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Background@#This study was designed to evaluate the clinical and radiographic outcomes of patients with nutcracker syndrome (NCS) who were treated with three-dimensional printing (3DP) extravascular titanium stents (EVTSs). The 3DP EVTS was expected to release the hypertension of the left renal vein (LRV) produced by its compression between the superior mesenteric artery (SMA) and the aorta without causing any complications.@*Method@#The pre-operative kidney model of each patient was printed out to enable surgical planning. After that, the EVTS was designed based on the LRV’s primitive physiologic structure using computer-aided design software, and each stent was printed out with a precision setting of 20 μm. Seventeen patients who had been suffering from NCS underwent laparoscopic 3DP EVTS placement. The surgical procedure was designed for the placement of EVTS, taking great care in positioning and fixing the stent. Surgical data, which included patient demographic characteristics as well as pre- and post-operative test results, were collected and analyzed.@*Results@#The mean duration of surgery was 75 ± 9 min, and the mean blood loss was 20 ± 5 mL. Computed tomography examinations revealed that the pre- and post-operative angle between the SMA and the aorta ranged from 18.7° ± 4.3° to 48.0° ± 8.8° (P < 0.05); in patients with left varicocele, the mean diameter of the left spermatic vein ranged from 3.7 ± 0.5 to 1.3 ± 0.2 mm (P < 0.05). Moreover, Doppler ultrasound examinations showed that the peak velocity of blood flow at the hilar area ranged from 12.4 ± 3.3 to 18.5 ± 3.4 cm/s (P < 0.05). No side effects were observed in the 24 to 42 months following surgery.@*Conclusion@#The findings after 2 years of follow-up suggest that the 3DP EVTS is a safe and effective minimally invasive alternative for the treatment of NCS.
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Objective To assess the safety and effectiveness of laparoscopic implantation of three-dimensional (3D)-printed extravascular stent for treatment of nutcracker syndrome (NCS).Methods The clinical data of NCS in our hospital were prospectively collected from August 2015 to August 2016.Doppler ultrasound and CT examination were performed before the operation of all the patients who were in line with the diagnostic criteria of NCS.The 3D model of extravascular stents with especial device to prevent migration was designed and was made by 3D metal printer with titanium alloy.The left renal vein(LRV) was exposed completely up to the inferior vena cava,then the stent was placed around the compressed LRV.Results 10 patients were enrolled in the study,including 9 males and 1 females,age (21.5 ±4.6) years.Among these patients,there were 4 cases with severe hematuria,1 case with proteinuria,5 cases with left lumbago,and 5 cases with left severe varicocele.The preoperative doppler ultrasound examination showed the diameter of the the compressed LRV was (1.57 ± 0.25) mm,and flow velocity was (164.40 ± 55.27) cm/s;the diameter of the LRV at the renal hilum was (8.7 ± 1.59) mm,and flow velocity was (10.70 ± 2.21) cm/s.The average operation time was (75 ± 11) min,and the average hospital stay after operation was 7 d.All symptoms were relieved at 3-7 d after operation.All patients were asymptomatic and all stents were stable after follow-up.At 12 months after surgery,the diameter of the LRV at the renal hilum was (8.23 ± 1.90) mm on doppler ultrasound,and there was significant decrease (P ＜ 0.01);the flow velocity was (21.20 ±3.88) cm/s,and there was significant increase (P ＜ 0.01).Conclusions Laparoscopic three-dimensional printed extravascular stent placement is a safe,effective and minimally invasive technique for treatment of NCS.
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Objective To report our experience of retroperitoneal laparoscopic extravascular stent placement for nutcracker syndrome.Methods The clinical data of 12 nutcracker syndrome patients (10 males and 2 females;mean age 26 years) who underwent retroperitoneal laparoscopic extravascular stent placement from March 2014 to Febuary 2016 were retrospectively reviewed.The main symptoms were gross hematuria in 8 patients(one with proteinuria)and flank pain was noted in 1 patient.Three male patients had left-sided secondary varicoceles.Ultrasonography and computed tomography showed the left renal vein clamped by the superior mesenteric artery and the aorta.The anteroposterior diameter of the left renal vein in the renal hilum was three-fold than the aortomesenteric area,and the peak velocity ratio of the aortomesenteric area was much faster than the renal hilum.Twelve patients underwent laparoscopic extravascular stent placement under general anesthesia.The preaortic fibrous tissue between the aorta and the superior mesenteric artery was released intraoperatively.Renal vein became fiat when the superior mesenteric artery was elevated.The 6-8 cm extravascular stent was set on the surface of the renal vein to prevent the compression.Results Stenting was successfully accomplished in all 12 patients.Mean operative time was 62 min (50-125 min),estimated blood loss was 35 ml(20-100 ml),and the hospital stay after operation was 8 days (6-12 days).Three patients had a transient orthostatic intolerance,and they were cured by conservative treatment.With a mean follow up of 14 months (5-30 months),symptoms of hematuria and flank pain resolved in 7/8 and 1/1,respectively.Varicoceles were cured in all three patients.One case got partial relief because of recurrent hematuria due to excessive exercise.Ultrasonography showed that extravascular stent was in the right place,and the angle between abdominal aorta and superior mesenteric artery became normal.The inner diameter of left renal vein was decreased,and the narrow segment was diminished in diameter meanwhile the blood outflow was smooth.Conclusions Retroperitoneal laparoscopic extravascular stent placement in the renal vein is a safe and effective approach for nutcracker syndrome.
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Objective To investigate the Laparoscopic management for Nutcraker Syndrome(NCS) with resection of fibrous ring and placing extravascular stent.Methods This was a retrospective analysis of clinical data and treatment process of cases from March 2010 to February 2015 in urology department,affiliated hospital of Guizhou medical university.Five cases with NCS,4 males and 1 female;age were 28-40 years,mean age was 35 years,all cases were afflicted with gross hematuria and flank pain,the history of gross hematuria were 6-72 months.3 cases were afflicted with proteinuria.Duplex ultrasound scanning before surgery revealed the compressed left renal vein (LRV) between the aorta and the superior mesenteric artery(SMA),with peak velocity 110-132 cm/s,an average of 121 cm/s.The flow velocity of LRV in the renal hilum were 18-25 cm/s,an average of 21 cm/s.CT scanning showed that the stricture segment diameter of LRV were 1.2-2.5 mm,an average of 1.8 mm;and the max diameter of proximal dilatation of the LRV in renal hilum were 8.3-15.2 mm,an average of 10.1 mm.The ratio between the dilated segment inner diameter and the stricture segment were 3.4-9.5.Bleeding from the left ureteral orifice was detected by cystoscopy in 3 cases.5 cases were treated by resection of fibrous ring and placing extravascular stent with Laparoscopic management,and the average length of extravascular stent was 4.0 cm.Results The operation was successful in the 5 cases.The average operation time was 83 min.The average blood loss was 65 ml.Hematuria gradually reduce 5-6 days and resolved 7-20 days after surgery in 5 patients.Proteinuria was disappeared successful 2 weeks after surgery in 3 patients.There was no recurrence at 8-24 months' follow-up.3 days after surgery Doppler ultrasound showed the stricture segment diameter of LRV were 3.8-5.6 mm,an average of 4.9 mm;the ratio between the dilated segment inner diameter and the stricture segment decreased were 1.1-2.0,an average of 1.6;the peak velocity of compressed LRV were 25-45 cm/s,an average of 34 cm/s.6 months after surgery,CTA result showed no LRV compression in the aortomesenteric region;the max diameter of LRV in renal hilum were 7.9-9.8 mm and 6.0-8.8 mm in the aortomesenteric region of LRV.Conclusion Etiology of NCS exist a fibrous ring around the left renal vein outflow of the inferior vena cava besides the commonly anatomic extrinsic compression on the LRV as it crosses between the superior mesenteric artery and the aorta.The Laparoscopic management for NCS with resection of fibrous ring and placing extravascular stent is an effective minimally invasive treatment.
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ObjectiveTo investigate the surgical management of left renal vein entrapment syndrome.MethodsEight cases with left renal vein entrapment syndrome (5 males and 3 female ; mean age 26 years) with history of gross hematuria for 3 to 46 months were reviewed.Doppler ultrasound reports suggested compression of the left renal vein at mesenteric angle in all cases.And the dilated segment of the left vein was three-fold than the stricture segment in diameter.CT scan showed the abnormal angle between aorta and superior mesentery artery in all cases.Bleeding from the left ureteral orifice was detected by cystoscopy in 6 cases.We treated 8 patients by extravascular stent immobilization with laparoscope.ResultsThe operation was successful in the 8 cases without surgical complications.The average operation time was 63 min.The average blood loss was 14 ml,and the average hospital stay after operation was 6 days.Follow-up of 3 -20 months,there was no hematuria relapse since been relieved in 7 cases,one case remained microscopic hematuria.Color Doppler ultrasound examination in all 8 cases showed the narrowest inner diameter of left renal vein was 7.4 mm (6.5 - 8.7 mm),the blood flow was smooth.The angle between abdominal aorta and superior mesenteric artery become normal.Conclusions Laparoscopic left renal vein extravascular stenting could be a new surgical method to treat left renal vein entrapment syndrome.The method of putting artificial blood vessel around renal vein is simple,safe and effective.