Monocentric Prospective Study to Valid Mutidisciplinary Diagnostic and Therapeutic Approach for Nutcracker Syndrome

Nutcracker Syndrome (NCS) is currently associated with diagnostic difficulties and uncertainties because a well-established procedure is lacking. Our study objective was to clarify the diagnostic and therapeutic criteria of patients with suspected NCS by monocentric prospective observational analysis. Left renal vein (LRV) transposition by mini-invasive robotic surgery (MRS) was carried out following diagnostic confirmation of NCS.

Methods:

All patients referred to the surgery team with suspected NCS were included in the study. Twenty two patients, of which only three were men, with a median age of 35± 14 years were presented with suspected NCS between January 2022 and February 2023. Nineteen had painful left flank or abdominal syndrome, one presented gross haematuria, ten had dyspareunia, five presented dysmenorrhea, six showed pelvic heaviness and two men presented varicocele. Systematic MRI eliminated a putative endometriosis diagnosis. Three patients had endometriosis antecedents and ten had given birth at term at least once. Our approach systematically included phleboscans, dynamic echodoppler and phlebography with occlusion test of the left gonadic vein (LGV). Diagnostic criteria included aorto-mesenteric angle, LGV diameter, LGV reflux, velocity ratios, diameters ratios and reno-caval gradient.

Results:

Fourteen patients presented an aorto-mesenteric angle below 20°, sixteen an LGV diameter above 5 mm with LGV reflux occurring in fifteen of these patients. The ratio of median velocities was 3.07 ± 1.62 m/s. Significant reno-caval gradient ( > 5 mmHg) was found in 6 cases which supported a NCS diagnosis. Overall, seven patients presented neither NCS nor pelvic vein varicosities; 7 had pelvic congestion without NCS and benefitted from embolisation and 8 cases of affirmed NCS underwent LRV transposition in the inferior vena cava by means of MRS with a median intervention time of 254 ± 16 min. Of the latter patients, 7 received complimentary pelvic varicose vein embolism 2 days later. Two months post-surgery, 100% of transposed LRVs were patent following echodoppler controls and all of these patients reported an improvement of their symptoms.

Conclusions:

The current study has allowed a clarification of diagnostic and therapeutic criteria of NCS. This multidisciplinary decisional algorithm permits, for the first time, NCS diagnostic certainty. Thirty six percent of patients initially referred for suspected NCS received diagnostic confirmation leading to appropriate therapeutic intervention. NCS can therefore be treated successfully by radical mini-invasive robotic surgery.