of Nutcracker Syndrome

Abstract

The favored approach in the management of nutcracker syndrome (NCS) has traditionally been renal vein transposition (RVT), with more recent efforts at endovascular therapies as well. Gonadal vein transposition (GVT) has been infrequently used and chiefly in special circumstances. GVT has the potential to reduce operative complexity and to improve safety of the left renal vein. In this study, we compare the safety and efficacy of GVT and RVT as the operative approach of choice in the treatment of NCS. Six patients who underwent open repair for NCS between January 2008 and March 2016 were identified from the medical record. Primary outcomes were symptom resolution and patency of the reconstruction, and secondary outcomes were the need for reintervention and occurrence of major morbidity. During the study period, four patients underwent repair of NCS by GVT; one patient required renal autotransplantation and one underwent RVT. The patients' mean age was 31 years, their mean body mass index was 24.9 kg/m2, and 83% were female. All presented with symptoms of flank pain. In addition, one-third had varicosities, and half had gross or microscopic hematuria. All patients had evidence of renal vein compression (one posterior, five anterior) and significant pelvic venous congestion on cross-sectional imaging. Average operative times and estimated blood loss for the non-GVT and GVT cohorts were 220 minutes and 108.5 minutes, respectively, and 125 mL and 450 mL, respectively. There were no major perioperative complications, including acute kidney injury, renal failure necessitating dialysis, prolonged ventilation, hemorrhage, or wound infection, among others. During an average follow-up of 572 days, all patients had either clinical (three) or radiographically proven (three) patency as well as complete (four) or partial (two) symptomatic relief, and no patient has required reintervention. In this series, GVT is as effective as RVT in reported series and offers the benefit of shorter operative times, lower blood loss, and avoidance of manipulation of the renal vein.