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CANCER OF THE CANCER OF THE BLADDER BLADDER

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Cancer of the bladder is the second most Cancer of the bladder is the second most common urologic malignancy.common urologic malignancy.

90% of all bladder cancers are transitional 90% of all bladder cancers are transitional cell carcinomas, which arise from the cell carcinomas, which arise from the epithelial lining if the UT; transitional cell epithelial lining if the UT; transitional cell tumors can also occur in the ureters, renal tumors can also occur in the ureters, renal pelvis, and urethra.pelvis, and urethra.

The remaining 10% of bladder cancers are The remaining 10% of bladder cancers are adenocarcinoma, squamous cell adenocarcinoma, squamous cell carcinoma, or sarcoma.carcinoma, or sarcoma.

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PATHOPHYSIOLOGY AND ETILOGYPATHOPHYSIOLOGY AND ETILOGY

Many bladder tumors are diagnosed when the Many bladder tumors are diagnosed when the lesions are superficial, papillary tumors that are lesions are superficial, papillary tumors that are easily resected.easily resected.

One fourth of pts with bladder cancer present One fourth of pts with bladder cancer present with nonpapillary, muscle invasive disease.with nonpapillary, muscle invasive disease.

Bladder tumors tend to be either low grade Bladder tumors tend to be either low grade superficial tumors / high grade invasive superficial tumors / high grade invasive cancers.cancers.

Metastasis occurs in the bladder wall and Metastasis occurs in the bladder wall and pelvis; para – aortic / supraclavicular nodes; in pelvis; para – aortic / supraclavicular nodes; in liver, lungs, and bone.liver, lungs, and bone.

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Although the specific etiology is unknown, it Although the specific etiology is unknown, it appears that multiple agents are linked to appears that multiple agents are linked to the development of cancer of the bladder, the development of cancer of the bladder, including:including:

a. Cigarette smoking – the risk of developing a. Cigarette smoking – the risk of developing bladder cancer is up to four times higher in bladder cancer is up to four times higher in smokers.smokers.

b. Prolonged exposure to aromatic amines or b. Prolonged exposure to aromatic amines or their metabolites – generally dye their metabolites – generally dye manufactured by the chemical industry and manufactured by the chemical industry and used by other industries.used by other industries.

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c. Exposure to cyclophosphamide (Cytoxan), c. Exposure to cyclophosphamide (Cytoxan), radiation therapy to the pelvis, chronic radiation therapy to the pelvis, chronic irritation of the bladder (as in long – term irritation of the bladder (as in long – term indwelling catheterization), and excessive indwelling catheterization), and excessive use of the analgesic drug phenacetin, which use of the analgesic drug phenacetin, which has been taken off the market.has been taken off the market.

Bladder cancer is the fourth most common Bladder cancer is the fourth most common cancer in men; peak incidence occurs four cancer in men; peak incidence occurs four times more frequently in men.times more frequently in men.

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CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS

1. Painless hematuria, either gross / 1. Painless hematuria, either gross / microscopic – most characteristic signmicroscopic – most characteristic sign

2. Dysuria, frequency, urgency - 2. Dysuria, frequency, urgency - bladder irritabilitybladder irritability

3. Pelvic / flank pain – obstruction / 3. Pelvic / flank pain – obstruction / metastases metastases

4. Leg edema – from invasion of pelvic 4. Leg edema – from invasion of pelvic lymph nodeslymph nodes

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DIAGNOSTIC EVALUATIONDIAGNOSTIC EVALUATION

Cystoscopy for visualization of number, Cystoscopy for visualization of number, location, and appearance of tumors; for location, and appearance of tumors; for biopsybiopsy

Urine and bladder washing for Urine and bladder washing for cystolgic study cystolgic study

Urine flow cytometry – uses a Urine flow cytometry – uses a computer – controlled fluorescence computer – controlled fluorescence microscope to scan and image the microscope to scan and image the nucleus of each cell on a slide; based nucleus of each cell on a slide; based on the fact that cancer cells contain on the fact that cancer cells contain abnormally large amounts of DNAabnormally large amounts of DNA

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IVU – may reveal filling defect indicative of IVU – may reveal filling defect indicative of bladder tumor, also to determine status of bladder tumor, also to determine status of upper tracts.upper tracts.

To evaluate for metastatic disease:To evaluate for metastatic disease:

a. CT scan / MRI – to evaluate extent of a. CT scan / MRI – to evaluate extent of disease and tumor responsivenessdisease and tumor responsiveness

b. Chest X ray – to evaluate for pulmonary b. Chest X ray – to evaluate for pulmonary metastasesmetastases

c. Pelvic lymphadenectomy (during c. Pelvic lymphadenectomy (during cystectomy) – most accurate for stagingcystectomy) – most accurate for staging

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MANGEMENTMANGEMENT Surgery –Surgery – Transurethral resection and fulguration Transurethral resection and fulguration

– endoscopic resection for superficial – endoscopic resection for superficial tumors.tumors.

Partial cystectomy - Partial cystectomy - Radical cystectomy – in men, includes Radical cystectomy – in men, includes

removal of bladder, prostate and seminal removal of bladder, prostate and seminal vesicles, proximal vas deferens, and part vesicles, proximal vas deferens, and part of proximal urethra.of proximal urethra.

In women, consists of anterior In women, consists of anterior exenteration with removal of bladder, exenteration with removal of bladder, urethra, uterus, fallopian tubes, ovaries, urethra, uterus, fallopian tubes, ovaries, and segment of anterior wall of the and segment of anterior wall of the vagina. vagina.

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Intravesical (within the bladder) Intravesical (within the bladder) ChemotherapyChemotherapy

1.1. Instillation of antineoplastic agent, Instillation of antineoplastic agent, such as thiotepa, mitomycin – C, such as thiotepa, mitomycin – C, doxorubicin allows a high doxorubicin allows a high concentration of drug to come in concentration of drug to come in contact with the tumor and contact with the tumor and urothelium with minimal systemic urothelium with minimal systemic toxicity.toxicity.

2.2. Instillation of immunotherapeutic Instillation of immunotherapeutic agent BCG stimulates immune agent BCG stimulates immune response to prevent recurrence of response to prevent recurrence of transitional cell bladder tumors.transitional cell bladder tumors.

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Systemic chemotherapySystemic chemotherapy Radiation therapyRadiation therapy

ComplicationsComplications

Regional metastasis through the pelvis Regional metastasis through the pelvis as well as metastasis to the lung, liver, as well as metastasis to the lung, liver, and bone.and bone.

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Nursing DiagnosesNursing Diagnoses Impaired Urinary Elimination related Impaired Urinary Elimination related

to hematuria and transurethral to hematuria and transurethral surgery surgery

Acute pain related to irritative Acute pain related to irritative voiding symptoms and catheter – voiding symptoms and catheter – related discomfort.related discomfort.

Anxiety related to diagnosis for Anxiety related to diagnosis for cancer cancer

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NURSING INTERVENTIONSNURSING INTERVENTIONS Maintaining Urinary Elimination After Maintaining Urinary Elimination After

Transurethral SurgeryTransurethral Surgery

1.1. Maintain patency of indwelling urinary Maintain patency of indwelling urinary drainage catheter; manual irrigation is not drainage catheter; manual irrigation is not recommended due to dangers of bladder recommended due to dangers of bladder perforation; continuous bladder irrigation perforation; continuous bladder irrigation may be used if necessary.may be used if necessary.

2.2. Ensure adequate hydration either orally / Ensure adequate hydration either orally / IV.IV.

3.3. Monitor I&O, including irrigation solution.Monitor I&O, including irrigation solution.

4.4. Monitor urine output for clearing of Monitor urine output for clearing of hematuria.hematuria.

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Controlling PainControlling Pain

1.1. Administer analgesic medication for Administer analgesic medication for pelvic discomfort.pelvic discomfort.

2.2. Administer anticholinergic Administer anticholinergic medications / belladona and opium medications / belladona and opium suppositories to relive bladder spasms.suppositories to relive bladder spasms.

3.3. Ensure patency of catheter drainage; Ensure patency of catheter drainage; do not irrigate unless specifically do not irrigate unless specifically ordered.ordered.

4.4. Remove indwelling catheter as soon Remove indwelling catheter as soon as possible after procedure.as possible after procedure.

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Relieving AnxietyRelieving Anxiety

1.1. Allow pt to verbalize fears and Allow pt to verbalize fears and concerns.concerns.

2.2. Provide realistic information about Provide realistic information about diagnostic studies, surgery, and diagnostic studies, surgery, and treatments.treatments.

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Pt Education and Health MaintenancePt Education and Health Maintenance Advise pt that irritative voiding Advise pt that irritative voiding

symptoms and intermittent hematuria symptoms and intermittent hematuria are possible for several weeks after are possible for several weeks after transurethral resection of bladder transurethral resection of bladder tumors.tumors.

Teach pt importance of vigilant Teach pt importance of vigilant adherence to follow up schedule: adherence to follow up schedule: Cystoscopy every 3 months for 1 year, Cystoscopy every 3 months for 1 year, then every six months to 1 year then every six months to 1 year thereafter for the rest of pt’s life (70% of thereafter for the rest of pt’s life (70% of superficial tumors will recur)superficial tumors will recur)

Review purpose and adverse effects of Review purpose and adverse effects of intravesical chemotherapy treatments intravesical chemotherapy treatments (usually not given after recurrence) (usually not given after recurrence)