This document discusses carcinoma of the bladder. It begins by defining bladder cancer and noting that it forms in bladder tissues and may infiltrate the bladder wall. It then covers the epidemiology, risk factors, pathophysiology, types, clinical manifestations, staging, grading, diagnosis and management of bladder cancer. Management includes surgery such as TURBT and cystectomy, chemotherapy, radiation therapy, and intravesical drug therapy. Nursing management involves assessment, education, managing anxiety and pain, and monitoring the urinary drainage system after any procedures.

1. CARCINOMA
BLADDER
Moderator: Ms.Manju Presenter:Jiya Maria Thomas
Lecturer MSc Nsg 1 st yr
CON,AIIMS

2. At the end of the class….
Understand what is cancer bladder
Epidemiology
Risk factors
Pathophysiology
Types and clinical manifestations
Staging and grading
Management

3. Carcinoma Bladder
 Cancer that forms in tissues of the bladder and that
may infiltrate the bladder wall.
As tumor progresses it may extend in to the
retroperitoneal structures.

4. Layers Of Urinary Bladder

5. Epidemiology
In India 4th
common cancer in men &
8th
common cancer in females.
 2-3 times common in men
 Male to female ratio= 2.4:1
 Commonly occurs in people over 55yrs or above

6. Risk factors
Smoking-active and passive
Exposure to carcinogen (aniline, asbestos,
aromatic amines, arsenic)
Occupational risk (hair dressers,
painters, truck drivers, rubber,
textile, metal workers)
Chronic bladder irritation (UTI’s)

7. Risk factors…
Chemotherapy and Pelvic
radiation
Bladder birth defects
Diet high in saturated fat
Personal/family Hx of bladder
Cancer
Excessive Consumption of
coffee, artificial sweetners, low
fluid diet.

8. Pathophysiology
Exposure of the bladder wall to a carcinogen
Bladder wall irritation
Pre malignant changes start from the transitional layer
These changes are called as cell dysplasia
Formation of warts like growths in the wall

9. Pathophysiology
Formation of locally invasive carcinoma in situ
Penetrates the submucosal and mucosal layer of the
bladder forming deep invasive cancers
Progress to adjacent structures {retroperitoneal
structures}
Distant metastasis to liver,bone,lungs through LNs,Bld

10. Types
 Transitional cell
carcinomas
 Adenocarcinoma
 Squamous cell
carcinoma

11. Clinical manifestations
 Microscopic /gross painless hematuria
 Bladder irritative symptoms
 Obstructive symptoms
Urinary tract infections
Alterations in voiding pattern
Pelvic / back pain (metastasis)

12. Staging
TX: Main tumor cannot be
assessed due to lack of
information
T0: No evidence of a primary tumor
Ta: Non-invasive papillary carcinoma
Tis: Non-invasive flat carcinoma (flat carcinoma in
situ, or CIS)

13. T1: The tumor has grown from the layer of cells
lining the bladder into the connective tissue below. It
has not grown into the muscle layer of the bladder.
T2: The tumor has grown into the muscle layer.
T2a: The tumor has grown only into the inner half of
the muscle layer.
T2b: The tumor has grown into the outer half of the
muscle layer.

14. T3: The tumor has grown through the muscle layer
of the bladder and into the fatty tissue surrounding it
T3a: The spread to fatty tissue can only be seen by
using a microscope.
T3b: The spread to fatty tissue is large enough to be
seen on imaging tests or to be seen or felt by the
surgeon

15. T4: The tumor has spread beyond the fatty tissue and
into nearby organs or structures. It may be growing into
any of the following: the stroma (main tissue) of the
prostate, the seminal vesicles, uterus, vagina, pelvic wall,
or abdominal wall.
T4a: The tumor has spread to the stroma of the prostate
(in men), or to the uterus and/or vagina (in women).
T4b: The tumor has spread to the pelvic wall or the
abdominal wall

17. NX: Regional lymph nodes cannot be assessed due
to lack of information.
N0: There is no regional lymph node spread.
N1: The cancer has spread to a single lymph node in
the true pelvis.
N2: The cancer has spread to 2 or more lymph nodes
in the true pelvis.
N3: The cancer has spread to lymph nodes along the
common iliac artery

18. M0: There are no signs of distant spread.
M1: The cancer has spread to distant parts of the
body. (The most common sites are distant
lymph nodes, the bones, the lungs, and the liver).

19. Staging of Ca Bladder
Stage 0:Stage 0: Cancer cells are found only on the inner
lining of the bladder
Stage IStage I: Cancer cells have proliferated to the layer
beyond the inner lining of the urinary bladder but
not to the muscles of the urinary bladder.
Stage II:Stage II: Cancer cells have proliferated to the
muscles in the bladder wall but not to the fatty tissue
that surrounds the urinary bladder.

20. Stage IIIStage III:: Cancer cells have proliferated to the fatty
tissue surrounding the urinary bladder and to the
prostate gland, vagina, or uterus, but not to the lymph
nodes or other organs.
Stage IVStage IV: Cancer cells have proliferated to the lymph
nodes, pelvic or abdominal wall, and/or other organs.
RecurrentRecurrent: Cancer has recurred in the urinary bladder
or in another nearby organ after having been treated

22. Grading bladder cancer
Grading describes how aggressive the cancer cells
are:
• Low grade – The cancer cells look fairly normal
and behave similarly to healthy cells. The cells tend
to grow slowly. Most bladder tumours are low grade.
• High grade – The cancer cells look very abnormal
and grow in a disorderly way. These cells tend to
grow very quickly.
Bladder cancer can also be graded on a scale of 1–3.
Grade 1 cancers are the slowest growing and grade 3
cancers are the most aggressive

23. Diagnosis
Complete medical Hx
Cystoscopy and biopsy
CT, USG, Excretory urography
Bimanual examination
Cytologic examination of fresh urine and saline bladder
washing.
Bladder tumour antigens, nuclear matrix proteins, growth
factors, cytoskeletal proteins etc.

24. MANAGEMENTMANAGEMENT
1. Surgery
2. Chemotherapy
3. Radiation therapy
4. Intra vesical
therapy

25. Surgical Management
TURBT(Trans-Urethral Resection Of
Blader Tumour)

26. Surgical Management
CYSTECTOMY
 Partial cystectomy
 Radical cystectomy
with urinary diversion

27. Types of Urinary diversions
1. Cutaneous /Non-continent urinary diversion:
 Conventional Ileal conduit
 Cutaneous ureterostomy
 Vesicostomy
 Percutaneous Neprostomy
2. Continent urinary diversion:
 Indiana pouch
 Kock pouch
 Ureterosigmoidostomy

28. Illeal conduit Uretrostomy

29. Vesicostomy Nephrostomy

30. Percutaneous nephrostomy

31. Continent Urinary Diversions
Indiana pouch Kock Pouch

32. Ureterosigmoidostomy

33. Complications of urinary diversion
Major
Pyelonephritis, HDN
Minor
Obstruction,
stomal defects
leakage
skin irritation & ulceration,
peristomal hernia
Bacteriuria

34. Chemotherapy
Intravenous administration
Commonly used agents:
Cisplatin M - methotrexate
Doxorubicin V - vinblastin
Gemcitabin A - adriamycin
Methotrexate C - cisplatin
Vinblastin

35. Intravesical drug therapy
/Immunotherapy
Bacille Calmette-Guerin (BCG)

36. Complications of chemotherapy
Bladder irritation
Hemorrhage,
Fatigue, headache
Nausea, vomiting
Anemia
Abdominal pain
Kidney damage

37. Radiation therapy
Only advanced disease/ inoperable cancers
( most requires high doses)
Palliative use is to relieve pain, bowel obstruction,
leg edema
Complications :
Abacterial cystitis
 Fistula formation
Erectile dysfunction
Skin irritation
Hemorrhage
Incontinence

38. Nursing ManagementNursing Management

39. Meet Sam….

40. Nursing assessment
Take careful health, medical and Sx history.
Assess for changes in urine or urination patterns.
Assess risk from carcinogen exposure.
Assess for any drug, chemical or food allergy.

41. Nursing assessment
Assessment of the client for anxiety, coping,
disease related knowledge.
Assist in Routine investigations
Written informed consent.
 monitoring pre-op vital signs
Complete self-care & functional assessment.

42. Pre-op Nursing Management
1. Deficient knowledge R/T Ca bladder diagnosis,
diagnostic testing, surgical intervention
 Provide teaching
 Encourage discussion
 Explain purpose of various tubings like catheters,
NG tube etc.
 Explanation abt various tubes ,catheters
 Discuss abt bowel preparation
 Pre –op teaching abt stoma care, catheterisation of
stoma.

43. Pre-op Nursing Management
2.Risk for disturbed body image R/t Sx, possible post op stoma,
sexual dysfunction, change in urinary elimination
 Explanation for surgical procedure
 Suggest a visit to a client with similar diagnosis and
procedure.
 Choosing the appropriate site for stoma construction
 Discuss lifestyle changes because of stoma or urinary
diversion
 Counselling for risk for sexual dysfunction
 Community support groups
 Family counselling

44. 3.Anxiety related to crisis situations (cancer), health change,
socio-economics, the role and functions, form interaction,
preparation of death, separation of the family.
Determine the patient's experience prior to the illness.
Provide accurate information about prognosis
Give the client an opportunity to express anger, fear,
confrontation. Give the information with reasonable emotion
and expression of the corresponding
Explain the treatment, the purpose and side effects. Helps
patients prepare for treatment
Note the ineffective coping such as lack of social interaction,
impotence etc.
Encourage to develop interaction with the support system
Provide a quiet environment and comfortable
Maintain contact with patients, talk and touch with them.

45. Post –op Nursing Management
AssessmentAssessment
Routine post op evaluation
Stoma site monitoring
Maintaining NPO status untill bowel sounds returns
Assessment of nasogastric contents and stools
Minimal handling of the tubings
Monitor Hrly urine output, pH.

46. Post –op Nursing Management
AssessmentAssessment
Adequate fluid support
 patency & cont. drainage monitoring
Catheterise the client if stoma is present
Observe for hematuria, stenosis, incontinence,
difficult catheterazation
Prevent electrolyte imbalances

47. Post –op Nursing Management
Acute pain r/t surgical incision
 Administration of analgesic medication
 Deep breathing exercises
 Patient controlled analgesia
 Pain intensity scale is used to evaluate the adequacy
of the medication and the approach to pain
management

48. Post –op Nursing Management
Risk for injury R/t occlusion of urinary
drainage
 Monitor vitals, incision lines, s/s of bleeding
 Maintain continuous drainage of urine
 Frequent catheter irrigation with N/S
 Catheterise stoma until it heals
 Label & seperately monitor each tubes
 Inspect the abdomen for distention

49. Post –op Nursing Management
Risk for impaired skin integrity r/t problems
in managing the urine collection appliance
 Keep the drainage system intact
 Proper skin care
 Skin care techniques are teached to the family
members to prevent ulceration around the stoma
 Adequate nutrition
 Long –term management of the stoma is teached

50. Post-op care after urinary diversion
Altered urinary elimination related to urinary diversion
 Maintain a transparent urostomy pouch over the stoma
post operatively for easy assessment
 Inspect the stoma for colour and size
 Report any bleeding , necrosis, sloughing, suture
separation
 Check patency of ureteral stents
 Keep the pouch on at all times and observe normal urine
drainage

51. Post-op care after urinary diversion
2. Stoma care:
 Inspect the stoma every hr for first 24 hrs post-op,
and atleast 8 hrs thereafter.
 Note size, shape & colour of stoma
 Assess for any leakage, bleeding
 Aeration of skin
 Keep the area dry & clean
 Nystatin powder or cream application to avoid
yeast infection
 Check pH of urine
 Change appliances when necessary
 Assess for s/s of peritonitis

52. Post-op care after urinary diversion
3. Diet
 Fluids are very important.
Eat several small meals rather than fewer large meals
Take a multivitamin with iron daily after surgery
Keep bowel movements soft with stool softener of
choice
Avoid diet that gives urine a strong odor( high fat
diet)
take ascorbic acid tablets daily to maintain urine
acidity.

53. Post-op care after urinary diversion
4. Activity
Avoid lifting heavy wts for 6 weeks after surgery
Walk every day. Short frequent walks are better that
1 long walk
It is normal to be fatigued after surgery
Patients recover at different rates.

54. Post –op Nursing Management
Risk for sexual dysfunction r/t structural &
physiologic alterations
 Counseling the partners
 Encourage open discussions
 Sexual rehabilitation
 Encourage partners to seek sexual councelling and
alternate ways of expressing sexuality
 A visit from another ‘ostomate’ who is functioning
fully in society and family life

55. Post –op Nursing Management
Risk for complications r/t the condition
To reduce the risk take following interventions:
Adequate fluid intake
Regular stoma care
Acidification of urine
Prevent leakage of urine
Regular catheterisation
Prevent urinary stasis
Peritonitis

56. Post –op Nursing Management
Client education:
Teaching pt self-care for stoma
Managing the ostomy appliances
Changing the appliance
Controlling odour
Cleaning and deodorizing the appliance
Clean with soap & water, use white vinegar solution.
Teaching skin care: apply skin barrier
Teaching pt self-care for urine reservoir
catheterization of the reservoir
Irrigation
Encourage follow –up

57. Assist in intravesical drug administrations
Instruct the pt to retain fluid for atleast 2 hrs
Instruct to change position frequently
After voiding, instruct to drink fluids to flush the
bladder
Clean the toilet with bleach after voiding.
Assess for complications like bleeding, fever,
bladder irritation etc.
Nursing Management of pt
undergoing chemotherapy

58. Conclusion
Carcinoma bladder is one of the common urological
cancer . Patients with Cancer bladder requires
special care and attention during the treatment and
afterwards also.

59. Summary
What is carcinoma bladder?
Risk factors
Pathophysiology
Types
Clinical manifestations and diagnosis
Staging
Management – Sx, Chemotherapy, radiation therapy
Nursing management

60. References:
Brunner & Suddarth’s, Textbook of Medical
Surgical Nursing.10th ed. Lippincott.
Black M. Joyce, Hawks Hokanson Jane, Medical
Surgical nursing.7th ed.2005, Saunders
Harrison's Principles of internal medicine,
Seventeenth Edition, 2008, The McGraw-Hill
Companies.
www.cancer.gov