Prophylactic intravesical instillation of mitomycin C and cytosine arabinoside for prevention of recurrent bladder tumors following surgery for upper urinary tract tumors: a prospective randomized study.

BACKGROUND: A recurrence of bladder tumors following surgery for transitional cell carcinoma of the upper urinary tract is not rarely observed. A prospective randomized study was conducted to examine the significance of prophylactic intravesical instillation of mitomycin C (MMC) and cytosine arabinoside (Ara-C) to prevent recurrent bladder tumors after surgery for superficial transitional cell carcinoma of the upper urinary tract. METHODS: The patients were randomized into an instillation group, who received postoperative intravesical instillation of MMC (20 mg) and Ara-C (200 mg) 28 times over a period of 2 years, and a non-instillation group. The non-recurrence rate was then compared between the groups. RESULTS: Of the 27 patients registered, 25 patients (13 with instillation and 12 without instillation) were able to be evaluated, with a median follow-up period of 45 months. The non-recurrence rate of bladder tumors in the instillation group was higher than that in the non-instillation group. Although the difference was not statistically significant, the P-value (P = 0.079) demonstrated a strong trend. When any possible bias was allowed for a multivariate analysis, the difference was almost significant (P = 0.0567). No patients withdrew from this study due to any side-effects. CONCLUSION: The postoperative instillation of MMC and Ara-C may be a useful approach for reducing the recurrence of bladder tumors after surgery for upper urinary tract tumors.

Carcinoma-associated antigens MK-1 and CEA in urological cancers.

BACKGROUND: The MK-1 antigen, recognized by monoclonal antibody FU-MK-1, is widely associated with human carcinomas. However, the expression and distribution of MK-1 in urological cancers is not well known. MATERIALS AND METHODS: We examined the expression of MK-1 in 10 urological tumor cell lines using flow cytometry and reverse transcription-polymerase chain reaction (RT-PCR) and in 15 cancer tissue specimens by immunohistochemical staining, and then compared it with that of carcinoembryonic antigen (CEA). RESULTS: When analyzed by flow cytometry, MK-1 was positive in 2 out of 3 bladder, 3 out of 3 prostate and one out of 4 renal tumor cell lines, whereas CEA was negative in all the 10 tumor cell lines. RT-PCR confirmed the presence of MK-1 mRNA in all the six MK-1-positive tumor cell lines. An immunohistochemical study demonstrated that MK-1 was positive in 2 out of 5 bladder, 2 out of 5 prostate and one out of 5 renal cancer tissues. Again, however, CEA was negative in all the 15 urological cancer tissues tested. CONCLUSION: These findings suggest that MK-1 seems to be a useful biological marker for malignant urological tumors, especially in cases of bladder and prostate cancer.

Sarcomatoid carcinoma of the urinary bladder: a clinicopathologic and immunohistochemical analysis of 14 patients.

Sarcomatoid carcinoma of the urinary bladder is a rare entity, in which both the histogenesis and biological behavior remain controversial. We herein describe the clinicopathologic and immunohistochemical profiles of sarcomatoid carcinomas and discuss the significance of cell adhesion molecules in the development of this peculiar neoplasm. The authors examined formalin-fixed and paraffin-embedded tissue samples from 14 patients with sarcomatoid carcinoma of the urinary bladder. An immunohistochemical analysis was performed by using antibodies against epithelial and mesenchymal antigens as well as adhesion molecules. Most patients suffered from an advanced stage of the tumor, extending to the muscular layer (7 cases) or to the perivesical tissues (5 cases). Microscopically, all 14 tumors were composed predominantly of a carcomatoid component and an obviously carcinomatous component. The sarcomatoid component was composed of a mixture of spindle cells, round cells, and pleomorphic giant cells. The carcinomatous components consisted of papillary or nonpapillary high-grade transitional cell carcinoma (TCC). The zones of gradual transition between the carcinomatous and the sarcomatous elements were focally apparent in each tumor. The findings of an immunohistochemical examination indicated that both carcinomatous and sarcomatoid components expressed epithelial antigens (pankeratin or EMA), even though the staining pattern varied from case to case. As for cell adhesion molecules, the carcinomatous components were positive for E-cadherin (8 of 12), CD44s (8 of 12), and CD44v6 (6 of 12). Although the sarcomatoid components were also positive for E-cadherin (5 of 12), CD44s (4 of 12), and CD44v6 (3 of 12), these rates were lower than those in the carcinomatous components. Six patients died of their disease between 5 and 36 months after the diagnosis was made. The recognition of sarcomatoid carcinomas has important therapeutic and prognostic implications. It seems appropriate to treat these neoplasms in the same manner as conventional high-grade TCCs with similar degrees of invasion. We consider that sarcomatoid carcinomas should be regarded as a high-grade carcinoma that shows a prominent pseudosarcomatous dedifferentiation. The sarcomatoid component of sarcomatoid carcinomas may result from either anaplastic changes or dedifferentiation related to the process of losing cell adhesion molecules.

[Clinical significance of urothelial dysplasia concomitant with superficial bladder cancer].

OBJECTIVE: Retrospective analysis was carried out to evaluate the prognostic value of urothelial dysplasia with superficial bladder cancer. PATIENTS AND METHODS: 62 patients with bladder cancer of pTa or pT1 who had been treated by transurethral resection (TUR-Bt), underwent random mucosal biopsies in the urinary bladder. The results of random biopsies were classified into 3 groups: negative group, dysplasia group and CIS group. The recurrence rate, progression rate and type of recurrences (true recurrence/new occurrence) were compared among the 3 groups. RESULTS: The results of random biopsies were as follows; negative group was found in 42 (68%), dysplasia group in 17 (27%) and CIS group in 3 (5%). There were no significant difference in the characteristics of the patients among the 3 groups. The recurrence rates at 1, 2 and 5 years after TUR-Bt were 3%, 12% and 21%, respectively, for negative group, and 37%, 51% and 67%, respectively, for dysplasia group (p < 0.01). For CIS group, 2 of 3 cases (67%) recurrenced within 1 year after TUR-Bt. Non of negative group progressed to muscle invasion, whereas 57% of dysplasia group invaded bladder muscle after 6 years post operatively (p < 0.001). No significant relationship was observed between the absence or presence of concomitant dysplasia and the rate of true recurrence. Dysplasia group revealed a higher rate (47.1%) of new occurrence than negative group (2.4%) (p = 0.0001). CONCLUSION: The presence or absence of concomitant dysplasia of superficial bladder cancer seems to be an important prognostic factor for future new ocurrence and progression after TUR-Bt.

Synovial sarcoma of the prostate with t(X;18)(p11.2;q11.2).

A case of monophasic synovial sarcoma of the prostate in a 37-year-old man is reported. Histologically, the tumor was chiefly composed of uniform spindle and oval cells, which often formed interlacing fascicles resembling those of fibrosarcoma. In some areas, the compact fascicles of tumor cells alternated with hypocellular myxoid tissue bearing a superficial resemblance to peripheral nerve sheath tumors, whereas small portions of the tumor showed a pericytomatous pattern consisting of polygonal cells arranged around dilated, thin-walled blood vessels. By immunohistochemistry, vimentin was detected in most cells, and a focal reactivity for epithelial membrane antigen was also observed. The tumor cells, however, were negative for keratin, S-100 protein, neuron-specific enolase, CD34, desmin, muscle-specific actin, and alpha-smooth muscle actin. Cytogenetic analysis and fluorescence in situ hybridization (FISH) using the cultured tumor cells demonstrated a translocation t(X;18)(p11.2;q11.2), an aberration specific for synovial sarcoma. To the authors' knowledge, this is the first report of a primary prostatic synovial sarcoma confirmed by cytogenetic analysis.

Prophylactic intravesical instillation chemotherapy against recurrence after a transurethral resection of superficial bladder cancer: a randomized controlled trial of doxorubicin plus verapamil versus doxorubicin alone. The Kyushu University Urological Oncology Group.

PURPOSE: We investigated whether verapamil (VR), a known chemosensitizing agent of P-glycoprotein-mediated multidrug resistance, could enhance the preventative effect of doxorubicin (Adriamycin, ADM) on both intravesical recurrence and disease progression after transurethral resection (TUR) of superficial bladder cancer. METHODS: The patients were randomized into two groups: one group received an intravesical instillation of ADM (30 mg) plus VR (15 mg) after TUR of superficial bladder cancer (19 times over 1 year), and the other group received ADM alone on the same treatment schedule. The nonrecurrence rate, the incidence of disease progression at the first recurrence and the side effects were compared over a median follow-up of 38.5 months. RESULTS: Of the 226 patients registered, 157 were evaluable. No significant differences were observed in the patients' characteristics between the two groups. Although the incidence of disease progression at the first recurrence was not significantly different between the two groups, the ADM plus VR instillation group did show a significantly higher nonrecurrence rate than the ADM-only instillation group, and such significance persisted even when any possible bias was allowed for in a multivariate analysis. In terms of side effects, the incidence and severity of bladder irritation symptoms were not significantly different between the two groups. CONCLUSIONS: Intravesical instillation chemotherapy with ADM plus VR was found to have a significantly greater beneficial effect than with ADM alone for preventing recurrence after TUR of superficial bladder cancer.

[Basic evaluation of Chlamydia antigen detection by EIA using a dual amplification enhanced immunoassay method].

Chlamydia trachomatis is one of the important pathogens of STD in our country. Therefore, rapid accurate, reliable and convenient tests for its detection are required. So far, IDEIA Chlamydia has been employed as a useful diagnostic kit. Now, IDEIA PCE Chlamydia, applied as a dual amplification EIA method, has been developed. In our present studies, the sensitivity, reproducibility, cross reactivity, and reliability of IDEIA PCE Chlamydia were investigated and compared with those of IDEIA Chlamydia and LCR Chlamydia. The sensitivity of IDEIA PCE Chlamydia showed 2.4 x 10(2) IFU/ml for C. trachomatis D, 1.2 x 10(2) IFU/ml for C. trachomatis E, 3.8 x 10 IFU/ml for C. trachomatis F, and 1.25 x 10(2) IFU/ml for C. trachomatis L2. With regard to reproducibility, more than 2.4 x 10(2) IFU/ml of all strains of C. trachomatis and negative samples gave highly reproducible values. Though no cross reactivity was recognized among three strains of Staphylococcus aureus with concentrations of more than 10(9) IFU/ml, non-heated samples of over 10(6) CFU/ml showed cross reactivity. In our observations, phosphate, Mg2+, Ca2+, and Fe3+ inhibited the efficacy of both IDEIA and IDEIA PCE Chlamydia. Ca2+ per se could be an inhibitor in the case of urine samples analyzed by IDEIA and IDEIA PCE Chlamydia. These results indicate that IDEIA PCE Chlamydia kit for detection of C. trachomatis may be clinically useful because of its improved sensitivity over IDEIA Chlamydia and its invariable specificity and reliability.

Significance of the preoperative intravesical instillation of doxorubicin and the oral administration of 5-fluorouracil in preventing recurrence after a transurethral resection of superficial bladder cancer. Kyushu University Urological Oncology Group.

BACKGROUND: The postoperative intravesical instillation of doxorubicin (ADM) has a preventative effect on recurrence after a transurethral resection (TUR) of superficial bladder cancer. However, the significance of preoperative ADM instillation remains unclear. Although the oral administration of 5-fluorouracil (5-FU) has been observed to show some clinical response against bladder cancer, its preventative effect on the recurrence of superficial bladder cancer after TUR is unknown. METHODS: Patients were randomized into 4 groups. All 4 groups received postoperative ADM instillation. In addition, patients in groups C and D received preoperative ADM instillation, whereas patients in groups B and D additionally received oral 5-FU postoperatively. The nonrecurrence rate and side effects were both compared among the 4 groups. RESULTS: Of the 282 patients registered, 200 were evaluable, with a median follow-up period of 21.4 months. There were no significant differences in the characteristics of the patients among the 4 groups. Group C (pre- and postoperative ADM) showed a significantly longer disease-free interval than group A (postoperative ADM alone). However, there was no significant difference in the disease-free interval between groups A and B (postoperative ADM plus 5-FU), or between groups C and D (pre- and postoperative ADM plus 5-FU). Bladder irritation symptoms were the most frequently noted side effect encountered in all groups, but the severity was generally mild. CONCLUSIONS: Preoperative ADM instillation was found to prevent recurrence to a greater extent than the usual postoperative instillation alone, whereas oral 5-FU was found to have no additional beneficial effect on the disease-free interval in patients with superficial bladder cancer.

[Flow cytometry analysis of the DNA content of the prostate cancer--study on the tumor heterogeneity in prostate cancer].

PURPOSE: Clinical significance of DNA ploidy pattern and its DNA heterogeneity is examined in prostate cancer. METHODS: Fresh needle biopsy specimens were analyzed with flow cytometry and were compared with histopathological findings in 42 patients. RESULTS: Seven patients had stage B (1 case of B1, 6 cases of B2), 14 had stage C and 21 had stage D disease respectively. Histopathologically, 18 of the cases were well, 12 were moderately and 12 were poorly differentiated adenocarcinoma. Diploid was observed in 20, aneuploid in 22. Though 22 cases showed no DNA heterogeneity, 14 had type A heterogeneity with aneuploid in association with diploid pattern, and 6 cases had type B heterogeneity in which multiple aneuploid patterns with different D.I. values were observed. The heterogeneity was observed in 28% of well, 58% of moderately and 67% of poorly differentiated adenocarcinoma, respectively, and also in 14% of stage B, 50% of stage C and 57% of stage D patients, respectively. CONCLUSION: We conclude that DNA heterogeneity in prostate cancer is more frequently seen in poorer differentiated ones on histologic grade and in more advanced ones on clinical stage.

Upper urinary tract involvement after cystectomy and ileal conduit diversion for primary bladder carcinoma.

OBJECTIVES: To design a proper follow-up for cystectomy and ileal conduit urinary diversion for primary bladder transitional carcinoma, we compared the radiographic characteristics of recurrent malignant upper tract lesions with those of benign ureteroileal anastomosis strictures. METHODS: Over a 20-year period, we followed 61 patients who underwent cystectomy and ileal conduit diversion at our hospitals for a minimum period of 3 years. Excretory urography was performed routinely at 1, 3, 6 and 12 months after cystectomy and once yearly thereafter. RESULTS: Five patients (8.2%) developed malignant ureteral obstruction (4 had metachronous upper tract tumors, and 1 patient had retroperitoneal lymph node metastasis which compressed the ureter). Eleven patients (18.0%) developed benign ureteroileal anastomotic stricture. The interval between cystectomy and initial detection of the malignant and benign upper tract lesion ranged between 34 and 118 months (mean 69 months) and between 1 and 20 months (mean 5.1 months), respectively. In all patients with malignant upper tract obstruction, a complete loss of renal function occurred within 10 months after the detection. Conversely, a progressive renal dysfunction was observed in patients with benign ureteroileal anastomotic stricture. All patients were asymptomatic before the detection of lesions on excretory pyelography. CONCLUSIONS: Our results suggest that cancer recurrence can occur even 10 years after cystectomy, typically progressing very rapidly within 1 year. A benign ureteroileal anastomotic stricture, on the other hand, tends to occur within 2 years but advances slowly. Consequently, a proper follow-up necessitates annual excretory urography and/or renal ultrasonography in all patients with ileal conduit urinary diversion after cystectomy.

Metastatic adrenocortical carcinoma treated by repeated resection: a case report of long-term survival over 18 years.

A case of recurrent and metastatic nonfunctioning adrenocortical carcinoma in a 40-year-old woman is reported. The patient received 4 laparotomies and 1 thoracotomy for recurrent and metastatic disease after removal of the primary adrenal tumor. She has been alive for over 18 years following multiple surgery for diseases after the first adrenalectomy. In selected patients with recurrence and/or metastasis, repeated surgical resection offers the possibility of a cure or extended palliation.

Ileal ureter: another option for the treatment of localized amyloidosis of the upper urinary tract.

Ileal ureteral replacement has been accepted as treatment for extensive ureteral loss. To our knowledge we report the first case of localized pelviureteral amyloidosis to be managed by surgical construction of an ileal ureter.

Prophylactic intravesical chemotherapy with adriamycin plus verapamil for primary superficial bladder cancer: preliminary results. The Kyushu University Urological Oncology Group.

A prospective randomized trial was conducted to compare the prophylactic effect of intravesical installation of Adriamycin (ADM) plus verapamil (VR) with that of ADM alone for recurrence of superficial bladder cancer. A total of 226 patients were enrolled and randomized into 2 groups. Group A received intravesical instillation of ADM (30 mg/30 ml physiological saline) on 19 occasions during a 1-year period after transurethral resection, whereas group B received intravesical instillation of ADM (30 mg/24 ml physiological saline) plus VR (15 mg/6 ml saline) according to the same schedule used for group A. Evaluation was possible in 157 of the 226 registered patients (group A, 76; group B, 81). There was no significant difference in the patients' characteristics between the two groups, and there was no significant difference in the overall nonrecurrence rate determined over a 24-month follow-up period. However, group B showed a significantly higher nonrecurrence rate than did group A for tumors measuring less than 1 cm in diameter (P < 0.05) and for histological grade 2 tumors (P < 0.01) in spite of there being no significant difference in the other characteristics of each subgroup of patients. The incidence and severity of side effects were similar in both groups, and VR caused no significant systemic toxicity. Although further follow-up is necessary, these results suggest that intravesical instillation of ADM plus VR is clinically safe and may be more effective than instillation of ADM alone in preventing the postoperative recurrence of superficial bladder cancer (less than 1 cm in diameter, histological grade 2).

An experimental model for unilateral ischaemic acute renal failure in dog.

We determined the recovery of unilateral ischaemic acute renal failure in both ischaemic and non-ischaemic canine kidneys. Split renal clearance studies were repeated for seven weeks after 90 minutes of left renal artery clamping. Clearance of inulin and para-aminohippuric acid in the ischaemic kidneys dropped significantly for 3 weeks. Significant increase of the fractional excretion of sodium in those kidneys was observed at only 1 week after ischaemia. In the contralateral non-ischaemic kidneys, these indices did not change significantly throughout the experiments. This animal model of acute renal failure would be helpful in testing possible preventive measures and therapy for human acute renal failure.

[Antiandrogen therapy of benign prostatic hypertrophy: clinical effects of allylestrenol evaluated by transrectal ultrasonographic measurement].

A multicenter trial was carried out on 100 patients with benign prostatic hypertrophy to elucidate the efficacy of anti-androgen therapy with allylestrenol (AE). AE was administered at a daily dose of 50 mg for 16 weeks to the patients and its efficacy was evaluated with subjective symptom scores, residual urine volume and uroflow rates. The effects of AE on prostatic volume and morphology were evaluated using transrectal ultrasound. Of these patients 65 completed the protocol, and only three patients withdrew from the study owing to side effects. Very modest adverse effects on sexual performance were seen in one patient. In this study, significant beneficial effects of AE on symptom scores, residual urine, maximum flow rate, and prostate size were demonstrated. However, volumetric reduction was not associated with urodynamic improvement. Prostatic shape was not changed throughout the study. These findings suggest that allylestrenol can be used as an alternative to prostatectomy in patients who are at high risk for surgery.

Adjuvant chemotherapy with early intravesical instillation of adriamycin and long-term oral administration of 5-fluorouracil in superficial bladder cancer. The Kyushu University Urological Oncology Group.

A randomized controlled trial was performed to study the efficiency of adjuvant chemotherapy with early intravesical instillation of Adriamycin and long-term oral administration of 5-fluorouracil in 275 patients with superficial bladder cancer. All of the patients were randomized into four groups. Group A received early (immediately and 2 days after transurethral resection) instillation of Adriamycin alone; Group B received early instillation of Adriamycin with oral administration of 5-fluorouracil; Group C received delayed (7 days after transurethral resection) instillation of Adriamycin alone; and group D received delayed instillation of Adriamycin with oral administration of 5-fluorouracil. All patients subsequently received instillations weekly for 2 weeks and then every 2 weeks for a further 14 weeks. After 4 months, they received monthly instillations for 8 months. 5-Fluorouracil (groups B and D) was given daily p.o. for 1 year. Evaluation was possible in 187 patients. The postoperative follow-up period for determination of non-recurrence rates was 36 months, during which no significant difference was detected among the four groups. Moreover, no statistically significant difference was found between the early- and delayed-instillation groups. However, the non-recurrence rates obtained in the groups undergoing early instillation were higher than those determined in the delayed-instillation groups during the 36-month follow-up period, and this difference was especially significant at 4 and 5 months. In addition, the early-instillation groups showed significantly higher non-recurrence rates than did the delayed-instillation groups in terms of primary cases (P less than 0.01), tumor size of less than 1 cm (P less than 0.05), multiple tumors (P less than 0.01), pathological stage pTa (P less than 0.01), and histological grades G1 and G2 (P less than 0.05). Groups B and D, which were treated by intravesical instillation of Adriamycin with oral administration of 5-fluorouracil, showed no significant prophylaxis of recurrence during the 36-month follow-up as compared with groups A and C, which received intravesical instillations alone. The main side effect, which required discontinuation of the treatment, was bladder irritation. However, no significant difference in its incidence was found between the early- and delayed-instillation groups. No severe systemic side effect was encountered in this study. These results suggest that early as well as repeated intravesical instillation of Adriamycin is clinically tolerable and may be effective in preventing the recurrence of superficial bladder cancer.

Intravesical therapy with adriamycin plus verapamil in patients with superficial bladder cancer: a pilot study.

Nineteen patients with histologically proven superficial bladder cancer (Ta, T1) were treated with intravesical instillation of 30 mg of adriamycin (ADM) dissolved in 24 ml physiological saline plus 15 mg of verapamil (VR) (6 ml) every day for 10 days. In spite of the short period of treatment, 6 of the 18 evaluable patients (33.3%) showed complete response (CR) and a further 5 (27.8%) showed partial response (PR). Five of the 6 patients with CR were recurrent cases who had previously received prophylactic intravesical instillation chemotherapy including ADM. Irritative urinary symptoms were observed in 11 of the 19 patients (57.9%). However, these symptoms were mild in the majority of patients and the treatment was completed without interruption in all but 1 patient. There was no significant absorption of ADM and VR into the systemic circulation. No clinical evidence of systemic toxicity was observed. These results suggest that combination of ADM and VR has a possibility to be a useful prophylactic intravesical instillation chemotherapy after endoscopic resection of not only primary but also recurrent chemoresistant bladder cancers.

Prognostic factors and value of adjunctive nephrectomy in patients with stage IV renal cell carcinoma.

We reviewed 57 cases of Stage IV renal cell carcinoma to clarify the factors influencing prognosis and to evaluate the value of nephrectomy. Cumulative survival from the initial diagnosis was analyzed with respect to the patients' age, sex, side of primary tumor, initial performance status (PS), site of metastasis, and nephrectomy. Overall survival for the patients was 51 percent at one year, 22 percent at three years, and 11 percent at five years. Age, sex, and side of primary tumor had no influence on survival. Improved survival was correlated with good PS, metastases limited to single organ, and removal of the primary tumor. With regard to histopathologic features in nephrectomized patients, low grade and stage were correlated with longer survival. These factors should be considered in the analysis of results of future clinical trials of metastatic renal cell carcinoma.

[A 17-year experience with ileal conduit urinary diversion--early and late complications].

A series of 185 patients, 133 males and 52 females, were treated by ileal conduit urinary diversion in the past 17 years. The patients ranged in age from 7 months to 81 years with an average of 59 years. Diversions were performed for malignant diseases in 174 patients, 85% of whom underwent a simultaneous radical surgery. The follow-up covered the postoperative period from 4 months to 16 years 8 months with an average of 4 years 8 months. Six patients (3%) died within 1 month of operation, and 43 of a total of 58 mortal cases died of cancer thereafter. The survival rates of 143 patients with bladder cancer were 84% for 1 year, 72% for 3 years, 67% for 5 years, 62% for 10 years and 54% for 15 years. Early complications were noticed in 38% of the patients. Delayed wound healing due to local infection (20%) and intestinal obstruction (10%) were the two major complications in this period. Late complications were encountered in 51% of the patients. Mild peristomal dermatitis (22%) and gradually developing renal complications (22%) are two major problems in the standard ileal conduit urinary diversion. The latter was significantly more frequent in patients who underwent the operation between 1973 and 1981 than in those who had the surgery between 1982 and 1989. Postoperative hydronephrosis was observed in 15 (13%) of 117 patients who showed normal urograms preoperatively. Ileoureteral reflux was observed in 50% of the cases with nonobstructing conduits, while it increased up to 70% along with obstruction of the conduit.(ABSTRACT TRUNCATED AT 250 WORDS)

Renal hematuria caused by "nutcracker" phenomenon: a more logical surgical management.

A case of renal hematuria caused by the "nutcracker" phenomenon in a young man is reported. Resection of a preaortic fibrous tissue, renocaval venous reimplantation, and placement of a synthetic wedge into the bifurcation of the superior mesenteric artery were performed to resume an unstagnant flow of the left renal vein.