1 CANCER OF THE BLADDER

2  Cancer of the bladder is the second most common urologic malignancy.  90% of all bladder cancers are transitional cell carcinomas, which arise from the epithelial lining if the UT; transitional cell tumors can also occur in the ureters, renal pelvis, and urethra.  The remaining 10% of bladder cancers are adenocarcinoma, squamous cell carcinoma, or sarcoma.

3 PATHOPHYSIOLOGY AND ETILOGY  Many bladder tumors are diagnosed when the lesions are superficial, papillary tumors that are easily resected.  One fourth of pts with bladder cancer present with nonpapillary, muscle invasive disease.  Bladder tumors tend to be either low grade superficial tumors / high grade invasive cancers.  Metastasis occurs in the bladder wall and pelvis; para – aortic / supraclavicular nodes; in liver, lungs, and bone.

4  Although the specific etiology is unknown, it appears that multiple agents are linked to the development of cancer of the bladder, including: a. Cigarette smoking – the risk of developing bladder cancer is up to four times higher in smokers. a. Cigarette smoking – the risk of developing bladder cancer is up to four times higher in smokers. b. Prolonged exposure to aromatic amines or their metabolites – generally dye manufactured by the chemical industry and used by other industries.

5 c. Exposure to cyclophosphamide (Cytoxan), radiation therapy to the pelvis, chronic irritation of the bladder (as in long – term indwelling catheterization), and excessive use of the analgesic drug phenacetin, which has been taken off the market.  Bladder cancer is the fourth most common cancer in men; peak incidence occurs four times more frequently in men.

6 CLINICAL MANIFESTATIONS 1. Painless hematuria, either gross / microscopic – most characteristic sign 2. Dysuria, frequency, urgency - bladder irritability 3. Pelvic / flank pain – obstruction / metastases 4. Leg edema – from invasion of pelvic lymph nodes

7 DIAGNOSTIC EVALUATION  Cystoscopy for visualization of number, location, and appearance of tumors; for biopsy  Urine and bladder washing for cystolgic study  Urine flow cytometry – uses a computer – controlled fluorescence microscope to scan and image the nucleus of each cell on a slide; based on the fact that cancer cells contain abnormally large amounts of DNA

8  IVU – may reveal filling defect indicative of bladder tumor, also to determine status of upper tracts.  To evaluate for metastatic disease: a. CT scan / MRI – to evaluate extent of disease and tumor responsiveness a. CT scan / MRI – to evaluate extent of disease and tumor responsiveness b. Chest X ray – to evaluate for pulmonary metastases b. Chest X ray – to evaluate for pulmonary metastases c. Pelvic lymphadenectomy (during cystectomy) – most accurate for staging

9MANGEMENT  Surgery – Transurethral resection and fulguration – endoscopic resection for superficial tumors. Transurethral resection and fulguration – endoscopic resection for superficial tumors. Partial cystectomy - Partial cystectomy - Radical cystectomy – in men, includes removal of bladder, prostate and seminal vesicles, proximal vas deferens, and part of proximal urethra. Radical cystectomy – in men, includes removal of bladder, prostate and seminal vesicles, proximal vas deferens, and part of proximal urethra. In women, consists of anterior exenteration with removal of bladder, urethra, uterus, fallopian tubes, ovaries, and segment of anterior wall of the vagina. In women, consists of anterior exenteration with removal of bladder, urethra, uterus, fallopian tubes, ovaries, and segment of anterior wall of the vagina.

10  Intravesical (within the bladder) Chemotherapy 1.Instillation of antineoplastic agent, such as thiotepa, mitomycin – C, doxorubicin allows a high concentration of drug to come in contact with the tumor and urothelium with minimal systemic toxicity. 2. Instillation of immunotherapeutic agent BCG stimulates immune response to prevent recurrence of transitional cell bladder tumors.

11  Systemic chemotherapy  Radiation therapy Complications Regional metastasis through the pelvis as well as metastasis to the lung, liver, and bone. Regional metastasis through the pelvis as well as metastasis to the lung, liver, and bone.

12 Nursing Diagnoses  Impaired Urinary Elimination related to hematuria and transurethral surgery  Acute pain related to irritative voiding symptoms and catheter – related discomfort.  Anxiety related to diagnosis for cancer

13 NURSING INTERVENTIONS  Maintaining Urinary Elimination After Transurethral Surgery 1.Maintain patency of indwelling urinary drainage catheter; manual irrigation is not recommended due to dangers of bladder perforation; continuous bladder irrigation may be used if necessary. 2. Ensure adequate hydration either orally / IV. 3. Monitor I&O, including irrigation solution. 4. Monitor urine output for clearing of hematuria.

14  Controlling Pain 1.Administer analgesic medication for pelvic discomfort. 2. Administer anticholinergic medications / belladona and opium suppositories to relive bladder spasms. 3. Ensure patency of catheter drainage; do not irrigate unless specifically ordered. 4. Remove indwelling catheter as soon as possible after procedure.

15  Relieving Anxiety 1.Allow pt to verbalize fears and concerns. 2. Provide realistic information about diagnostic studies, surgery, and treatments.

16 Pt Education and Health Maintenance Pt Education and Health Maintenance  Advise pt that irritative voiding symptoms and intermittent hematuria are possible for several weeks after transurethral resection of bladder tumors.  Teach pt importance of vigilant adherence to follow up schedule: Cystoscopy every 3 months for 1 year, then every six months to 1 year thereafter for the rest of pt’s life (70% of superficial tumors will recur)  Review purpose and adverse effects of intravesical chemotherapy treatments (usually not given after recurrence)