Bladder cancer and its management

1. BLADDER CANCER
AND ITS
MANAGEMENT
SUBMITTED BY:
MISS.SHWETA SHARMA
M.SC. NURSING
1ST YEAR
AIIMS, JODHPUR

2. INTRODUCTION
Bladder cancer is a cancer
that forms in tissues of the
bladder.
Common symptoms include
blood in the urine, pain with
urination, and low back
pain.

4. •Most frequent neoplasm of the urinary
tract, accounting for about 6% of all
cancer cases in men and 2% in women.
•More common in people older than 55
years.
•It affects more men than women (4:1).

5. NORMAL ANATOMY OF URINARY
BLADDER

7. ETIOLOGY AND RISK
FACTORS

9. PATHOPHYSIOLOGY
TNM staging system
Cancer stage grouping

19. CLINICAL MANIFESTATIONS

21. COMPLICATIONS

23. DIAGNOSTIC EVALUATION

25. • Bladder tumour antigens
• Telomeric repeat amplification protocol (TRAP)
• Nuclear matrix proteins
• Adhesion molecules
• Cytoskeletal proteins
• Growth factors

26. MEDICAL MANAGEMENT
Treatment of bladder cancer depends on: -
•the grade of the tumour (the degree of cellular
differentiation)
•the stage of tumour growth (the degree of local
invasion and the presence or absence of metastasis)
•the multicentricity (having many centers)
The patient’s age and physical, mental, and
emotional status are considered when determining
treatment modalities.

27. Chemotherapy
Combination of methotrexate, 5-fluorouracil,
vinblastine, doxorubicin and cisplatin has been
effective in producing partial remission of
transitional cell carcinoma of bladder.
-IV chemotherapy may be accompanied by
radiation therapy.
-Topical chemotherapy (intravesical
chemotherapy or instillation of anti-neoplastic
agents into the bladder, resulting in contact of
the agent with the bladder wall) is considered
when there is a high risk of recurrence, when
cancer in situ is present, or when tumour
resection has been incomplete.

28. -Topical chemotherapy delivers a high
concentration of medication (thiotepa,
doxorubicin, mitomycin, and BCG live) to the
tumour to promote tumour destruction.
-Bladder cancer may also be treated by direct
infusion of the cytotoxic agent through the
bladder’s arterial blood supply to achieve a
higher concentration of the chemotherapeutic
agent with fewer systemic toxic effects.

29. BCG Live
- It is conservative intravesical agent for recurrent
bladder cancer, especially superficial transitional
cell carcinoma.
-BCG Live has a 43% advantage in preventing tumour
recurrence, a significantly better rate than the 16%
to 21% advantage of intravesical chemotherapy.
-The optimal course of BCG Live appears to be a 6-
week course of weekly instillations, followed by a 3-
week course at 3 months for tumours that do not
respond. In high-risk cancers, maintenance BCG Live
administered in a 3-week course at 6, 12, 18 and 24
months may limit recurrence and prevent
progression.

30. The patient is allowed to eat and drink
before the instillation procedure. Once the
bladder is full, the patient must retain the
intravesical solution for 2 hours before
voiding, with side-to-side position changes or
supine-to-prone changes required every 15 to
30 minutes. At the end of the procedure, the
patient is encouraged to void and drink
liberal amounts of fluid to flush the
medication from the bladder.

31. Radiation therapy
To reduce micro extension of
the neoplasm .
Also used in combination with
surgery or to control the
disease in patients with
inoperable tumours.
Side effects of radiation are
haemorrhagic cystitis and
bladder irritation.

32. External super voltage radiation is effective when
used in combination with surgery or chemotherapy.(to
treat deep tumours)
Hyperbaric radiation therapy increases the oxygen
tension of the tumour cells and their radio sensitivity.
Palliative radiation may be used to relieve pain, to
prevent and relieve bowel obstruction, to control
potential haemorrhage, and to alleviate leg oedema
secondary to venous or lymphatic obstruction.

34. Hydrostatic therapy
For more advanced bladder cancer or for patients
with intractable haematuria (especially after
radiation therapy), a large, water-filled balloon
placed in the bladder produces tumour necrosis by
reducing the blood supply of the bladder wall. The
instillation of formalin, phenol, or silver nitrate
relieves haematuria and strangury (slow and
painful discharge of urine) in some patients.

35. Investigational therapy
This procedure involves systemic injection of a
photosensitizing material (hematoporphyrin), which
the cancer cells pick up. A laser-generated light then
changes the hematoporphyrin in the cancer cell into a
toxic agent.
Chemoprevention is the use of drugs, vitamins, or
other substances to reduce the risk of developing
cancer or to reduce the risk of it returning.

36. SURGICAL
MANAGEMENT

37. Transurethral resection of the bladder
Local resection and fulguration (destruction of tissue
by electrical current through electrodes place in
direct contact with the tissue)
Perform for early tumor for cure or for inoperable
tumors for palliation.

38. Partial Cystectomy
 Done for early tumors and for clients who cannot tolerate radical
cystectomy.
 Maintenance of a continuous output of urine following surgery is
critical to prevent bladder distention and stress on the suture line.
 A urethral catheter and a suprapubic catheter maybe in place, and
the suprapubic catheter maybe left in place for 2 weeks until healing
occurs.

39. Cystectomy and urinary diversion
 The procedure involves removal of the bladder and
urethra in the women, and the bladder, the urethra, and
usually the prostrate and seminal vesicles in men.
 When the bladder and urethra are removed, permanent
urinary diversion is required.
 The surgery may be performed into stages if the tumor is
expensive, with the creation of the urinary diversion first
and the cystectomy several weeks later.
 If a radical cystectomy is performed lower extremity
lymphedema may occur as a result of lymph node
dissection, and impotence may occur in the may client.

40. Ileal conduit
The ileal conduit also is called
ureteroileostomy or Bricker’s
procedure.
Complications include
obstruction, pyelonephritis,
leakage at the anastomosis site,
stenosis, hydronephrosis,
calculuses, skin irritation and
ulceration, and stomal defects.

41. Indiana pouch
 A continent reservoir is created from the
ascending colon and terminal ileum,
making a pouch larger than the Koch
pouch.
 Postoperatively, the client will have a 24 to
26 Foley catheter in place to drain urine
continuously until the pouch has healed.
 The Foley catheter is irrigated gently with
NS to prevent obstruction from mucus or
clots.
 Following removal of the Foley catheter,
the client is instructed in how to self-
catheterize and to drain the reservoir at 4
to 6-hour intervals.

43. Kock pouch

44. Creation of a neobladder

49. Percutaneous nephrostomy or
pyelostomy
 These procedures are used when
the cancer is inoperable to
prevent obstruction.
 The procedures involve a
percutaneous or surgical
insertion of a nephrostomy tube
into the kidney for drainage.
 Nursing interventions involves
stabilizing the tube to prevent
dislodgement and monitoring
output.

50. Ureterostomy
Ureterostomy may be
performed as a palliative
procedure if the ureters are
obstructed by the tumor.
Potential problems include
infection, skin irritation,
and obstruction to urinary
flow as a result of strictures
at the opening.

51. Vesicostomy
The bladder is sutured
to the abdomen, and a
stoma is created in the
bladder wall.
The bladder empties
through the stoma.

53. ASSESSMENT
•Health history- Medical and surgical history.
•Assess for hematuria, irritative voiding symptoms, risk factors
(especially smoking history), weight loss, fatigue, and signs of
metastasis.
•Ask about drug, chemical and food allergies.
•Explain risk factors from exposure to known carcinogens.
•Ask the client about changes in urine or urination patterns,
noting changes in colour, frequency and amount.
•Assess coping ability and knowledge of the disease and
explore feelings about impotence.

54. NURSING DIAGNOSIS
Acute pain related to irritative voiding
symptoms and catheter related discomfort.
Impaired urinary elimination related to
hematuria and transurethral surgery.
Anxiety related to diagnosis of cancer.
Deficient knowledge related to progress of
disease and future treatment.

55. PATIENT EDUCATION
1. Advise patient that irritative voiding symptoms and
intermittent hematuria are possible for several weeks
after transurethral resection of bladder tumors.
2. Teach patient with superficial bladder cancer
importance of vigilant adherence to follow-up
schedule: after initial 6-week induction course of BCG
they need cystoscopy and 3-weekly instillation of BCG
at 3 and 6 months then every 6 months thereafter for
3 years.
3. Yearly cystoscopy is required as 70% of superficial
tumors will recur.

56. PREVENTION

57. RESEARCH ARTICLES
1. Impact of Bladder Cancer on Health-Related Quality of Life
in 1,476 Older Americans: A Cross-Sectional Study
Chunkit Fung et al (2014) conducted a cross-sectional study in 1,476 patients
65 years old or older with bladder cancer in the SEER-MHOS linkage database
between 1998 and 2007 to assess differences in physical and mental
component summary scores in 620 and 856 who completed a survey before
and after bladder cancer diagnosis, respectively. To determine differences in
physical and mental scores in the pre-diagnosis and post-diagnosis cohorts,
ANOVA was used. There were statistically significant differences in physical
and mental component summary scores between the pre-diagnosis and post-
diagnosis groups. Patients with bladder cancer who had 4 or more comorbid
medical conditions and 1 or more deficits in daily living activity were most at
risk for low physical component summary scores. It concluded that future
research into interventions to improve health related quality of life and
methods to incorporate health related quality of life into decision making
models are critical to improve outcomes in older patients with bladder
cancer.

58. 2. Non-muscle Invasive Bladder Cancer Influences
Physical Health Related Quality of Life and Urinary
Incontinence.
Brisbane WG et al (2019) conducted a study to evaluate the
effects of non-muscle invasive bladder cancer (NMIBC) on health-
related quality of life (HRQOL) and urinary function within
patients diagnosed with NMIBC as compared to the general
population. Using the Surveillance, Epidemiology, and End
Results-Medicare Health Outcome Survey (SEER-MHOS) database
(1998-2013), 325 patients diagnosed with NMIBC with baseline
and postdiagnosis MHOS surveys were propensity-matched 1:5 to
noncancer controls (NCC). It concluded that NMIBC diagnosis was
associated with significant decreases in physical HRQOL and
urinary function compared with NCC. Further study focused on
NMIBC patients, and the inherent HRQOL factors to this diagnosis
is needed to assess where improvements can be made in treating
this patient population.

59. SUMMARY AND CONCLUSION
•As discussed throughout the presentation, learning
about Bladder cancer and its management will help
nurses to care for patients with Bladder cancer.
•Nurses can do assessment of patients with bladder
cancer, observe the sign and symptoms, provide the
necessary nursing care and support the patient
psychologically.
•Nurses can also counsel the patients and their family for
various options available in treatment for bladder
cancer.

60. REFERENCES
1.Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of Medical Surgical Nursing. 2015. New
Delhi. Wolters Kluwer.13th Edition. Volume 2. Pg. no. 1597-1598.
2.Joyce M. Black, Jane Hokanson Hawks. Medical Surgical Nursing Clinical Management of Positive
Outcomes.2015. New Delhi. Reed Elsevier India Private Limited. Volume I. Pg. No.735-748.
3.Lippincott Williams & Wilkins. Lippincott Manual of Nursing Practice. 10th Edition. Wolters Kluwer Pvt Ltd,
New Delhi. 2014. Pg. no. 816-818.
4.Cancer.Net. Bladder Cancer: Stages and Grades. Available from https://www.cancer.net/cancer-
types/bladder-cancer/stages-and-grades [cited 15 feb 2020]
5.MedlinePlus. Bladder Cancer. Available from https://medlineplus.gov/ency/article/000486.htm [cited 15 feb
2020]
6. Chunkit Fung, Chintan Pandya, Elizabeth Guancial, Katia Noyes, Deepak M. Sahasrabudhe, Edward M.
Messing, and Supriya G. Mohile. Impact of Bladder Cancer on Health-Related Quality of Life in 1,476 Older
Americans: A Cross-Sectional Study. 2014. J Urol. 2014 Sep; 192(3): 690–695. PMID: 24704007.
7. Brisbane WG. Nonmuscle Invasive Bladder Cancer Influences Physical Health Related Quality of Life and
Urinary Incontinence. 2019. Urology. 2019 Mar;125:146-153. doi: 10.1016/j.urology.2018.11.038. Epub 2018
Dec 12.

62. Q1- Risk factors for development of Bladder
Cancer include all the following except:
A-Tobacco smoking
B- Industrial carcinogens: e.g. aniline dyes.
C-Chronic irritation e.g. infection, stones
D- Excessive fat consumption
E-Pelvic irradiation
Ans - D

63. Q2- As regards incidence of bladder cancer
male to female ratio is
A- 3:1
B- 2:1
C- 1:1
D- 4:1
Ans- D

64. Q 3. Lines of treatment of superficial bladder
cancer:
A- Transurethral resection of bladder tumour
(TURBT)
B- Intravesical BCG
C- Intravesical Chemotherapy
D- All of the above
Ans- A

65. Q4. Standard treatment of first occurrence
of CIS is:
A- TURBT and I.V. BCG
B- TURBT alone
C- TURBT and I.V. chemotherapy
D- Radical cystectomy
Ans- A