Renal nutcracker syndrome presenting with varicocele: A case series

Abstract

Introduction and importance: Nutcracker syndrome (NCS) is a rare condition characterized by left renal vein compression and presents with diverse clinical manifestations. This case series study aims to evaluate the clinical presentations and outcomes of patients with NCS and varicocele.

Case presentation: We reviewed the cases of four male patients, aged 15 to 19 years, who presented with recurrent and grade 3 varicocele after varicocelectomy. All patients reported pain in the hypogastric, flank, or groin areas. Despite the absence of hematuria, NCS was diagnosed based on duplex ultrasound and contrast-enhanced computed tomography (CT) scans. Patients underwent open surgical interventions, including gonadal vein transposition or saphenous vein bypass.

Clinical discussion: The absence of hematuria in these cases poses a diagnostic challenge, as current diagnostic criteria for NCS relies on its presence. Our findings underscore the need to consider NCS in patients with varicocele, even in the absence of hematuria. Surgical interventions were effective in resolving the symptoms. After NCS surgery, the varicocele in one patient resolved, and three patients underwent varicocelectomy successfully without recurrence throughout the recovery period.

Conclusion: This case series highlights the diagnosis of NCS presenting with varicocele and local pain without hematuria, emphasizing the need for improved diagnostic and management approaches.

Keywords: Case series; Gonadal vein transposition; Nutcracker syndrome; Saphenous vein bypass; Varicocele.

Fig. 1

Preoperative Computed Tomography scan image of patients with anterior and posterior nutcracker syndrome (NCS). a) Anterior NCS - Axial view showing compression of the left renal vein (LRV) between the abdominal aorta (AA) and the superior mesenteric artery (SMA) (beak sign). b) Anterior NCS - Sagittal view showing the angle between SMA and AA is measured at approximately 19.4°. c) Posterior NCS - Axial view showing compression of LRV between AA and vertebrae body. d) Posterior NCS – Sagittal view.

Fig. 2

Intraoperative photographs. a) Gonadal vein transposition in a patient with anterior nutcracker syndrome. b) Saphenous vein bypass in a patient with posterior nutcracker syndrome. LRV: Left Renal Vein; IVC: Inferior Vena Cava; SMA: Superior Mesenteric Artery.