Urothelial (Bladder) Cancer Flashcards
What is the pathophysiology of urothelial (bladder) cancer?
Urothelial cancers are malignant tumors of the urothelium, which is the lining of transitional cells in the kidney, renal pelvis, ureters, urinary bladder, and urethra. Most urothelial cancers occur in the bladder, and the term bladder cancer describes this condition. Urothelial cancer is also known as transitional cell carcinoma (TCC). Urothelial cancers are usually low grade, have multiple points of origin (multifocal), and are recurrent. Once the cancer spreads beyond the transitional cell layer, it is highly invasive and can spread beyond the bladder. Because of the nature of this cancer, patients may have recurrence up to 10 years after being cancer free.
What are risk factors associated with urothelial (bladder) cancer?
- Exposure to toxins such as gasoline and diesel fuel.
- Exposure to chemicals used in hair dyes and in the rubber, paint, electric cable, and textile industries, increases the risk for bladder cancer.
- The greatest risk factor for bladder cancer is tobacco use.
- Schistosoma haematobium (a parasite) infection
- Excessive use of drugs containing phenacetin
- Long-term use of cyclophosphamide.
What are physical assessment signs and symptoms?
- Observe the patient’s overall appearance, especially skin color and nutrition status.
- Inspect, percuss, and palpate the abdomen for asymmetry, tenderness, and bladder distention.
- Examine the urine for color and clarity. Blood in the urine is often the first indication of bladder cancer. It may be gross or microscopic and is usually painless and intermittent. -
- Dysuria, frequency, and urgency occur when infection or obstruction is also present.
What are questions the nurse should ask the patient during the physical assessment?
- Ask about the patient’s perception of his or her general health. Document the gender and age of the patient.
- Ask about active and passive exposure to cigarette smoke.
- To detect exposure to harmful environmental agents, ask the patient to describe his or her occupation and hobbies in detail.
- Ask the patient to describe any change in the color, frequency, or volume of urine elimination and any abdominal discomfort.
What is assessed during the psychosocial assessment?
- Assess the patients emotions, including the response to a tentative diagnosis of bladder cancer and note, anxiety, anger, fear, sadness, sadness, and guilt.
- Early symptoms are painless, and many patients ignore the blood in the urine because it is intermittent.
- They also may be reluctant to seek treatment if they suspect a sexually transmitted infection (STI). As a result, they may have guilt or anger about their own delays in seeking medical attention.
- Assess the patient’s coping methods and available support from family members.
- Social support may provide motivation and improve coping during recovery from treatment.
What diagnostics could a patient have done to identify the presence of bladder cancer?
Urinalysis
- Looking for gross or microscopic hematuria.
Bladder-Wash & Bladder Biopsies
- Most specific test for identifying cancer.
Cystoscopy
- Performed to evaluate painless hematuria. A biopsy of a visual bladder tumor can be performed during cystoscopy.
Cystoureterography
- Used to identify obstructions, especially where the ureter joins the bladder.
CT Scan
- Shows tumor invasion of surrounding tissues.
Ultrasonography
- Show masses but it is less valuable for tumor staging.
MRI
- May help assess deep, invasive tumors.
What are non-surgical interventions associated with bladder cancer?
Prophylactic immunotherapy with intravesical instillation of bacille Calmette-Guérin (BCG), a live virus compound, is used to prevent tumor recurrence of superficial cancers. This procedure is more effective than single-agent chemotherapy. Usually the agent is instilled in an outpatient cancer clinic and allowed to dwell in the bladder for a specified length of time, usually 2 hours. When the patient urinates, live virus is excreted with the urine.
Multiagent chemotherapy is successful in prolonging life after distant metastasis has occurred but rarely results in a cure.
Radiation therapy is also useful in prolonging life.
What should the nurse teach a patient regarding prophylactic immunotherapy with intravesical installation of bacille Calmette- Guerin (BCG)?
- Teach patients receiving this treatment to prevent contact of the live virus with other members of the household by not sharing a toilet with others for at least 24 hours after instillation.
- Instruct men to urinate while sitting down to avoid splashing the urine.
- After 24 hours, the toilet should be completely cleaned using a solution of 10% liquid bleach.
- If only one toilet is available in the household, teach the patient to flush the toilet after use and follow this by adding one cup of undiluted bleach to the bowl water. The bowl is then flushed after 15 minutes, and the seat and flat surfaces of the toilet are wiped with a cloth containing a solution of 10% liquid bleach.
- Instruct the patient to wear gloves during the cleaning and to dispose of the cloth after sealing it in a plastic bag.
- Underwear or other clothing that has come in contact with the urine during the immediate 24 hours after instillation should be washed separately from other clothing in a solution of 10% liquid bleach.
- Sexual intercourse is avoided for 24 hours after the instillation.
What are surgical interventions associated with bladder cancer?
Cystectomy
- Complete bladder removal with additional removal of surrounding muscle and tissue offer the best chance of a cure for the large.
Transurethral resection of the bladder tumor (TURBT) or partial cystectomy.
What is included in preoperative care for surgical interventions?
- Specific patient education depends on the type and extent of the planned surgical procedure. Coordinate education before surgery with the patient, surgeon, and enterostomal therapist (ET) or wound, ostomy, and continence nurse.
- Discuss the type of planned urinary diversion and the selection of a site for the stoma. The site selected for the stoma should be visible to the patient and avoid folds of skin, bones, and scar tissue. When possible, the waistline or belt area is avoided to reduce the risk for reducing tissue integrity.
- Including the patient in this planning improves the chances for the patient to have a positive attitude about body image and a positive self-image.
- Use educational counseling to ensure understanding about self-care practices, methods of pouching, control of urine drainage, and management of odor.
- Prepare the patient for the number and type of drains that will be present after surgery.
What is included in postoperative care for surgical intervention?
- After cutaneous ureterostomy, an external pouch covers the ostomy to collect urine and maintain tissue integrity. Collaborate with the enterostomal therapist to focus care on the wound, the skin, and urinary drainage.
- The patient with a Kock’s pouch, a continent reservoir, may have a Penrose drain and a plastic Medena catheter in the stoma. The drain removes lymphatic fluid or other secretions; the catheter ensures urine drainage so incisions can heal.
- The patient with a neobladder usually requires 2 to 4 days in the ICU and will have a drain at first in the event the neobladder requires irrigation. Later, irrigation can be performed with intermittent catheterization. Irrigation is performed to ensure patency. There is no sensation of bladder fullness with a neobladder because sensory nerves are not attached. As a result, the patient will need to learn new cues to void, such as prescribed times or noticing a feeling of neobladder pressure.
- Different types of drains and nephrostomy catheters are used, sometimes on a temporary basis, to drain urine from the kidney. Some are totally internal, with no drainage to the outside. Others may drain exclusively to the outside, and urine is collected in a pouch or bag. For this type of drainage system, urine output remains constant. Decreased or no drainage is cause for concern and must be reported to the surgeon or nephrologist, as is leakage around the catheter. Some nephrostomy tubes are connected both to the new bladder (internal drainage) and to an external drainage system. With this type of system, urine output from the external portion of the catheter varies.
- With any drainage system, intervention is needed if the external catheter is partially or completely pulled out accidentally. Immediately notify the surgeon or nephrologist. If the catheter remains partially in place, secure it from further movement. This action may result in a reinsertion process rather than a total replacement.
What are ureterostomies?
Ureterostomies divert urine directly to the skin surface through a ureteral skin opening (stoma). After ureterostomy, the patient must wear a pouch.
What are conduits?
Conduits collect urine in a portion of the intestine, which is then opened onto the skin surface as a stoma. After the creation of a conduit, the patient must wear a pouch.
What are sigmoidostomies?
Sigmoidostomies divert urine to the large intestine, so no stoma is required. The patient excretes urine with bowel movements, and bowel incontinence may result.
What are ileal reservoirs?
Ileal reservoirs divert urine into a surgically created pouch, or pocket, that functions as a bladder. The stoma is continent, and the patient removes urine by regular self-catheterization.
