Laparoscopic treatment of ovarian vein syndrome: A case series

Introduction: Ovarian vein syndrome is a rare entity of ureteral obstruction. Its pathogeny and clinical expression are highly polymorphic. The treatment gains great advances because of the development of laparoscopy. Case Series: We reported two cases of ovarian vein syndrome occurring in two multiparous women, with unremarkable past medical history. The patients were presented with isolated right flank pain. The diagnosis was confirmed by computed tomography angiography in the two cases. Ovarian vein ligation was successfully performed throughout a retroperitoneoscopic approach with excellent outcomes. Conclusion: The ovarian vein syndrome continues to be a rare diagnosis that should be recognized. The diagnosis is mainly urographic. Owing to its simplicity, low morbidity, and good results attained, the laparoscopic approach will continue to advance the surgical management of ovarian vein syndrome. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 5 No. 11, November 2014. ISSN – [0976-3198] Int J Case Rep Images 2014;5(11):739–743. www.ijcasereportsandimages.com Hmida et al. 739 CASE SERIES OPEN ACCESS Laparoscopic treatment of ovarian vein syndrome: A case series Wissem Hmida, Mouna Ben Othmen, Faouzi Mallat, Sidiya Oueld Chavey, Mehdi Jaidane, Faouzi Mosbah


INTRODUCTION
Ovarian vein syndrome is an uncommon cause of ureteral obstruction caused by an aberrant dilated ovarian vein [1]. It is a poorly understood clinicpathological condition first described in 1964 [2]. Typically occurring in young multiparous woman with a right-sided predilection. The symptoms are non-specific including acute or chronic lumbar pain. The diagnosis is urographic. The treatment gains great advances because of the development of laparoscopy.

CASE SERIES
We reported two cases of ovarian vein syndrome treated by laparoscopic approach.
Case 1: A 43-year-old female with obstetric history of three gestations, presented with a 24-month history of recurrent right flank pain. She denied having a history of gross hematuria or urinary tract infection. On physical examination, BMI was at 17. Laboratory tests revealed a creatinine 90 μmol/L. The urine analysis was normal.
Ultrasound followed by computed tomography (Figure 1) showed a moderate dilatation of the right upper urinary tract and confirmed the diagnosis of right ovarian vein syndrome.
Through a retroperitoneoscopic approach, the ovarian vein was dissected, ligated and resected. The mean operating time was one hour. Preoperative and postoperative period were uneventful, and the patient was discharged after 48 hours of surgery.
In a follow-up of nine months the patient remained asymptomatic. Urine cultures repeated every three months were negative and there were no radiologic signs of ureteral obstruction.
Case 2: A 38-year-old female with obstetric history of two gestations, presented with a nine-month history of recurrent right lumbar pain. She reported that the pain was exacerbated in premenstrual period, but she did not have any history of hematuria or urinary tract infection. The physical examination did not reveal any abnormality. Laboratory tests showed a negative urine culture and a creatinine value of 65 μmol/L.
Imaging investigations showed moderate dilation of upper right urinary tract. The diagnosis was confirmed by computed tomography angiography revealing the compression of the right ureter by a dilated ovarian vein measuring 9 mm in diameter.
The patient underwent a ligation of ovarian vein throughout a retroperitoneoscopic approach. The procedure was successfully performed and the mean operating time was 55 minutes. Postoperative outcomes were good and the patient was discharged after 48 hours. In a follow-up of two years, the patient was asymptomatic with resolution of obstruction in radiologic finding.

DISCUSSION
Ovarian vein syndrome is a rare cause of ureteral obstruction [1]. In 1964, Clark reported a series of 129 right-sided ovarian vein syndromes. Many authors have published case reports of the ovarian vein syndrome, but the largest study includes only eight cases [2]. It is classically described on the right side in 95% of cases [3,4].
The pathophysiology of ovarian vein syndrome is still poorly understood. Several mechanisms have been suggested [2], mainly a ureteral compression by an aberrant ovarian vein draining into the right renal vein, hormonal changes associated with pregnancy may also explain ovarian vein syndrome [2,5,6]. It is probably a multifactorial syndrome [7].
The symptoms appear frequently in multiparous women, but have been also described in nulliparous women and children [2,[8][9][10][11][12]. The clinical features have no specificity including an acute or chronic lumbar pain, recurrent urinary tract infection, and frank hematuria [2,9,13]. Typically, the pain is exacerbated in premenstrual period or during pregnancy [7,4]. In this cases, the two patients were presented with isolated right lumbar pain; one of the exacerbated in premenstrual period.
A careful preoperative evaluation must be required to eliminate other ureteral obstruction causes such as tumor compression and retroperitoneal fibrosis [1]. That is why some radiological examinations were indicated to confirm the diagnosis of ovarian vein syndrome [4]. The abdominal ultrasound showed generally moderate dilatation of the upper urinary tract. Tranvaginal ultrasound can reveal dilated ovarian veins [7].
The gold standard for diagnosis was intravenous urography showing typically dilation and tortuosity of upper ureter with transverse defect at L3/L4 level [2,7].
The computed tomography angiography revealed the crossing ovarian vein and excludes other causes of ureteral compression such as tumor compression retroperitoneal fibrosis [8].
In the case of our patients, the diagnosis was confirmed by computed tomography angiography.
Various management options for ovarian vein syndrome have been described; including conservative measures (medical treatment and embolization), and surgical excision, Wish represent the radical treatment of this entity [14].
Traditionally, ligation of ovarian vein has been performed through an open surgery. However, the laparoscopic approach has gained traction since the first report of transperitoneal laparoscopic ovarian vein ligation published by Elashry et al. in 1996.
The laparoscopic treatment, as a minimally invasive alternative to the open surgery [8]. It had progressed well recently to involve use of retroperitoneoscopic approach [2]. It had proven to be a valuable technique, offering superior visualization of the operative field. It permits careful assessment of the periureteral anatomy and identification of the ovarian vein [1].
It may limit the risk of hemorrhagic complications [1], reducing postoperative pain and analgesic requirement improvement in convalescence time and patient outcomes [1,8,15,16]. As seen in these cases, the ligation of the ovarian vein and ureteral dissection by retroperitoneoscopic approach was easy, with an excellent immediate and long-term outcomes and the patients being discharged after a short hospital stay.

CONCLUSION
The ovarian vein syndrome continues to be a rare diagnosis that should be recognized. The diagnosis is mainly urographic. Owing to its simplicity, low morbidity, and good results attained, the retroperitoneoscopic approach will continue to advance the surgical management of ovarian vein syndrome. *********

AN INTRODUCTION
Edorium Journals: On Web

About Edorium Journals
Edorium Journals is a publisher of high-quality, open access, international scholarly journals covering subjects in basic sciences and clinical specialties and subspecialties.

Edorium Journals: An introduction
Edorium Journals Team

But why should you publish with Edorium Journals?
In less than 10 words -we give you what no one does.

Vision of being the best
We have the vision of making our journals the best and the most authoritative journals in their respective specialties. We are working towards this goal every day of every week of every month of every year.

Exceptional services
We care for you, your work and your time. Our efficient, personalized and courteous services are a testimony to this.

Editorial Review
All manuscripts submitted to Edorium Journals undergo pre-processing review, first editorial review, peer review, second editorial review and finally third editorial review.

Peer Review
All manuscripts submitted to Edorium Journals undergo anonymous, double-blind, external peer review.

Early View version
Early View version of your manuscript will be published in the journal within 72 hours of final acceptance.

Manuscript status
From submission to publication of your article you will get regular updates (minimum six times) about status of your manuscripts directly in your email.

Mentored Review Articles (MRA)
Our academic program "Mentored Review Article" (MRA) gives you a unique opportunity to publish papers under mentorship of international faculty. These articles are published free of charges.

Favored Author program
One email is all it takes to become our favored author. You will not only get fee waivers but also get information and insights about scholarly publishing.

Institutional Membership program
Join our Institutional Memberships program and help scholars from your institute make their research accessible to all and save thousands of dollars in fees make their research accessible to all.

Our presence
We have some of the best designed publication formats. Our websites are very user friendly and enable you to do your work very easily with no hassle. Something more...
We request you to have a look at our website to know more about us and our services.
We welcome you to interact with us, share with us, join us and of course publish with us.

Invitation for article submission
We sincerely invite you to submit your valuable research for publication to Edorium Journals.

Six weeks
You will get first decision on your manuscript within six weeks (42 days) of submission. If we fail to honor this by even one day, we will publish your manuscript free of charge.

Four weeks
After we receive page proofs, your manuscript will be published in the journal within four weeks (31 days). If we fail to honor this by even one day, we will publish your manuscript free of charge and refund you the full article publication charges you paid for your manuscript.