Diagnosis and successful surgical management of posterior nutcracker syndrome in a patient with loin pain hematuria

The syndrome of loin pain hematuria in the absence of stones is poorly understood but must be considered in the differential diagnosis for patients with clinical manifestations resembling nephrolithiasis. A 22-year-old white female with a 4-year history of left flank pain and hematuria underwent an extensive workup with normal renal ultrasound and cystourethroscopies. CT scan and MRI revealed a retro-aortic left renal vein. Posterior nutcracker syndrome was considered the most likely diagnosis. The patient underwent a left laparoscopic nephrectomy with auto-transplantation in the right iliac fossa. She developed azotemia shortly after, which resolved and since then has become asymptomatic.