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Causes and symptoms
bladder cancerA malignant epithelial neoplasm arising in the transitional epithelium of the renal pelvis, ureter and urinary bladder; it is the 5th most common cancer of men in developed nations.
±55,000 new cases/year (US); 90% 5-year survival; 9% if distant metastasis when diagnosed.
Hematuria, increased urinary frequency.
Superficial (80% of total) throughout their entire clinical course; invasive ab initio.
Tobacco use (2- to 3-fold increased risk); occupational exposure to petrochemicals (benzene, exhaust fumes) and carcinogens in rubber, chemical and leather industries; schistosomiasis.
History, PE, urine cytology, imaging; confirm by cystoscopy and biopsy.
Depends on growth, size and location of tumour; for superficial UC, close follow-up is appropriate; for invasive BC, cystectomy, cystoprostatectomy and radical cystectomy may be needed; RT, neoadjuvant (preemptive) chemotherapy or bCG may be used.
Bladder cancer staging
Stage I—Cancer spreads to bladder mucosa but not to muscle wall.
Stage II—Cancer spreads to muscle wall of bladder.
Stage III—Cancer spreads through muscle wall to peritoneum and/or nearby reproductive organs.
Stage IV—Cancer spreads to abdominal wall, pelvis, to nearby lymph nodes, or metastasised.
bladder cancerCancer of urinary bladder Urology A malignant epithelial neoplasm of the urinary bladder; it is the 5th most common cancer of ♂ in developed nations Statistics 52,300 new cases/1993–US; 90% 5-yr survival; 9% if distant metastasis when diagnosed Clinical types Superficial—80% of total—throughout their clinical course; invasive ab initio Risk factors Tobacco, occupational exposure to petrochemicals–benzene, exhaust fumes and carcinogens in rubber, chemical and leather industries, schistosomiasis Diagnosis History, PE, urine cytology, imaging; confirm by cystoscopy & biopsy Clinical Hematuria, ↑ urinary frequency Management Depends on growth, size, location of tumor; for superficial UC, close followup is appropriate; for invasive BC, cystectomy, cystoprostatectomy, and radical cystectomy may be needed; RT, neoadjuvant–preemptive chemotherapy, or bCG may be used
Bladder cancer staging
- Stage I
- Cancer spread to bladder mucosa but not to muscular wall
- Stage II
- Cancer spread to muscular wall of bladder
- Stage III
- Cancer spread through muscular wall to peritoneum and/or to the nearby reproductive organs
- Stage IV
- Cancer spread to abdominal wall, pelvis, to nearby lymph nodes, or it has metastasized
|Mean LOS:||9.5 days|
|Description:||SURGICAL: Kidney and Ureter Procedures for Neoplasm With Major CC|
|Mean LOS:||4.7 days|
|Description:||MEDICAL: Kidney and Urinary Tract Neoplasms With CC|
Cancer of the urinary bladder is the second-most common genitourinary (GU) cancer after prostate cancer. It accounts for approximately 4% of all cancers and 2% of deaths from cancer in the United States. The American Cancer Society estimates that in 2013, there were 72,570 new cases of bladder cancer and 15,210 people died from the disease.
The majority of bladder tumors (> 90%) are urothelial or transitional cell carcinomas arising in the epithelial layer of the bladder, although squamous cell (4%), adenocarcinoma (1% to 2%), and small cell (1%) may occur. Urothelial tumors are classified as invasive or noninvasive and according to their shape (papillary or flat). Noninvasive urothelial cancer affects only the innermost layer of the bladder, whereas invasive urothelial cancer spreads from the urothelium to the deepest layers of the bladder. The deeper the invasion is, the more serious that the cancer is. Papillary tumors have fingerlike projections that grow into the hollow of the bladder. Flat urothelial tumors involve the layer of cells closest to the inside of the bladder.
Most bladder tumors are multifocal because the environment of the bladder allows for the continuous bathing of the mucosa with urine that contains tumor cells that can implant in several locations. The ureters, bladder neck, and prostate urethra may become obstructed. Direct extension can occur to the sigmoid colon, rectum, and, depending on the sex of the patient, the prostate or uterus and vagina. Metastasis occasionally occurs to the bones, liver, and lungs.
Bladder cancer is staged on the basis of the presence or absence of invasion and is graded (I to IV) on the basis of the degree of differentiation of the cell, with grade I being the best differentiated and slowest growing. Both the stage and the grade of the tumor are considered when planning treatment.
The cause of bladder cancer is not well understood; however, cigarette smoking and occupational exposure to aromatic amines (textile dyes, rubber, hair dyes, and paint pigment) are established risk factors. These cancer-causing chemicals enter the bloodstream, are filtered through the kidneys, become concentrated in the urine, and then damage the endothelial cells that line the inside of the bladder. Other associated factors include chronic bladder irritation and infection, vesical calculi, and exposure to cyclophosphamide (Cytoxan). Moderate to high amounts of caffeine could also possibly increase risk.
Although bladder cancer is generally considered to come from somatic (rather than germ line) mutations in bladder cells, mutations in several genes (e.g., HRAS, KRAS, RB1, and FGFR3) have been associated with susceptibility to bladder carcinogenesis.
Gender, ethnic/racial, and life span considerations
Bladder cancer occurs most frequently in persons over age 50, with more than half of the cases occurring in individuals over age 72. It is rare in persons under age 40. Bladder cancer is more common in men (1 in 30) than in women (1 in 90). Incidence is highest among European American men, with a rate twice that of African American men and four times that of European American women. Asians have the lowest incidence of bladder cancer. Younger men have reported less impotency following radical cystectomy than have older men. Persons living in urban areas are at higher risk for bladder cancer than persons living in rural areas.
Global health considerations
The global incidence is 8 per 100,000 males and 2.7 per 100,000 females. Developed countries have an incidence of bladder cancer from 6 to 10 times higher than developing countries. In North and South America, Europe, and Asia, transitional cell carcinoma is the most common type of bladder cancer.
Gross, painless, intermittent hematuria is the most frequently reported symptom. Occult blood may be discovered during a routine urinalysis. Dysuria and urinary frequency are also reported. Burning and pain with urination are present only if there is infection. The patient may not seek medical attention until urinary hesitance, decrease in caliber of the stream, and flank pain occur. Other symptoms may include suprapubic pain after voiding, bladder irritability, dribbling, and nocturia.
The physical examination is usually normal. A bladder tumor becomes palpable only after extensive invasion into surrounding structures.
After a diagnosis of cancer, treatment with radical cystectomy and creation of a urinary diversion system can threaten the sexual functioning of both men and women. The procedure can cause impotence in men and psychological problems similar to those that accompany a hysterectomy and oophorectomy in women. In addition, a portion of the vagina may be removed, thus affecting intercourse. The psychological impact of a stoma and external urinary drainage system can cause changes in body image and libido.
General: Urinalysis generally reveals gross hematuria and occasionally pyuria.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Cystoscopy/biopsy||Normal view of bladder, free of growths||Suspicious growths are seen; a small piece is removed and biopsied||Biopsy confirms the malignancy|
|Serum carcinoembryonic antigen (CEA) level||< 2.5 ng/dL in nonsmokers; < 5 ng/mL in smokers||Approximately 50% of patients with late-stage bladder cancer have moderately elevated CEA levels||Useful in monitoring response to treatment and extent of disease|
|Urine cytology||Normal type and amount of squamous and epithelial cells of urinary tract||Abnormal cells are seen under the microscope (tumor and pretumor cells)||Evidence of urinary tract neoplasm|
Other Tests: Urine culture, urinalysis with microscopy, intravenous pyelogram, ultrasonography, pelvic computed tomography scan, magnetic resonance imaging, bone scan, complete blood count, liver and kidney function tests, alkaline phosphatase (bony fraction)
Primary nursing diagnosis
DiagnosisRisk for altered urinary elimination related to the obstruction of urinary flow
OutcomesUrinary continence; Urinary elimination; Knowledge: Disease process and treatment regime; Self-care: Toileting; Self-esteem
InterventionsUrinary elimination management; Urinary incontinence care; Teaching: Individual; Fluid monitoring; Urinary catheterization; Anxiety reduction; Infection control; Skin surveillance; Tube care: Urinary
Planning and implementation
Patients with higher stage invasive disease are usually treated with radical curative surgery, whereas patients with lower stage noninvasive disease can be controlled with more conservative measures. Papillary tumors, even when noninvasive, have a high rate of recurrence. Carcinoma in situ (CIS) is usually multifocal and also has a high rate of recurrence.
conservative.Superficial bladder tumors can be treated effectively with conservative measures that consist of surgical removal of the tumor by transurethral resection of the bladder (TURB) followed by electrical destruction or fulguration, intravesical instillation of chemotherapy or immunotherapy, and frequent follow-up cystoscopic examination. Superficial bladder tumors can also be destroyed with the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser. Patients with multiple superficial bladder tumors receive intravesical instillation of chemotherapy and immunotherapy, such as bacillus Calmette-Guérin (BCG) vaccine. This vaccine is made from a strain of Mycobacterium bovis and helps to prevent a relapse.
surgical.Partial or segmental cystectomy may be recommended for patients with diffuse, unresectable tumors or tumors that fail to respond to intravesical therapy. Because tumors are likely to continue to spread and metastasize to distant sites, procedures such as radical cystectomy with creation of a urinary diversion, external radiation therapy, or a combination of preoperative radiation therapy followed by radical cystectomy and urinary diversion are recommended.
The Bricker ileal conduit is the most popular method for creating the urinary diversion. In this procedure, the ureters are implanted into an isolated segment of the terminal ileum. The proximal end of the ileal segment is closed, and a stoma is formed by bringing the distal end out through a hole in the abdominal wall. An external pouch for the collection of urine is worn continuously. Ureteral stents, which are left in place up to 3 weeks after surgery, may be placed during the procedure to promote the flow of urine.
postoperative.Postoperatively, direct nursing care toward providing comfort, preventing complications from major abdominal surgery, and promoting urinary drainage. Monitor the patient’s vital signs, dressings, and drains for symptoms of hemorrhage and infection. Monitor the color of the stoma, as well as the amount and color of the urine in the collection pouch, every 4 hours. Urine should drain immediately. Some stomal edema is normal during the early postoperative period, but the flow of urine should not be obstructed.
radiation.External beam radiation therapy can be used as both adjuvant and definite treatment for bladder cancer. High-dose, short-course therapy consisting of 16 to 20 Gy can be delivered preoperatively to decrease the size of the tumor(s) and prevent spread during surgery. Radiation therapy with a curative intent may be a treatment option for patients who are opposed to a cystectomy and urinary diversion. Unfortunately, 50% of patients with invasive bladder cancer eventually relapse.
|Medication or Drug Class||Dosage||Description||Rationale|
|Thiotepa, mitomycin, doxorubicin||Varies with drug||Intravesical chemotherapy||Reduce recurrence in those who had complete transurethral resection|
|M-VAC (methotrexate, vinblastine, adriamycin, cisplatin) MCV (methotrexate, cisplatin, vinblastine) GemCIS (gemcitabine, cisplatin)||Varies with drug||Combination systemic antineoplastic chemotherapy||Combination systemic chemotherapy may be effective in prolonging life but is rarely curative|
For patients who require radical cystectomy with urinary diversion, offer support and reinforcement of the information. Ensure that the patient knows what to expect. Involve another family member in the preoperative education. If it is needed, arrange a preoperative visit by someone who has adjusted well to a similar diversion.
If any type of stoma is to be created, arrange for a preoperative visit from the enterostomal therapist. The enterostomal therapist can assist in the selection and marking of the stoma site (although the stoma site is somewhat contingent on the type of urinary diversion to be performed) and can introduce the patient to the external urine collection pouch and related care. Suggest involvement with community associations such as the United Ostomy Association and the American Cancer Society.
postoperative.Encourage the patient to look at the stoma and take an active part in stoma care as soon as possible. Allow him or her to hold the equipment, observe the amount and characteristics of urine drainage, and empty the urine collection pouch. Implement care to maintain integrity of the skin around the stoma or urinary diversion that has been created. Empty the urinary drainage pouch when it is about one-third full to prevent the weight of the pouch from breaking the skin seal and leaking urine onto the skin. Depending on the type of urinary diversion created, begin teaching stoma care and care of the system 2 to 3 days after surgery.
Be sensitive to the patient’s feelings about the potential for altered sexual functioning after radical cystectomy. Listen attentively and answer any questions honestly. Encourage the patient and his or her partner to explore alternative methods of sexual expression. Consider referral to a sex therapist. If appropriate, suggest that men investigate the possibility of a penile prosthesis with their physician.
Evidence-Based Practice and Health Policy
Mohamed, N.E., Herrera, P.C., Hudson, S., Revenson, T.A., Lee, C.T., Quale, D.Z., …Diefenbach, M.A. (2013). Muscle invasive bladder cancer: Examining survivor burden and unmet needs. The Journal of Urology. Advanced online publication. doi 10.1016/j.juro.2013.07.062
- Investigators of one study explored unmet needs among a sample of 30 patients who underwent cystectomy and urinary diversion for treatment of bladder cancer. They found that patients experiencing bladder cancer have varying informational, medical, and psychological needs along the cancer trajectory.
- At the point of diagnosis, 57% of patients felt the information they received was insufficient and indicated they needed more information on postoperative self-care, the healing process, and finances and medical insurance. Only 20% of patients reported receiving information about possible changes in sexual function, and 33% of patients reported feeling severely depressed when diagnosed but none received a referral for care.
- Postoperatively, 53% of patients received support at home from a visiting nurse. However, 30% of these patients reported needing more support in stomal or continent reservoir care.
- At survivorship (6 to 72 months postoperatively), 43% of patients experienced changes in sexual function; however, only 17% of these patients received advice on sexual dysfunction. Similar to the time of diagnosis, 33% of patients reported feeling depressed; however, less than 7% received professional assistance for depressive symptoms.
- Description of all dressings, wounds, and drainage collection devices
- Physical findings related to the pulmonary assessment, abdominal assessment, presence of edema, condition of extremities, bowel and bladder patterns of voiding
- Response to and side effects experienced related to intravesical instillations of chemotherapy or BCG; systemic chemotherapy
- Teaching performed, the patient’s understanding of the content, the patient’s ability to perform procedures demonstrated
Discharge and home healthcare guidelines
patient teaching.Following creation of an ileal conduit, teach the patient and significant others how to care for the stoma and urinary drainage system. If needed, arrange for follow-up home nursing care or visits with an enterostomal therapist.
Teach the patient the specific procedure to catheterize the continent cutaneous pouch or reservoir. A simple stoma covering made from a feminine hygiene pad can be worn between catheterizations. Stress the need for the patient to wear a medical ID bracelet.
Following orthotopic bladder replacement, teach the patient how to irrigate the Foley catheter. Suggest the use of a leg bag during the day and a Foley drainage bag at night. Once the pouch has healed and the Foley catheter, ureteral stents, and pelvic drain have been removed, teach the patient to “push” or “bear down” with each voiding. Instruct the patient on methods for performing Kegel exercises during and between voidings to minimize incontinence. Suggest wearing incontinence pads until full control is achieved. Also instruct the patient on self-catheterization techniques in case the patient is unable to void. Instruct patients where to obtain ostomy pouches, catheters, and other supplies. Teach the patient how to clean and store catheters between use following the clean technique.