The nutcracker syndrome: Its role in the pelvic venous disorders

Background: Symptoms of pelvic venous congestion (chronic pelvic pain, dysp areunia, dysuria, and dysmenorrhea) have been attributed to massive gonadal reflux. However, obstruction of the gonadal outflow may produce similar sy mptoms. Mesoaortic compression of the left renal vein (nutcracker syndrome) produces both obstruction and reflux, resulting in symptoms of pelvic cong estion. We describe the diagnosis and management of nine patients studied i n our institutions. Materials and Methods. From a group of 51 female patients with pelvic conge stion symptoms studied at our institutions, there were nine patients with s ymptoms of pelvic congestion, microscopic hematuria, and left-sided flank p ain. The diagnosis of the nutcracker syndrome was suspected based on clinic al examination, Doppler scan, duplex ultrasound scan, computed tomography s can, and magnetic resonance imaging. The diagnosis was confirmed by retrogr ade cine-video-angiography with renocaval gradient determination and cathet erization of both internal iliac venous systems. All patients had a renocav al pressure gradient >4 mm Hg (normal, 0-1 nun Hg), Renal compression was r elieved by external stent (ES) in two patients, internal stent (IS) in one patient, and gonadocaval bypass (GCB) in three. GCB was preceded by coil em bolization of internal iliac vein tributaries connecting with lower-extremi ty varicose veins in three patients. Three patients deferred surgery and ar e under observation. Mean follow-up time was 36 months (range, 12-72 months ). Results: Hematuria disappeared postoperatively in all patients. ES and IS n ormalized the renocaval gradient and resulted in significant alleviation of symptoms (90% improvement on a scale of 0-10 where 0 = no improvement and 10 = greatest improvement). Two patients with GCB had a residual gradient o f 3 nun Hg. The third patient normalized the gradient. In this group, impro vement of symptoms was 60%. Patients awaiting surgery are being treated con servatively (elastic stockings, hormones, and pelvic compression). They hav e shown only moderate improvement. Conclusion: The nutcracker syndrome should be considered in women with symp toms of pelvic venous congestion and hematuria. The diagnosis is suspected by compression of the left renal vein on magnetic resonance imaging or comp uted tomography scan and confirmed by retrograde cine-video-angiography wit h determination of die renocaval gradient. Internal and external renal sten ting as well as gonadocaval bypass are effective methods of treatment of th e nutcracker syndrome. IS and ES were accompanied by better results than GC B. Surgical and radiologic interventional methods should be guided by the c linical, radiologic, and hemodynamic findings.