Posterior nut-cracker syndrome: Urologist’s perspective – A mini review

Abstract

Posterior Nut Cracker Syndrome (PCNS) is a rare clinical condition that occurs when the left renal vein gets compressed between the abdominal aorta and vertebral body. Posterior nutcracker phenomenon is a common anatomical abnormality, which is totally asymptomatic and diagnosed in a routinely performed abdominal imaging. The pressure gradient that develops between the renal vein and the inferior vena cava is the basic reason for all the features associated with this condition. Left renal venous entrapment would result in stagnation of blood in gonadal vessels that results in cascading effect resulting in a venous congestion and increased resistance to arterial blood flow in the kidney. Patients with pelvic congestion syndrome present with left loin pain and unilateral left varicocele. Gastrointestinal symptoms and arterial hypertension may also be the presenting symptoms. The symptoms depend upon the degree of pressure in renal veins and gonadal veins. When the dilated veins communicate with renal calyx, haematuria occurs. PNCS is best managed based on the severity of symptoms and the extent of clinical manifestations. Treatment options include conservative treatment, intra-vascular stents, chemical cauterisation, open surgical intervention and finally if everything fails, nephrectomy. PCNS is a rare entity that affects mostly females and can present with a variety of signs and symptoms. A high index of clinical suspicion is needed to achieve a prompt diagnosis. Conservative treatment is recommended for patients with mild symptoms. Severely symptomatic patients might benefit from endovascular treatment.