Robotic Assisted Left Gonadal Vein Transposition: A Treatment for Pelvic Congestion Syndrome

Study Objective

To describe the clinical presentation and surgical management of a patient with secondary pelvic congestion syndrome caused by posterior nutcracker syndrome.

Design

Video-based case presentation of a robotic-assisted left gonadal vein transposition.

Setting

Operating room at a tertiary academic medical center.

Patients or Participants

A 44-year-old G3P2012 with a five-year history of abnormal uterine bleeding, chronic pelvic pain, and fibromyalgia. Symptoms began following a 40-pound weight loss. She declined medical therapy and found minimal relief with pelvic floor physical therapy. CT imaging revealed a retroaortic left renal vein compressed by the aorta, with associated dilated left gonadal vein and periuterine varices up to 1 cm—findings consistent with posterior nutcracker syndrome and secondary pelvic congestion syndrome.

Interventions

Robotic-assisted left gonadal vein transposition was performed, given that this vein served as the primary drainage pathway of the left kidney. Due to persistent heavy menstrual bleeding and pelvic pain, a hysterectomy, bilateral salpingectomy, and left oophorectomy were also completed.

Measurements and Primary Results

Retroaortic left renal vein is a rare anatomical variant (≈4%) where the vein courses posterior to the aorta before draining into the inferior vena cava. In posterior nutcracker syndrome, this vein is compressed between the aorta and lumbar spine, leading to venous hypertension and pelvic congestion. Treatment options range from conservative management to surgical intervention, depending on anatomy and symptom severity. In this case, the patient recovered well postoperatively with resolution of pelvic pain, nausea, diarrhea, and GI upset. A 4-week follow-up CT venogram confirmed a patent transposed left gonadal vein draining into the patent left iliac vein.

Conclusion

Robotic-assisted gonadal vein transposition is a feasible treatment for pelvic congestion secondary to posterior nutcracker syndrome, with symptom resolution and restored venous drainage observed postoperatively.