V05-02 ROBOTIC ASSISTED LAPAROSCOPIC PLACEMENT OF EXTRAVASCULAR STENT FOR NUTCRACKER SYNDROME

Abstract

You have accessJournal of UrologyUpper-Tract Reconstruction (V05)1 Apr 2020V05-02 ROBOTIC ASSISTED LAPAROSCOPIC PLACEMENT OF EXTRAVASCULAR STENT FOR NUTCRACKER SYNDROME Buddima Ranasinghe*, Sohrab Arora, Amit Patel, Judith Lin, and Craig Rogers Buddima Ranasinghe*Buddima Ranasinghe* More articles by this author , Sohrab AroraSohrab Arora More articles by this author , Amit PatelAmit Patel More articles by this author , Judith LinJudith Lin More articles by this author , and Craig RogersCraig Rogers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000874.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Renal nutcracker syndrome (NCS) is a venous entrapment caused by compression of the left renal vein (LRV) between the aorta and superior mesenteric artery (SMA). Surgical options for treatment of NCS include LRV transposition, gonadal vein transposition, renocaval bypass, and renal autotransplantation. Endovascular left renal vein stenting may lead to stent migration and fracture. Thus, we present an alternative, unique, minimally invasive treatment option. METHODS: A 20-year-old man presents with intermittent, debilitating left flank pain for 6 months. He developed an episode of gross hematuria without hypertension, oliguria, dysuria, or fever. CT venogram showed compression of the LRV between the aorta and SMA with an acute, aortomesenteric angle of 25 degrees. Venogram with pressure measurement showed a gradient of 3 mmHg across the compression. Intravascular ultrasound showed 94.4% luminal compression of the LRV. After discussion of all surgical and endovascular options, the patient decided to proceed with robotic-assisted laparoscopic resection of fibrous ring and placement of extravascular graft. The patient was positioned with right lateral decubitus. Six ports were used via transperitoneal technique. After the retroperitoneal space was incised along the inner margin of the descending colon, the LRV was mobilized. The pancreas and the left adrenal vein was identified. Tissue surrounding the left gonadal vein was excised. The fibrous bundles were excised around the outflow end between the aorta and SMA to release the renal vein compression. An externally reinforced, expanded PTFE, 16 mm in diameter, was introduced and bound to the surface of the renal vein along the long axis to prevent blood vessel compression. The PTFE cuff was sutured and tacked to the surface of the aorta and retroperitoneal tissues. SMA was lowered and stabilized over the graft. RESULTS: The operative time was 3 hours. Estimated blood loss of 10 ml. Length of stay was 1 day with no complications. At 4-week postop visit, he was doing well with full resolution of the left flank pain. Post-op intravascular ultrasound showed patent left renal vein with no evidence of elevated flow velocities. Renal vein cuff visualized at SMA with PSV of 67 cm/sec. Left gonadal vein patent with retrograde flow noted. CONCLUSIONS: Robotic-assisted laparoscopic resection of a fibrous ring and placement of an extravascular cuff around the left renal vein is an effective, minimally invasive approach for treatment of nutcracker syndrome with no warm ischemic injury and no venous anastomosis. Magnification and stability of the dual-lens robotic camera offer excellent visibility and substantially lower blood loss compared to open surgery. Source of Funding: NONE © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e470-e470 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Buddima Ranasinghe* More articles by this author Sohrab Arora More articles by this author Amit Patel More articles by this author Judith Lin More articles by this author Craig Rogers More articles by this author Expand All Advertisement PDF downloadLoading ...