Use of Cryopreserved Vascular Allograft Reconstruction in Robotic-Assisted Kidney Autotransplantation for Nutcracker Syndrome After Failed Renal Vein Transposition: Description of a Novel Technique.

Robotic-assisted kidney autotransplantation (RAKAT) is a minimally invasive approach to managing complex renal pathologies. While increasingly utilized, experience with RAKAT in patients with prior renal surgery remains limited. We present a case of recurrent nutcracker syndrome (NCS) in a 29-year-old female who had previously undergone left renal vein transposition. Due to recurrent symptoms, she underwent RAKAT with extracorporeal vascular reconstruction using cryopreserved allografts to manage the foreshortened renal vessels. The surgical technique involved a multiport robotic approach with a hand-assist device, extracorporeal bench surgery, and repositioning for the autotransplantation phase. The procedure was completed successfully with a total operative time of 779 minutes and estimated blood loss was 100 mL. The cold ischemic time was 90 minutes. Postoperative complications included urinary tract infections requiring intravenous antibiotics (Clavien-Dindo grade II). At 7 months follow-up, the patient had excellent graft function and no evidence of recurrent NCS. This case demonstrates the feasibility of RAKAT with extracorporeal vascular reconstruction using allografts as a salvage therapy for recurrent NCS after prior open surgery. This approach requires advanced robotic and vascular expertise and careful preoperative planning.