Bladder Cancer

Bladder Cancer

- The most frequent tumor of the urinary track is transitional cell carcinoma of the bladder. Most bladder tumors are papillomatous growths within the bladder. Cancer of the bladder is most common between the age 60 &70 years and is at least three times as common in men as in women.

- Risk factors for bladder cancer include cigarette-smoking exposure to dyes used in the rubber & cable industries & chronic abuse of phenacetin-containing analgesics. Women treated with radiation for cervical cancer & patient as receiving cyclophosphamide (Cytoxan) also have increased risk, but the reason is unknown.

- Individuals with chronic, recurrent stones (often bladder) and chronic lower urinary infection have or increased risk of squamous cell cancer of the bladder. Patients who have indwelling catheters for long period can develop this chronic condition.


* Clinical Manifestation &
Diagnostic Studies :

- Gross, patient's hematuria (chronic or intermittent) is the most common clinical finding. Bladder irritability with dysuria, frequency. And urgency may also occur. When cancer is suspected, urine specimens for cytology can be obtained to determine the presence of neoplastic or atypical cells. Exfoliated cells from the epithelial surface of the bladder can readily be detected in voided specimens. Other recent urine test assess for specific factors associated with bladder cancer, such as bladder tumor antigens. Bladder cancers can be detected using IVP, ultrasound, CT, or MR. However, the presence of cancer is confirmed by cystoscopy and biopsy.

- The clinical staging of carcinoma of the bladder is determined by the depth of invasion of the bladder wall and surrounding tissue. The Jewett-Strong-Marshall classification system broadly classifies bladder cancer superficial (carcinoma is situ] CIS [, O, A) invasion (B1, B2, C), or metastatic (D1 to D4) disease.

- Pathologic grading systems are also used to classify the malignant potential of tumor cells, indicating a scale from well-differentiated to anaplastic categories. Low-stage, low-grade bladder cancers are the most responsive to treatment and are more easily cured.



* Collaborative Care :

 Diagnostic :
- History & physical examination.
- Urinalysis.
- Intravenous pyelogram.
- Cystoscopy with biopsy.
- Cytology studies.
- Ultrasound.
- CT scan.

 Collaborative Care :
 Surgical treatment :
- Transurethral resection with fulguration.
- Laser photocoagulation.
- Open loop resection or fulguration.
- Segmental cystectomy.
- Radical cystectomy.

 Radiation.

 Intravesical immunotherapy:
- Bacille Calmette-Guérin (BCG).
- Α-interferon .

 Intravesical chemotherapy :

- Thiotepa.
- Mitomycin (Mutamycin).
- Doxorubicin (Adriamycin).
- Valrubicin (Valster).

 Systemic chemotherapy.













* Surgical Therapy...

- Surgical therapies include a variety of procedures. Transurethral resection with fulguration (electrocautey) is used for the diagnosis and treatment of superficial lesion with a low recurrence rate. This procedure as also used to control bleeding in the patient who is a poor operative risk or who has advanced tumors. With this technique the tumor mass is excised by means of a blade inserted through the cystoscopy. The remaining portions of the tumor are cauterized.

- A second technique, laser photocoagulation, is also used to treat superficial bladder cancers. This procedures can be repeated a number of times for recurrence. The advantages of laser include bloodless destruction of the lesion, minimal risk of perforation, and lack of need for a urinary catheter. The primary disadvantage is destruction of the tumor, so pathologic evaluation for grading and staging cannot be completed.

- A third technique used is open loop resection (snaring of polyp types of lesion) with fulguration. It is used for the control of bleeding, for large superficial tumors, and for multiple lesions. Treatment of large lesion entails a segmental resection of the bladder (segmental cystoscopy).




- Postoperative management of the patient who has had any of these surgical procedures includes instruction to drink a large volume of fluid each day for the first week following the procedures and to avoid intake of alcoholic beverages. The patient is taught to self-monitor the urine. It is anticipated to be pink during the first several days after the procedures, but it should not be bright red or contain blood clots. Approximately 7 to 10 days following tumor resection or ablation. The patient may observe dark red or rust colored fleck in the urine. These are anticipated and present scabs from the healing tumor resection sites. Opioid analgesics may be required for a brief period after the procedures, along with stool softeners. The patient can be encouraged to take a 15- to 20-minute size bath two to three times a day to promote muscle relaxation and to reduce the risk of urinary retention. The nurse should also help the patient and family cope with fears about cancers, surgery, and sexuality and should emphasize the importance of regular follow up care. Frequent routine cystoscopies are required.

- when the tumor is invasive or when it involves the trigone (the area where the ureters insert into the bladder) and the patient is free from metastasis beyond the pelvic area, a partial or radical cystectomy with urinary diversion is the treatment of choice (see the following section on urinary diversion). A partial cystectomy includes resection of the bladder wall containing the tumor, along with a margin of normal tissue. A radical cystectomy involves removal of the bladder, prostate, and seminal vesicles in men and the bladder, uterus, cervix, urethra, and ovaries in women.
* Radiation Therapy and Chemotherapy ...

- Radiation therapy is used with cystectomy or as primary therapy when the cancer is inoperable or when surgery is refused. Increasingly, radiation therapy is being combined with systemic chemotherapy. Sometimes combination systemic chemotherapy is used for bladder cancer, usually preoperatively or before radiation therapy, or is used to treat distant metastases. Chemotherapy drugs used in treating invasive bladder cancer include cisplatin (Platinol), vinblastin (velban), Doxorubicin (Adriamycin), and methotrexate.



* Intravesical Therapy ...

- Chemotherapy with local instillation of chemotherapy or immune-stimulating agents can be delivered directly into the bladder by a urethral catheter. Protocols vary, but intravesical therapy is usually initiated at weekly intervals for 6 to 12 weeks. The chemotherapeutic agents are instilled directly into the patientُs bladder and retained for about 2 hours. The patients position may be changed every 15 minutes for maximum contact in all areas of the bladder, especially if the tumor occurred on the bladder dome. The use of maintenance therapy after the initial induction regimen may be beneficial.

- BCG, a weekend strain of Mycobacterium bovis, is the treatment of choice for carcinoma in situ. BCG stimulates the immune system rather than acting directly on cancer cells in the bladder. When BCG fails, α-interferon in addition to BCG may be used. Other treatment that can used when BCG fails include thiotepa, an alkylating agent, and Valrubicin (Valstar), an antineoplastic antibiotic.

- Most patients have irritative voiding symptoms and hemorrhagic cystitis following intravesical therapy. Thiotepa (when absorbed into circulation from the bladder wall) can significantly reduce WBC and platelet counts in some individuals. BCG may cause flulike symptoms, hematuria, or systemic infection. Other side effect usually associated with chemotherapy, such as nausea, vomiting, and hair loss, are not experienced with intravesical chemotherapy.

- Nursing responsibilities include encouraging the patient to increase the daily fluid intake and to quit smoking, assessing the patient for secondary UTI, and stressing the need for routine urologic follow-up. The patient may have fears or concerns about sexual activity or bladder function that will need to be addressed.