Different treatment options have been proposed for this syndrome, including follow-up, conservative treatment and surgical therapy [1, 9, 10]. The common viewpoint for management should be based on the age of the patient at the onset of the disease . For patients under 18-years-old, follow-ups and conservative treatment are recommended until collateral circulation establishment or a superior mesenteric artery augmentation is achieved to palliate the compression of the left renal vein between the AO and SMA. If for two years after the conservative treatment, the symptoms persist or complications such as anemia, loin pain, varicocele and functional lesion in the renal vein appear, surgical procedures are reasonable. However, for adults 18-years-old and above, only after a six-month medical treatment and after nutcracker syndrome is diagnosed can surgical procedures be recommended.
The available surgical procedures include intra- or extravascular stents and open surgical procedures. Expandable metallic stents were first reported by Neste et al. Now, a variety of stents can be deployed in the narrow portion of the left renal vein, such as intravascular stenting treatment for nutcracker syndrome [12–14]. Intravascular stenting is a simple, micro-invasive, repetition management procedure. Its shortcomings include venous occlusion caused by fibromuscular hyperplasia, proximal migration or embolization of the stents, and the need for anticoagulation medication . Extravascular stenting using a ring-reinforced Polytetrafiuoroethylene (PTFE) graft by open or laparoscopic surgery was tested in sporadic cases .
Open surgical procedures employed to rectify the problem include the transposition of left renal vein , transposition of the superior mesenteric artery , renal autotransplantation  and gonadocaval bypass . The transposition of the left renal vein is an efficient and less complex surgical approach to treat anterior nutcracker syndrome. Left renal vein transposition involves dividing the left renal vein at its junction with the inferior vena cava. It also involves the repair of the vena cava defect and the re-anastomosis of the left renal vein to the inferior vena cava at a lower level away from the superior mesenteric artery. A transposition of the superior mesenteric artery is based on similar surgical principles, but is more difficulty compared to a left renal vein transposition. Vessel transpositions involve risks that include bleeding, thrombosis and a paralytic ileus . A thrombosis of the superior mesenteric arterial would be disastrous for patients undergoing this operation.
Renal autotransplantation has been used in the management of renal vessel trauma, thrombosis, stenosis, and aneurysms. It has also been advocated for ureteral avulsion, urothelial malignancy, renal calculus disease, renal tumor, renal trauma, retroperitoneal fibrosis, and nutcracker syndrome . Recent developments in micro-invasive surgery have made laparoscopic donor nephrectomy a more attractive technique option . Currently, despite the increasing number of case reports describing such scenarios, the repair of nutcracker syndrome in patients through laparoscopic donor nephrectomy and autotransplantation is not well-described in the literature.
Laparoscopic donor nephrectomy was first carried out in 1995. In less than a decade, most centers adopted laparoscopic surgery. The conventional open approach to autotransplantation requires either a large, single, midline incision from the xiphoid process to the pubic symphysis or two separate incisions: one flank incision to procure the kidney, and another in the iliac fossa for transplantation. There is no doubt that this represents a considerable disincentive to potential donors. Compared to the open approach [23, 24], laparoscopic nephrectomy and autotransplantation are feasible and minimally invasive alternatives. This approach avoids the need for an extended abdominal or flank incision, resulting in less postoperative morbidity without compromising the outcome. A laparoscopic nephrectomy is also associated with improved cosmesis, less postoperative discomfort, a shorter hospital stay, and decreased convalescence.
In our case a woman with nutcracker syndrome was treated with a retroperitoneal laparoscopic nephrectomy with ex vitro autograft repair and autotransplantation. Compared with a transperitoneal laparoscopic nephrectomy and autotransplantation, our approach had only one minor oblique incision in the iliac fossa both for the autograft to be procured through and for transplantation. Moreover, using only a small incision on the left hypogastrium can improve the cosmetic outcome of patients and may be well-accepted by patients, especially young women. In order to shorten the hot ischemic time of the autograft, the oblique incision had to be prepared in advance of the laparoscopic nephrectomy. Operation in a restricted retroperitoneal working space led to a shorter operation time and a lower chance of lesions in intraperitoneal organs. With no need of blood vessel manipulation, there was no risk of thrombosis. Postoperative anticoagulation medication was not needed and the cost of the surgery was reduced. This approach resulted in a faster recovery, less fatigue, and better quality of life for the donor.
With no accepted protocol for nutcracker syndrome repair, retroperitoneal laparoscopic donor nephrectomy and renal autotransplantation should be determined on a case-by-case basis. Based on the advantages of retroperitoneal laparoscopic surgery, this approach should become a standard method for nutcracker syndrome repair. From our experience, during renal allotransplantation , care must be taken to avoid irreversible ischemic injury of the patient's kidney autograft to prevent long-term graft damage.