Diagnosis And Treatment Of The Nutcracker Phenomenon: 20 Cases Report

INTRODUCION&OBJECTIVES: In patients with a nutcracker syndrome the left renal vein is compressed between the aorta and superior mesenteric artery. The consecutively increased venous pressure within the renal circulation can promote hematuria and flank or abdominal pain. For this condition we evaluated the diagnosis and therapeutical methods of the nutcracker syndrome.MATERIALS&METHODS: 20 patients {13 males, 7 females} aged between 8-54 years old {mean age 19.8 years old} underwent different diagnostic methods and treatment associated with recurrent hematuria and flank pain. Phase contrast microscopy revealed isomorphic RBCs in all patients. IVU were free. Urethrocystoscopy localized the hematuria to the left side, coagulation profile and renal biopsy showed no abnormalities. B ultrasonic , CT, MRI and left renal venography were performed, and found compression of the left renal vein. 15 patients of them, who were under 18-year-old, received conservative treatment. Five patients receivedsurgical intervention, because they did not relieved, though they have received conservative therapy more than 2 years. And 3 patients of them received transposition of the superior mesenteric artery, and 2 patients of them received stent embedded. Postoperative follow-up was 6-48 months {mean 25.6 months}.RESULTS: Through the CT, MRI, ultrasonography and angiography the mean angle between the aorta and superior mesenteric artery were more narrow and the distance between the superior mesenteric artery and aorta were stricture. The 15 patients, received conservative therapy, much relieved during the follow-up. The 3 patient, who got transposition of the superior mesenteric artery, efficiently relieved symptoms related to the nutcracker phenomenon, while 2 of them encountered with retroperitoneal hematoma necessitating surgical revision. 2 patients with the stent implantation got much relieved without perioperative complications.CONCLUSION: Phase contrast microscopy, Urethrocystoscopy, ultrasonography, CT, MRI, angiography and left renal venography are valuable in diagnosis of nutcracker syndrome. Conservative treatment is effective to the patients of nutcracker syndrome, and will be first considered in the children. Transposition of the superior mesenteric arteryis a effective therapeutic method to the nutcracker syndrome, and has many complications. Expendable metallic stent placement is a effective way to treat the nutcracker syndrome and has a bright future.