Robotic left renal vein transposition for nutcracker syndrome: side‐clamp to tailored reconstruction

Objective Our objective was to evaluate the safety and efficacy of staged, anatomy‐tailored robot‐assisted left renal vein (LRV) transposition procedures for the treatment of nutcracker syndrome (NCS). Patients and Methods This retrospective single‐centre study (2019–2025) included 88 patients stratified by technique: conventional ( n = 27), robotic side‐clamp two‐step ( n = 21), LRV‐proximal left gonadal vein (LGV) transposition ( n = 20), and LRV‐distal LGV transposition ( n = 20). The primary outcome was the renocaval pressure gradient (RPG), with secondary outcomes including operative metrics, symptom resolution, and complications. Median follow‐up was 12 months. Results Robot‐assisted LRV‐distal LGV transposition groups demonstrated superior perioperative outcomes to conventional surgery: operative time (median 200 vs 344 min; P < 0.001), blood loss (36.5 vs 66.0 mL; P < 0.001), and hospital stay (4.5 vs 8.0 days; P < 0.001). Postoperative RPG was ≤3 mmHg in all patients. The LRV–proximal LGV transposition yielded the greatest RPG reduction (Δ2.8 mmHg) and lowest postoperative RPG (1.5 mmHg). Complete resolution of varicocele and pelvic/scrotal pain was achieved in all eligible patients undergoing the LRV–distal LGV transposition. Pain scores were low across all groups (mean pain score: 1.7). Conclusion The staged technical evolution in robotic LRV transposition, from the side clamp two‐step technique to anatomy‐tailored LRV–LGV transposition, demonstrated favourable renocaval pressure gradient normalization, symptom relief, and perioperative outcomes. Based on our single‐centre experience, we propose a preliminary anatomy‐tailored treatment algorithm: the side clamp two‐step technique for uncomplicated cases, LRV‐proximal LGV transposition for proximal LGV dilation (≥5 mm), and LRV‐distal LGV transposition for patients with varicocele or pelvic congestion. This framework serves as an institutional reference that warrants further multicentre validation.