Cancer of bladder

1. BLADDER CANCER
Presented by
Ms. Jinumol Jacob
2nd Year M.sc Nursing Student
NUINS

2. PROBLEM BASED LEARNING
A 73-year-old male with intermittent gross hematuria and irritative voiding symptoms presented
to Casualty. Patient has the past medical history of hypertension, hyperlipidemia, and BPH
(enlarged prostate). Before coming to our hospital, the patient had a cystoscopy and bladder
tumor resection that showed a high-grade urothelial carcinoma, which was not invading the
detrusor layer of the bladder. Re-staging cystoscopy and biopsy at our institution revealed
pathologic upstaging to a muscle-invasive tumor. It got diagnosed as Urothelial carcinoma of the
bladder. A radical cystectomy with urinary diversion was recommended. The patient was seen in
our cancer clinic and was recommended to proceed with neoadjuvant chemotherapy
(gemcitabine & cisplatin) followed by radical cystectomy and urinary diversion. After successful
completion of neoadjuvant chemotherapy, Doctors performed a robotic-assisted laparoscopic
cystoprostatectomy, bilateral pelvic and iliac lymphadenectomy and an ileal conduit urinary
diversion. The conduit was created by harvesting a 15cm segment of distal ileum to which the
ureters were connected proximally, after a which an abdominal stoma was made with the distal
end

3. CONTINUE..
After reading the history
Explain details about Carcinomas of the Bladder and its management
Enumerate on various type Urinary diversion
Explain the postoperative management of patient with Urinary diversion

4. INTRODUCTION
Cancer of bladder is more common in people older than 55 years . It affect more men than
women and more common in Caucasians than African American. Bladder cancer combined with
prostatic cancer is the most common urologic malignancy, accounting for about 90 % of all
malignancy seen . Cancer arise from prostate , colon and rectum in males and from lower
gynaecologic tract in females may metastasize to the bladder.

5. DEFINITION
Bladder cancer starts when the cells makes up the urinary bladder starts to grow out of
control.
(American cancer society)
Cancer that forms in the tissue of bladder. Most of the cancer tissues are transitional cell
carcinomas.
( National cancer institute)

6. INCIDENCE
 Fourth common CA in men and ninenth in
women.
Annual new cases = 68,810
Annual death = 14,100

7. ETIOLOGY & RISK FACTORS
 Cigarette smoking.
Exposure to environmental carcinogens such as dyes, rubber, leather , ink or paint.
Recurrent or chronic bacterial infection of the urinary tract.
Bladder stones.
Pelvic radiation therapy
Cancer arising from the prostate , colon, and rectum in males.
Spinal chord injuries requiring long term indwelling catheter.

8. PATHOPHYSIOLOGY

9. CLASSIFICATION
Based on histology
Transitional cell tumour
Transitional cell papilloma
Transitional cell carcinoma
Carcinoma In Situ
Squamous cell carcinoma
Adenocarcinoma
Mixed carcinoma

10. Transitional cell tumour
 90 % of all epithelial tumors of bladder are transitional cell tumours.
It consist of transitional cell papilloma and transitional cell carcinoma
Transitional cell papilloma
Papiloma’s may occur singly or may be multiple. They are generally small less than 2 cm in
diameter.
Each papilloma is composed of fibrovascular stromal core covered by normal looking transitional
cells .
The individual cells resemble the normal transitional cells and does not vary in size and shape.
 Mitosis are absent and Basal polarity is maintained.

11. Continue…

12. Continue..
Transitional cell carcinoma.
This is the commonest cancer of bladder and is divided into 3 grades based on degree of
anaplasia and extent of invasion.
GRADE 1
Tumour cells are transistional type.
Show increased number of layers of cells
Individual cells are generally regular, but slightly larger and show mild hyperchromatism.

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GRADE 2
Tumour cells are clearly recognisable, as transitional cell origin and number of cells are increased.
Individual tumour cells are less, regular , larger in size and show pronounced nuclear
hyperchromatism, mitotic activity and loss of polarity.
Tumour may or may not be invasive.
GRADE 3
 Anaplastic tumour
Invasive extending into bladder wall to variable depth depending upon the clinical stage.
Individual tumour shows features of anaplasia such as marked pleomorphism , hyperchromatism etc.

14. Squamous cell carcinoma
 Composed od 5 %of the bladder cancer.
Most of squamous cell carcinoma are sessile , nodular infiltrating and ulcerating.

15. Carcinoma In Situ
Proliferation confined to epithelium of
mucosa.
Considerable potential for invasiveness
Within 4 yrs- 80% of pts. develop invasive ca.
Asymptomatic/ Frequency/Urgency/Dysuria
Urine cytopathology – Positive in 80-90%
cases
Cystoscopy- Velvety patch of erythematous
mucosa

16. ADENOCARCINOMA
 Adenocarcinoma of the bladder is rare.
Has association with exostrophy of bladder
with glandular metaplasia.
The tumour is characterized by glandular and
tubular with or without mucus production.

17. MIXED CARCINOMA
 About 50 % of epithelial tumours of bladder
show mixed pattern, usually of transitional and
squamous cell combination.

18. Stages of Bladder cancer
 Stage 0 --Non-invasive tumors that are only in
the bladder lining
 Stage I --Tumor goes through the bladder
lining, but does not reach the muscle layer of the
bladder
Stage II --Tumor goes into the muscle layer of
the bladder
Stage III --Tumor goes past the muscle layer into
tissue surrounding the bladder
Stage IV --Tumor has spread to neighboring
lymph nodes or to distant sites (metastatic
disease)
Stage V– Spread to Prostate ,Rectum ,Ureters
,Uterus ,Vagina ,Bones ,Liver ,Lungs etc.

19. CLINICAL FEATURES
Painless gross Hematuria.
Irratative Bladder symptoms.( e.g. dysuria, urgency, frequency of urination)
Pelvic or bony or lower extremity edema.
Flank pain
Palpable mass on Physical examination

20. DIAGNOSIS
History collection and Physical Examination
Urine analysis
Urine culture
Voided urinary cytology
Cystoscopy with biopsy
Laparoscopy
PET scanning
Chest x-ray
Ultrasound

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MRI
Diagnostic tumour markers.
CYSTOSCOPY
Gold Standard
Complete visualisation of urethral and bladder mucosa.
Can be performed with minimal discomfort , local anaesthesia in the urethra.

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BIMANUAL EXAMINATION
Under GA with full relaxation
Performed prior to tumour resection and then again after endoscopic resection

23. MANAGEMENT
1. MEDICAL MANAGEMENT
2. PHARMACOLOGICAL MANAGEMENT
3. SURGICAL MANAGEMENT

24. MEDICAL MANAGEMENT
The treatment of bladder cancer depends on the grade of the tumour, stage of
tumour, multicentry ( having many centres) of tumour, Patient age, physical ,
mental and emotional status are considered when determining the treatment
modalities

25. PHARMACOLOGICAL MANAGEMENT
CHEMOTHERAPY
Chemotherapy with a combination of methotrexate, 5-fluorouracil,vinblastine,
doxorubicin (Adriamycin), and cisplatin.
Intravenous chemotherapy may be accompanied by radiation therapy.
Topical chemotherapy (intravesical) or instillation of antineoplastic agents into
the bladder, (resulting in contact of the agent with the bladder wall) is
considered when there is a high risk for recurrence, when cancer in situ is
present, or when tumor resection has been incomplete.
Topical chemotherapy delivers a high concentration of medication
(doxorubicin, mitomycin, and BCG) to the tumor to promote tumor destruction.
BCG is now considered the most effective intravesical agent for recurrent
bladder cancer because it enhances the body’s immune response to cancer.

26. RADIATION THERAPY
Radiation of the tumor may be performed preoperatively to reduce micro extension of the neoplasm
and viability of tumor cells.
Radiation therapy is also used in combination with surgery or control the disease in patients with
inoperable tumors.
Instillation of formalin or silver nitrate relives hematuria and stangury ( slow and painful discharge of
urine) in some patients during or after radiation.
For more advanced bladder cancer or for patients with intractable hematuria a large , water filled
balloon placed in the bladder produces tumor necrosis by reducing the blood supply of bladder wall.

27. PHOTODYNAMIC THERAPY
 This procedure involves systemic injection of a photosensitising material by cancer by cancer
cell pick up.
Combines nontoxic photo sensitivity dyes plus visible light to destroy cancer cell.
Chemoprevention is the use of drugs,vitimins , or other substances to reduce the risk of
developing cancer or to reduce the risk of it returning.

28. SURGICAL MANAGEMENT
Surgical management includes a variety of procedures
 Trans- urethral resection of Bladder Tumour
Segmental Cystectomy
Radical Cystectomy.

29. Trans- urethral resection of Bladder Tumour
Trans- urethral resection of Bladder Tumour
 TURBT is used for superficial lesions of the bladder’s inner lining.
A wire loop inserted through the cystoscope is used to cauterize. ( with electric current or laser
and kill the cancer cell).
This Procedure is also used to control bleeding in the patient who is a poor operative risk or has
advanced tumors.

30. Segmental Cystectomy
 Also called as partial cystectomy.
Is used to treat larger tumour or that involves only one area of the bladder.
A portion of the bladder wall containing the tumour is removed with a margin of normal tissue.

31. Radical Cystectomy
A radical cystectomy involves removal of the bladder ,prostate and seminal vesicles in men’s
and the bladder , uterus , cervix ,urethra, and ovaries in women.
After a radical cystectomy, a new way must be created for urine to leave the body that is
urinary diversion.

32. POSTOPERATIVE MANAGEMENT
 Drink a large volume of fluid for the first week after the procedure.
Teach the patient to monitor the colour and consistency of the urine. The urine is pink for the
first several days after the procedure, but it should not be bright red or contain blood clots.
Administer opioid analgesics for a brief period after procedure along with stool softeners.
Help the patient and family cope with fears about cancer , surgery, and sexuality.
Emphasize the importance of regular follow up care .
Follow up cystoscopies are required on regular basis after surgery.

33. URINARY DIVERSION
The urinary diversion procedures are performed to divert the urine from the bladder to new
exit site, usually through a surgically created opening ( Stoma) in the skin. The major indications
of urinary diversions includes.
Cancer or Tumor of the urinary bladder, less frequently a benign condition.
Management of pelvic malignancy
Birth defects
Stricture
Trauma to ureter and urethra
Chronic Inflammatory conditions causing urethral and renal damage.

34. TYPES
PERMENTANT
Continent urinary diversion
Non – continent / incontinent urinary diversion ( urostomy)
TEMPORARY
 Nephrostomy
Urinary Catherization

35. PERMENTANT URINARY DIVERSION
Continent urinary diversion
A continent urinary diversion is an internal reservoir that surgeon creates from a section of the
bowel. Urine flows through the ureters into the reservoir and is drained by the patient.
It doesn’t require an external pouch.it is an intra-abdominal urinary reservoir that can be
catheterized.
The Patient with a continent reservoir need to self catherize every 4 to 6 hours , but does not
need to wear external attachments.
. E.g. Indiana pouch , Kock pouch etc.

36. Non continent urinary diversion
Also called as incontinent urinary diversion and urostomy.
Urostomy is a stoma that connects to urinary tract and make it possible for urine to drain out
of the body when regular urination cannot occur.
An external pouch is placed to collect the urine flowing through stoma.
Ileal conduit & cutaneous ureterostomy are the 2 major types of non- continent urinary
diversion

37. TYPES
ILEAL CONDUIT
An ileal conduit uses a section of the bowel
usually the small intestine surgically removed
from the digestive tract and repositioned to
serve as a passage for urine from ureter to
stoma.
One end of the conduit attaches to the
ureters and other end attaches to the stoma.
ILEAL CONDUIT

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CUTANEOUS URETEROSTOMY
In this the surgeon detaches one or both
ureters and attaches them directly to a stoma.
This is not common as ileal conduit ,because
of higher complication and need for further
follow up after the surgery.
A surgeon performs cutaneous ureterostomy
when bowel cannot be used to create a stoma.
CUTANEOUS URETEROSTOMY

39. TEMPORARY URINARY DIVERSION
Temporary urinary diversion reroutes the flow of urine for several days or weeks. Temporary
urinary diversions drain urine until the cause of blockage is treated or after urinary tract surgery.
This mainly includes a nephrostomy and urinary Catherization

40. NEPHROSTOMY
NEPHROSTOMY
A Nephrostomy involves a small tube inserted
through the skin directly into a kidney. The
Nephrostomy tube drain from the kidney into
an external drainage pouch.
NEPHROSTOMY

41. Urinary Catherization
URINARY CATHERIZATION
Urinary Catherization involves placing a thin
flexible tube called catheter into bladder.
The two major types includes insertion of a
catheter through the urethra or through the
skin, i.e. Foley's Catherization or Suprapubic
Catherization.
Urinary catheters may remain in place for
several days or weeks .
URINARY CATHERIZATION

42. COMPLICATIONS
Alterations in bowel motility
Anastomotic leaks
Fluid collections
Wound infections
Fistula
Peritonitis due to disruption of anastomosis
Stoma necrosis
Urinary leakage

43. POSTOPERATIVE NURSING DIAGNOSIS
 Risk for impaired Skin integrity related to problems in managing urine collection.
Acute pain related to surgical incision.
Disturbed body image related to urinary diversion
Ineffective sexuality pattern related to structural and physiological alteration
Deficient knowledge about the management of urinary dysfunction.

44. Conclusion
Bladder cells become abnormal and grow out of control. Over time, a tumor forms. It can spread
to nearby lymph nodes and other organs. In severe cases, it can spread to distant parts of your
body, including your bones, lungs, or liver. Bladder cancer is most common in white men over age
55. The major symptoms includes Painless gross Hematuria ,irratative Bladder symptoms.( e.g.
dysuria, urgency, frequency of urination) ,Pelvic or bony or lower extremity edema etc.

45. BIBLIOGRAPHY
1. https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-diversion.
2. Lewis “ Text book of Medical surgical Nursing” Elsevier’s Publication,5th edition,New Delhi,
pg no : 1022-1024
3. Ignataviciis , Donna “ Text book of Medical surgical nursing” Elsevier’s Publication,7th
edition,New Delhi, pg no : 1022-1024.