Original Paper
Urologia Internationalis
Received: March 4, 2014 Accepted after revision: March 24, 2014 Published online: August 14, 2014
Urol Int DOI: 10.1159/000362423
Retroperitoneal Laparoscopic Reimplantation of the Left Renal Vein for Nutcracker Syndrome Pengfei Shao Pu Li Xiaobing Ju Chao Qin Changjun Yin Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
Abstract Objective: To describe the feasibility of retroperitoneal laparoscopic reimplantation of the left renal vein (LRV) for nutcracker syndrome (NCS). Patients and Methods: Two patients with NCS underwent the surgery. Both patients complained of gross hematuria and flank discomfort that could not be relieved by resting. They were placed in a supine position and 5 ports were placed in the right abdominal wall. The procedures were performed with a retroperitoneal approach. The LRV was transected and then reimplanted into the distal inferior vena cava. Results: The procedures were performed successfully without any major complications. The total operation time was 105 and 120 min, respectively. Hematuria and flank discomfort were resolved after the surgery. Ultrasonography revealed a patent lumen without compression. Conclusions: Retroperitoneal laparoscopic reimplantation of the LRV appears to be a feasible procedure with satisfactory short-term outcomes. © 2014 S. Karger AG, Basel
Introduction
Nutcracker syndrome (NCS) results from the compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery (SMA). The most common symptoms associated with NCS include hematuria, left-flank pain, varicocele in males, and pelvic congestion syndrome in females [1]. Surgical intervention is recommended for patients exhibiting severe symptoms [1]. Various surgical procedures have been described such as endovascular stenting [2], external stenting of the LRV [3], splenorenal venous bypass [4], inferior mesenteric-gonadal vein bypass [5] and transposition of the SMA [6] or LRV [1, 7]. Among these procedures, reimplantation of the LRV into the distal inferior vena cava (IVC) is considered to be the gold standard method to treat NCS [8]. The majority of conventional procedures for correcting NCS are performed via open surgery. This case series describes the novel approach of retroperitoneal laparoscopic surgery for the reimplantation of the LRV in NCS.
P. Shao and P. Li contributed equally to this work.
© 2014 S. Karger AG, Basel 0042–1138/14/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/uin
Changjun Yin Department of Urology The First Affiliated Hospital of Nanjing Medical University 300 Guangzhou Road, Nanjing 210029 (PR China) E-Mail changjunyin @ hotmail.com
Downloaded by: St. Andrews University 138.251.14.35 - 11/26/2014 11:54:30 AM
Key Words Hematuria · Laparoscopy · Kidney · Renal vein · Reconstruction · Retroperitoneoscopy
Color version available online
Fig. 1. CT and CTA revealed the compres-
R E
Color version available online
Midaxillary line
Anterior axillary line
sion of the LRV between the aorta and the SMA.
12 mm 5 mm
D
C
A
B
Iliac crest
Fig. 2. Distribution of the 5 laparoscopic
Patients and Methods Two patients diagnosed with NCS were admitted to our department. One was a 22-year-old female (BMI 21.6), who had presented with consistent gross hematuria and left-flank discomfort for 4 years. The other was a 34-year-old male (BMI 22.4), who had presented with intermittent gross hematuria and lumbar discomfort for 2 years. Symptoms were not relieved by resting in either patients. Cystoscopic examination revealed hematuria originating from the left ureteric orifice. Computed tomographic angiography (CTA) revealed marked compression of the LRV at the point where it crossed the aorta (fig. 1). Reconstructed CTA revealed an aortomesenteric angle of 12 and 15°, respectively. Ultrasonography demonstrated that the diameter ratio between the anteroaortic LRV and hilar LRV was 3: 1 and 4: 1, respectively. The diagnosis of NCS was confirmed after all other possible causes of hematuria were excluded, and laparoscopic correction of NCS was planned. Both patients were placed in a supine position at an elevation of 30° on the right side. The first port (A, 10 mm) of the laparoscope was placed 2 cm above the right iliac crest of the anterior
2
Urol Int DOI: 10.1159/000362423
axillary line. The extraperitoneal space was penetrated by dissecting the muscular tissue through the incision. A balloon was then inserted to insufflate 800 ml of gas to create a working space. Four more ports were created, using the fingers. For the surgeon, ports B (12 mm) and C (12 mm) were placed at the right pararectalis line above the iliac crest and the right midaxillary line 3 cm above the iliac crest, respectively. For the assistant, ports D (12 mm) and E (5 mm) were placed 8 cm above port A in the anterior axillary line and 4 cm above port C, respectively (fig. 2). The retroperitoneal space was insufflated with CO2 at a pressure of 15 mm Hg. Gerota’s fascia was incised and the peritoneum was pushed anteriorly. Dissection proceeded along the psoas muscle to the front of the IVC and the aorta. The IVC was isolated circumferentially with a 2-cm suprarenal segment and 8-cm infrarenal segment. For this procedure, pairs of lumbar veins were clipped and transected to facilitate clamping. The right renal vein and LRV were fully exposed, and the LRV was isolated distally across the aorta to expose the adrenal vein and the left gonadal vein (GV). The LRV was noted to be compressed in the aortomesenteric space (fig. 3a). The distal IVC was then clamped 6 cm below the LRV with a tourniquet, the LRV was clamped proximal to the adre-
Shao/Li/Ju/Qin/Yin
Downloaded by: St. Andrews University 138.251.14.35 - 11/26/2014 11:54:30 AM
ports and postoperative incisions on the patients. A was for the camera, B and C for the surgeon and D and E for the assistant.
Color version available online
a
b
c
d
of retroperitoneal space and mobilization of the retroperitoneal vessels. b Clamping of the distal IVC using the tourniquet, and of the proximal IVC, LRV and GV using bulldog clamps. The reflux
nal vein by using bulldog clamps and the GV was also clamped. The proximal IVC was obliquely clamped using bulldog clamps from the lateral infrarenal side to the medial suprarenal side to protect the reflux of the right kidney (fig. 3b). The LRV was transected with a small cuff of the IVC, and the incision was sutured with 3–0 Prolene running sutures (fig. 3c). A new opening was created on the IVC with a size matched to the transected LRV 2 cm below the original position. The LRV and IVC were anastomosed with 3–0 Prolene running sutures (fig. 3d). The tourniquet and the bulldog clamps were unclamped with no observed leakage.
Results
Information about the patients and surgical outcomes are presented in table 1. The total operation time was 105 and 120 min, respectively. The LRV clamped time and IVC clamped time were 51 and 52 min in patient 1, and 55 and 56 min in patient 2, respectively. The anastomotic time was 31 and 35 min, respectively. The estimated blood loss was 50 and 120 ml, respectively. No major inRenal Vein Reimplantation for Nutcracker Syndrome
of the right renal vein is not affected. c Reimplantation of the LRV into the distal IVC with running sutures. d Transection of the LRV and repair of the IVC with running sutures.
Table 1. Patient demographic and outcomes data
Characteristics
Patient 1
Patient 2
Patient age, years BMI Aortomesenteric angle on CTA, degrees Total operation time, min LRV clamped time, min IVC clamped time, min Anastomotic time, min EBL, ml Preoperative SCr, μmol/l Postoperative SCr, μmol/l Complications, n Length of stay (postoperative), days Follow-up, months
22 21.6 12 105 51 52 31 50 48 55 0 3 10
34 22.4 15 120 55 56 35 120 67 89 0 3 6
EBL = Estimated blood loss; SCr = serum creatinine.
Urol Int DOI: 10.1159/000362423
3
Downloaded by: St. Andrews University 138.251.14.35 - 11/26/2014 11:54:30 AM
Fig. 3. Surgical procedure of LRV reimplantation. a Establishment
Discussion
The first case of laparoscopic transposition of the LRV for NCS was reported by Hartung et al. [8] in 2010 and was performed via a transperitoneal approach from the left side. In our study, a retroperitoneal approach from the right side was used to complete the laparoscopic procedure. This approach has been used previously in retroperitoneal lymph-node dissection for nonseminomatous germ-cell tumors, and its feasibility and efficacy for extensive lymphadenectomy have been demonstrated [9, 10]. It provides direct access to the IVC and its confluent branches, including the renal veins, lumbar veins and GV. Retroperitoneoscopy involves less interference with the visceral organs and decreases the risk of injury when compared to the transperitoneal approach [9]. It is also less invasive and allows for faster recovery than conventional open surgery. In our case series, the patients resumed a normal diet and activities 1 day after the operation. They were discharged at 3 days, with no flank or incision pain. As there is no natural space for the retroperitoneal surgery, dissection in an extensive retroperitoneal template is essential to provide good exposure and sufficient working space. Insufficient dissection and exposure decrease surgical efficiency and potentially increase the risk of adjacent injury during the laparoscopic procedure. Several key factors influence successful manipulation. The first is the well-designed distribution of instrument ports. The port distribution in our series was modified, based on our previous experience with retroperitoneal lymphadenectomy for a testicular tumor [9]. The second issue is the preservation of the integrity of the peritoneum throughout the procedure. A fan-shaped laparoscopic retractor assisted peritoneal exposure. The third factor is the patient’s position; the supine position with the left side elevated at 30° for an approach from the right side provided a large space and optimal visualization for successful venous anastomosis. 4
Urol Int DOI: 10.1159/000362423
No definite distance has been reported for the translocation of the LRV from the original position in NCS. In this study, the LRV was moved downward by approximately 2 cm from the transected site, keeping in mind the following considerations: (1) the translocation should ensure a tension-free anastomosis and (2) translocation should relieve the compression from the aortomesenteric space to the maximum possible extent. To meet these criteria, the transected LRV needs to be manipulated to a suitable position on to the IVC for reimplantation. To minimize the risk of complications, it is essential to ensure accurate orientation in the retroperitoneal space, along with careful manipulation of the vessels. The IVC and the psoas muscle orientate a proper dissection plane, avoiding peritoneum injury. The anterior side of the right kidney should be dissected to facilitate the establishment of retroperitoneal space. In our procedures, the proximal IVC was obliquely clamped using bulldog clamps to protect against a reflux from the right renal vein. No hemodynamic instability occurred in our series. The LRV was compressed for a long period before the operation in both patients, so the reflux of the LRV could be compensated by the established collateral circulation, including that via the adrenal and GV, which prevented a decrease in left renal function when the LRV was clamped.
Conclusion
Retroperitoneal laparoscopic reimplantation of the LRV provided minimal invasion, rapid recovery and satisfactory short-term results for NCS. We therefore consider this procedure to be a promising alternative treatment for NCS.
References
1 Reed NR, Kalra M, Bower TC, Vrtiska TJ, Ricotta JJ 2nd, Gloviczki P: Left renal vein transposition for nutcracker syndrome. J Vasc Surg 2009;49:386–393. 2 Chen S, Zhang H, Shi H, Tian L, Jin W, Li M: Endovascular stenting for treatment of nutcracker syndrome: report of 61 cases with long-term follow-up. J Urol 2011; 186: 570– 575. 3 Barnes RW, Fleisher HL III, Redman JF, Smith JW, Harshfield DL, Ferris EJ: Mesoaortic compression of the left renal vein (the socalled nutcracker syndrome): repair by a new stenting procedure. J Vasc Surg 1988; 8: 415– 421.
Shao/Li/Ju/Qin/Yin
Downloaded by: St. Andrews University 138.251.14.35 - 11/26/2014 11:54:30 AM
traoperative or postoperative complications were encountered. Both patients were discharged 3 days postoperatively and followed up for 10 and 6 months, respectively. Both the hematuria and the left-flank discomfort had resolved postoperatively. There was no recurrence during the follow-up period. Postoperative ultrasonography revealed a patent lumen of the LRV without signs of compression.
Renal Vein Reimplantation for Nutcracker Syndrome
7 Hohenfellner M, D’Elia G, Hampel C, Dahms S, Thuroff JW: Transposition of the left renal vein for treatment of the nutcracker phenomenon: long-term follow-up. Urology 2002;59: 354–357. 8 Hartung O, Azghari A, Barthelemy P, Boufi M, Alimi YS: Laparoscopic transposition of the left renal vein into the inferior vena cava for nutcracker syndrome. J Vasc Surg 2010; 52:738–741.
Urol Int DOI: 10.1159/000362423
9 Qin C, Shao P, Meng X, Li P, Cao Q, Lv Q, et al: Extraperitoneal laparoscopic retroperitoneal lymph node dissection for early-stage testicular nonseminomatous germ cell tumors: initial experience. J Endourol 2012; 26: 1203–1209. 10 Rassweiler JJ, Frede T, Lenz E, Seemann O, Alken P: Long-term experience with laparoscopic retroperitoneal lymph node dissection in the management of low-stage testis cancer. Eur Urol 2000;37:251–260.
5
Downloaded by: St. Andrews University 138.251.14.35 - 11/26/2014 11:54:30 AM
4 Chung BI, Gill IS: Laparoscopic splenorenal venous bypass for nutcracker syndrome. J Vasc Surg 2009;49:1319–1323. 5 Xu D, Gao Y, Chen J, Wang J, Ye J, Liu Y: Laparoscopic inferior mesenteric-gonadal vein bypass for the treatment of nutcracker syndrome. J Vasc Surg 2013;57:1429–1431. 6 Thompson PN, Darling RC III, Chang BB, Shah DM, Leather RP: A case of nutcracker syndrome: treatment by mesoaortic transposition. J Vasc Surg 1992;16:663–665.
Urologia Internationalis
Received: March 4, 2014 Accepted after revision: March 24, 2014 Published online: August 14, 2014
Urol Int DOI: 10.1159/000362423
Retroperitoneal Laparoscopic Reimplantation of the Left Renal Vein for Nutcracker Syndrome Pengfei Shao Pu Li Xiaobing Ju Chao Qin Changjun Yin Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
Abstract Objective: To describe the feasibility of retroperitoneal laparoscopic reimplantation of the left renal vein (LRV) for nutcracker syndrome (NCS). Patients and Methods: Two patients with NCS underwent the surgery. Both patients complained of gross hematuria and flank discomfort that could not be relieved by resting. They were placed in a supine position and 5 ports were placed in the right abdominal wall. The procedures were performed with a retroperitoneal approach. The LRV was transected and then reimplanted into the distal inferior vena cava. Results: The procedures were performed successfully without any major complications. The total operation time was 105 and 120 min, respectively. Hematuria and flank discomfort were resolved after the surgery. Ultrasonography revealed a patent lumen without compression. Conclusions: Retroperitoneal laparoscopic reimplantation of the LRV appears to be a feasible procedure with satisfactory short-term outcomes. © 2014 S. Karger AG, Basel
Introduction
Nutcracker syndrome (NCS) results from the compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery (SMA). The most common symptoms associated with NCS include hematuria, left-flank pain, varicocele in males, and pelvic congestion syndrome in females [1]. Surgical intervention is recommended for patients exhibiting severe symptoms [1]. Various surgical procedures have been described such as endovascular stenting [2], external stenting of the LRV [3], splenorenal venous bypass [4], inferior mesenteric-gonadal vein bypass [5] and transposition of the SMA [6] or LRV [1, 7]. Among these procedures, reimplantation of the LRV into the distal inferior vena cava (IVC) is considered to be the gold standard method to treat NCS [8]. The majority of conventional procedures for correcting NCS are performed via open surgery. This case series describes the novel approach of retroperitoneal laparoscopic surgery for the reimplantation of the LRV in NCS.
P. Shao and P. Li contributed equally to this work.
© 2014 S. Karger AG, Basel 0042–1138/14/0000–0000$39.50/0 E-Mail [email protected] www.karger.com/uin
Changjun Yin Department of Urology The First Affiliated Hospital of Nanjing Medical University 300 Guangzhou Road, Nanjing 210029 (PR China) E-Mail changjunyin @ hotmail.com
Downloaded by: St. Andrews University 138.251.14.35 - 11/26/2014 11:54:30 AM
Key Words Hematuria · Laparoscopy · Kidney · Renal vein · Reconstruction · Retroperitoneoscopy
Color version available online
Fig. 1. CT and CTA revealed the compres-
R E
Color version available online
Midaxillary line
Anterior axillary line
sion of the LRV between the aorta and the SMA.
12 mm 5 mm
D
C
A
B
Iliac crest
Fig. 2. Distribution of the 5 laparoscopic
Patients and Methods Two patients diagnosed with NCS were admitted to our department. One was a 22-year-old female (BMI 21.6), who had presented with consistent gross hematuria and left-flank discomfort for 4 years. The other was a 34-year-old male (BMI 22.4), who had presented with intermittent gross hematuria and lumbar discomfort for 2 years. Symptoms were not relieved by resting in either patients. Cystoscopic examination revealed hematuria originating from the left ureteric orifice. Computed tomographic angiography (CTA) revealed marked compression of the LRV at the point where it crossed the aorta (fig. 1). Reconstructed CTA revealed an aortomesenteric angle of 12 and 15°, respectively. Ultrasonography demonstrated that the diameter ratio between the anteroaortic LRV and hilar LRV was 3: 1 and 4: 1, respectively. The diagnosis of NCS was confirmed after all other possible causes of hematuria were excluded, and laparoscopic correction of NCS was planned. Both patients were placed in a supine position at an elevation of 30° on the right side. The first port (A, 10 mm) of the laparoscope was placed 2 cm above the right iliac crest of the anterior
2
Urol Int DOI: 10.1159/000362423
axillary line. The extraperitoneal space was penetrated by dissecting the muscular tissue through the incision. A balloon was then inserted to insufflate 800 ml of gas to create a working space. Four more ports were created, using the fingers. For the surgeon, ports B (12 mm) and C (12 mm) were placed at the right pararectalis line above the iliac crest and the right midaxillary line 3 cm above the iliac crest, respectively. For the assistant, ports D (12 mm) and E (5 mm) were placed 8 cm above port A in the anterior axillary line and 4 cm above port C, respectively (fig. 2). The retroperitoneal space was insufflated with CO2 at a pressure of 15 mm Hg. Gerota’s fascia was incised and the peritoneum was pushed anteriorly. Dissection proceeded along the psoas muscle to the front of the IVC and the aorta. The IVC was isolated circumferentially with a 2-cm suprarenal segment and 8-cm infrarenal segment. For this procedure, pairs of lumbar veins were clipped and transected to facilitate clamping. The right renal vein and LRV were fully exposed, and the LRV was isolated distally across the aorta to expose the adrenal vein and the left gonadal vein (GV). The LRV was noted to be compressed in the aortomesenteric space (fig. 3a). The distal IVC was then clamped 6 cm below the LRV with a tourniquet, the LRV was clamped proximal to the adre-
Shao/Li/Ju/Qin/Yin
Downloaded by: St. Andrews University 138.251.14.35 - 11/26/2014 11:54:30 AM
ports and postoperative incisions on the patients. A was for the camera, B and C for the surgeon and D and E for the assistant.
Color version available online
a
b
c
d
of retroperitoneal space and mobilization of the retroperitoneal vessels. b Clamping of the distal IVC using the tourniquet, and of the proximal IVC, LRV and GV using bulldog clamps. The reflux
nal vein by using bulldog clamps and the GV was also clamped. The proximal IVC was obliquely clamped using bulldog clamps from the lateral infrarenal side to the medial suprarenal side to protect the reflux of the right kidney (fig. 3b). The LRV was transected with a small cuff of the IVC, and the incision was sutured with 3–0 Prolene running sutures (fig. 3c). A new opening was created on the IVC with a size matched to the transected LRV 2 cm below the original position. The LRV and IVC were anastomosed with 3–0 Prolene running sutures (fig. 3d). The tourniquet and the bulldog clamps were unclamped with no observed leakage.
Results
Information about the patients and surgical outcomes are presented in table 1. The total operation time was 105 and 120 min, respectively. The LRV clamped time and IVC clamped time were 51 and 52 min in patient 1, and 55 and 56 min in patient 2, respectively. The anastomotic time was 31 and 35 min, respectively. The estimated blood loss was 50 and 120 ml, respectively. No major inRenal Vein Reimplantation for Nutcracker Syndrome
of the right renal vein is not affected. c Reimplantation of the LRV into the distal IVC with running sutures. d Transection of the LRV and repair of the IVC with running sutures.
Table 1. Patient demographic and outcomes data
Characteristics
Patient 1
Patient 2
Patient age, years BMI Aortomesenteric angle on CTA, degrees Total operation time, min LRV clamped time, min IVC clamped time, min Anastomotic time, min EBL, ml Preoperative SCr, μmol/l Postoperative SCr, μmol/l Complications, n Length of stay (postoperative), days Follow-up, months
22 21.6 12 105 51 52 31 50 48 55 0 3 10
34 22.4 15 120 55 56 35 120 67 89 0 3 6
EBL = Estimated blood loss; SCr = serum creatinine.
Urol Int DOI: 10.1159/000362423
3
Downloaded by: St. Andrews University 138.251.14.35 - 11/26/2014 11:54:30 AM
Fig. 3. Surgical procedure of LRV reimplantation. a Establishment
Discussion
The first case of laparoscopic transposition of the LRV for NCS was reported by Hartung et al. [8] in 2010 and was performed via a transperitoneal approach from the left side. In our study, a retroperitoneal approach from the right side was used to complete the laparoscopic procedure. This approach has been used previously in retroperitoneal lymph-node dissection for nonseminomatous germ-cell tumors, and its feasibility and efficacy for extensive lymphadenectomy have been demonstrated [9, 10]. It provides direct access to the IVC and its confluent branches, including the renal veins, lumbar veins and GV. Retroperitoneoscopy involves less interference with the visceral organs and decreases the risk of injury when compared to the transperitoneal approach [9]. It is also less invasive and allows for faster recovery than conventional open surgery. In our case series, the patients resumed a normal diet and activities 1 day after the operation. They were discharged at 3 days, with no flank or incision pain. As there is no natural space for the retroperitoneal surgery, dissection in an extensive retroperitoneal template is essential to provide good exposure and sufficient working space. Insufficient dissection and exposure decrease surgical efficiency and potentially increase the risk of adjacent injury during the laparoscopic procedure. Several key factors influence successful manipulation. The first is the well-designed distribution of instrument ports. The port distribution in our series was modified, based on our previous experience with retroperitoneal lymphadenectomy for a testicular tumor [9]. The second issue is the preservation of the integrity of the peritoneum throughout the procedure. A fan-shaped laparoscopic retractor assisted peritoneal exposure. The third factor is the patient’s position; the supine position with the left side elevated at 30° for an approach from the right side provided a large space and optimal visualization for successful venous anastomosis. 4
Urol Int DOI: 10.1159/000362423
No definite distance has been reported for the translocation of the LRV from the original position in NCS. In this study, the LRV was moved downward by approximately 2 cm from the transected site, keeping in mind the following considerations: (1) the translocation should ensure a tension-free anastomosis and (2) translocation should relieve the compression from the aortomesenteric space to the maximum possible extent. To meet these criteria, the transected LRV needs to be manipulated to a suitable position on to the IVC for reimplantation. To minimize the risk of complications, it is essential to ensure accurate orientation in the retroperitoneal space, along with careful manipulation of the vessels. The IVC and the psoas muscle orientate a proper dissection plane, avoiding peritoneum injury. The anterior side of the right kidney should be dissected to facilitate the establishment of retroperitoneal space. In our procedures, the proximal IVC was obliquely clamped using bulldog clamps to protect against a reflux from the right renal vein. No hemodynamic instability occurred in our series. The LRV was compressed for a long period before the operation in both patients, so the reflux of the LRV could be compensated by the established collateral circulation, including that via the adrenal and GV, which prevented a decrease in left renal function when the LRV was clamped.
Conclusion
Retroperitoneal laparoscopic reimplantation of the LRV provided minimal invasion, rapid recovery and satisfactory short-term results for NCS. We therefore consider this procedure to be a promising alternative treatment for NCS.
References
1 Reed NR, Kalra M, Bower TC, Vrtiska TJ, Ricotta JJ 2nd, Gloviczki P: Left renal vein transposition for nutcracker syndrome. J Vasc Surg 2009;49:386–393. 2 Chen S, Zhang H, Shi H, Tian L, Jin W, Li M: Endovascular stenting for treatment of nutcracker syndrome: report of 61 cases with long-term follow-up. J Urol 2011; 186: 570– 575. 3 Barnes RW, Fleisher HL III, Redman JF, Smith JW, Harshfield DL, Ferris EJ: Mesoaortic compression of the left renal vein (the socalled nutcracker syndrome): repair by a new stenting procedure. J Vasc Surg 1988; 8: 415– 421.
Shao/Li/Ju/Qin/Yin
Downloaded by: St. Andrews University 138.251.14.35 - 11/26/2014 11:54:30 AM
traoperative or postoperative complications were encountered. Both patients were discharged 3 days postoperatively and followed up for 10 and 6 months, respectively. Both the hematuria and the left-flank discomfort had resolved postoperatively. There was no recurrence during the follow-up period. Postoperative ultrasonography revealed a patent lumen of the LRV without signs of compression.
Renal Vein Reimplantation for Nutcracker Syndrome
7 Hohenfellner M, D’Elia G, Hampel C, Dahms S, Thuroff JW: Transposition of the left renal vein for treatment of the nutcracker phenomenon: long-term follow-up. Urology 2002;59: 354–357. 8 Hartung O, Azghari A, Barthelemy P, Boufi M, Alimi YS: Laparoscopic transposition of the left renal vein into the inferior vena cava for nutcracker syndrome. J Vasc Surg 2010; 52:738–741.
Urol Int DOI: 10.1159/000362423
9 Qin C, Shao P, Meng X, Li P, Cao Q, Lv Q, et al: Extraperitoneal laparoscopic retroperitoneal lymph node dissection for early-stage testicular nonseminomatous germ cell tumors: initial experience. J Endourol 2012; 26: 1203–1209. 10 Rassweiler JJ, Frede T, Lenz E, Seemann O, Alken P: Long-term experience with laparoscopic retroperitoneal lymph node dissection in the management of low-stage testis cancer. Eur Urol 2000;37:251–260.
5
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4 Chung BI, Gill IS: Laparoscopic splenorenal venous bypass for nutcracker syndrome. J Vasc Surg 2009;49:1319–1323. 5 Xu D, Gao Y, Chen J, Wang J, Ye J, Liu Y: Laparoscopic inferior mesenteric-gonadal vein bypass for the treatment of nutcracker syndrome. J Vasc Surg 2013;57:1429–1431. 6 Thompson PN, Darling RC III, Chang BB, Shah DM, Leather RP: A case of nutcracker syndrome: treatment by mesoaortic transposition. J Vasc Surg 1992;16:663–665.
