RS07 - Gonadal Vein Transposition: Updated Outcomes for Treatment of Nutcracker Syndrome

Objectives: Nutcracker syndrome (NCS), caused by compression of the left renal vein between the aorta and superior mesenteric artery, can lead to debilitating flank pain, hematuria, and pelvic congestion. Surgical intervention is indicated for severe, refractory symptoms, with left renal vein transposition (LRVT) traditionally considered the standard approach. Studies investigating outcomes of LVRT for NCS demonstrate 12- and 24-month freedom from reintervention of 76% and 68%, respectively.1 Left gonadal vein transposition (LGVT) offers a technically simpler and less invasive alternative that preserves renal vein integrity, yet outcomes data remain limited. This study aims to evaluate the safety, efficacy, and durability of LGVT for NCS in the largest reported case series to date.

Methods: A single center retrospective review was performed for all patients treated for NCS between January 1, 2000 and May 1, 2025 was performed. 96.6% of the GVTs were performed by one senior surgeon. Patients were identified via International Statistical Classification of Disease and Related Health Problems, 10th Revision (ICD-10) codes and Current Procedural Terminology (CPT) codes. LGVT was performed preferentially if certain anatomical conditions were met, alternatively LRVT or autotransplantation was considered. (Figure 1). Primary outcomes included symptom resolution and recurrence, which were used as surrogate measures of clinical success reflecting real-world decision-making, and reintervention. Secondary outcomes included post-operative length of stay and morbidity, as defined by return to the operating room, venous thromboembolism, acute kidney injury, wound infection, ileus, and readmission.

Results: Of 909 patients identified, 66 received treatment at the study institution, of which 34 underwent operative intervention (29 LGVT, 5 LRVT/autotransplant). (Table I).

After LGVT, 86.2% of patients achieved symptom resolution. Freedom from reintervention was 96.6% at 1 year and 89.7% at 3 years. Only one patient had persistent symptoms, and three experienced recurrence, with two requiring reintervention.

Overall, patients who underwent GVT had 1- and 3- year freedom from reintervention rates of 96.6% and 89.7%, respectively.

Conclusions: LGVT offers safe, effective, and durable treatment for NCS, with superior freedom from reintervention compared to published LRVT outcomes (96.6% vs 76% at 12 months). This represents the largest reported LGVT series and supports its role as a definitive surgical option in appropriately selected patients.