CANCER OF BLADDER AND

KIDNEY

BLADDER CANCER

• It is the carcinoma of the bladder

INCIDENCE

• About 73,510 new cases of bladder cancer diagnosed (about 55,600 in men and 17,910 in women).

• Bladder cancer occurs mainly in older people. About 9 out of 10 people with this cancer are over the age of 55. The average age at the time of diagnosis is 73.

ETIOLOGY AND RISK FACTORS

• Smoking• Workplace exposures• Race and ethnicity• Age• Gender• Chronic bladder irritation and infections • Personal history of bladder or other

urothelial cancer

Contd…

• Bladder birth defects• Genetics and family history• Chemotherapy and radiation therapy• Arsenic• Low fluid consumption

TYPES OF BLADDER CANCER

Transitional cell (urothelial) carcinoma

• About 95% of bladder cancers are this type.• The cells from transitional cell carcinomas look

like the urothelial cells that line the inside of the bladder.

• Urothelial cells also line other parts of the urinary tract, such as the lining of the kidneys (called the renal pelvis), the ureters, and the urethra, so transitional cell cancers can also occur in these places

• Non-invasive bladder cancers are still in the inner layer of cells (the transitional epithelium) but have not grown into the deeper layers

• Invasive cancers grow into the lamina propria or even deeper into the muscle layer.

Papillary carcinomas

• Grow in slender, finger-like projections from the inner surface of the bladder toward the hollow center.

Flat carcinomas

• Do not grow toward the hollow part of the bladder at all. If a flat tumor is only in the inner layer of bladder cells, it is known as a non-invasive flat carcinoma or a flat carcinoma in situ (CIS).

STAGING OF BLADDER TUMER

• Tis-flat carcinoma insitu• Ta-papillary ,confined to mucosa• T1-invasion of lamina propria• T2-invasion of superficial muscle• T3a-invasion of deep muscle• T3b-invasion of perivesical tissue• T4a-tumour fixed to prostate• T4b-tumour fixed to other pelvic organs

• M0-no evidence of metastatic disease• M1-metastasis present• MX-metastatic state unknown• N0-no regional lymph node metastasis• N1-metastasis in a single lymph node 2cm or

less in greatest dimension• N2-metastasis in a single lymph node more than

2 cm but not more than 5 cm in greatest dimension or multiple lymph nodes more than 5 cm in great dimension

• N3-metastasis in a lymph node morethan 5 cm in greatest dimension

PATHOPHYSIOLOGY OF BLADDER CANCER

Due to the etiological factors

Activation of oncogenes and inactivation or loss of tumor suppressor genes.

• Loss of genetic material on chromosome 9

That leads to bladder cancer

Exposure of the bladder wall to a carcinogen

Premalignant proliferative changes are found in the transitional cell layer.

These changes are called dysplasia and refers to abnormal cell configuration found in several degrees of sevearity.

The invasion progress through the pelvic lymph nodes and spreads to liver, bones and lungs ,rectum, vagina, and other pelvic soft tissues

CLINICAL FEATURES

• Blood in the urine• Frequency• Dysuria• Urgency• Lower back pain or being unable to urinate

DIAGNOSTIC MEASURES

• Medical history and physical exam• Cystoscopy• LAB TESTS

1. Urine cytology2. Urine culture3. Urine tumor marker tests(tests for NMP22 and

BTA)•Bladder biopsies

• Intravenous pyelogram• Computed tomography (CT) scan• CT-guided needle biopsy• Magnetic resonance imaging (MRI) scan• Ultrasound

MANAGEMENT

• The main types of treatment for cancer of the bladder are:

SurgeryIntravesical therapyChemotherapyRadiation therapy

SURGERIES FOR BLADDER CANCER

1. Transurethral surgery TURBT

2. CYSTECTOMYPartial cystectomyRadical cystectomy

RECONSTRUCTIVE SURGERY

• Urinary DiversionsUrinary diversion procedures are performed to

divert urine from the bladder to a new exit site, usually through a surgically created opening (stoma) in the skin.

The main types are:1. Cutaneous Urinary Diversions2. Continent Urinary Diversions

1.Cutaneous Urinary Diversions

cutaneous urinary diversion, in which urine drains through an opening created in the abdominal wall and skin,

A. Continent Urinary Diversions. In an ileal conduit, the urine is diverted by

implanting the ureter into a 12-cm loop of ileum that is led out through the abdominal wall.

B. Cutaneous UreterostomyA cutaneous ureterostomy, in which the ureters

are directed through the abdominal wall and attached to an opening in the skin, is used for selected patients with ureteral obstruction

C. Vesicostomy. The surgeon sutures the bladder to the

abdominal wall and creates an opening (stoma) through the abdominal and bladder walls for urinary drainage.

D. NephrostomyThe surgeon inserts a catheter into the renal

pelvis via an incision into the flank or, by percutaneous catheter placement, into the kidney.

2.Continent Urinary Diversions

• continent urinary diversion, in which a portion of the intestine is used to create a new reservoir for urine.

A.Continent Ileal Urinary Reservoir

1.Indiana PouchThe Indiana pouch uses a segment of the

ileum and cecum to form the reservoir for urine. The ureters are tunneled through the muscular bands of the intestinal pouch and anastomosed

2.Kock pouchU-shaped pouch constructed of ileum, with

a nipplelike one-way valve.With both of these methods, the pouch must be drained at regular intervals by a catheter

B. UreterosigmoidostomyImplantation of the ureters into the

sigmoid colon

NURSING MANAGEMENT

1.PREOPERATIVE MANAGEMENT

• Functional assessment • psychosocial resources • Bowel preparation • Adequate hydration • The procedure is explained

• For ileal or colon conduit, the stoma site is planned preoperatively

• Stoma site may also be marked

Postoperative Management• Assessed for immediate postoperative

complications; wound or UTI, urinary or fecal anastomotic leakage, small bowel obstruction, paralytic ileus, pelvic thrombophlebitis, pulmonary embolism, and necrosis of stoma.

• Intake and output are monitored including amount

• Suction drains are evaluated sudden increase in drainage suggests an anastomotic leak

• Ureteral stents are used to protect ureterointestinal anastomoses

Nursing Diagnoses• Impaired Urinary Elimination related to urinary

diversion• Acute Pain related to surgery• Disturbed Body Image related to urinary

diversion• Sexual Dysfunction related to reconstructive

surgery and impotence (in men)• Risk for impaired skin integrity related to

problems in managing the urine collection appliance

• Risk for complications related to complexity of surgery

1.Achieving Urinary EliminationFor ileal or colon conduit patients

• Maintain a transparent urostomy pouch • Inspect the stoma for color and size1. Stoma should be red, wet with mucus, soft,

and slightly rubbery to the touch (stoma lacks nerve ending, so feeling in stoma is absent).

2. Cyanotic stoma indicates poor circulation.3. Necrotic stoma is blue-black or tan-brown.

• Connect pouches to drainage bag when patient is in bed, and record urine volume hourly.

• Initial urostomy pouch remains in place for several days postoperatively; it is changed every 3 to 5 days when patient teaching begins.

• Report bleeding, necrosis, sloughing, suture separation.

• Check patency of ureteral stents.• Keep the pouch on at all times, and observe

normal urine

For continent urinary diversion patients

• Irrigate with 30 mL saline every 2 to 4 hours • Assess stoma• Record urine output and character of urine• irrigate with 30 mL saline every 2 to 4 hours • Assess stoma• Monitor output of pelvic drain • Record urine output and character of urine• Controlling Pain• Resolving Body Image Issues• Coping with Sexual Dysfunction

• Providing stoma and skin care• Monitoring And Managing Potential

Complications

Patient Education and Health Maintenance

For Ileal or Colon Conduit Patients• Obtain and familiarize the patient with the

appropriate equipment• Assist the patient to determine stoma size• The inside diameter of the skin barrier should

not be more than 1/16 to 1/8 inch larger than the diameter of the stoma.

DISPOSABLE UROSTOMY POUCH

• Teach how to change the pouch.• Pastes or cements, are not usually necessary

with a well-fitting pouch.• Pouches should be changed every 3 days • Emptying the pouch when it is a third to half

full to prevent weight of urine from loosening adhesive seal open drain valve

For Continent Ileal Urinary Reservoir Patients

• Teach irrigation of catheter• Teach how to change stoma

dressing • Instruct in use of leg bag or

bedside urinary drainage

Teach how to catheterize continent urinary diversion when healing is verified

• Red rubber or plastic, straight or coud catheters are used.

• Apply a small amount of water-soluble lubricant to the tip of the catheter.

• Use clean technique, wash hands before each catheterization.

• Maintain schedule of catheterizations • After training period, catheterize four to five times

per day; pouch should not hold more than 400 to 500 mL.

• Irrigate pouch with saline through catheter once per day to clear it of accumulated mucus.

INTRAVESICAL THERAPY • With intravesical therapy, the doctor puts the

drug directly into the bladder 1. INTRAVESICAL IMMUNOTHERAPY

A.Bacillus Calmette-Guerin therapy• The body’s immune system cells are attracted

to the bladder and activated by BCG, which in turn affects the bladder cancer cells

• Started a few weeks after a transurethral resection of the tumor and is given once a week for 6 weeks.

B. Interferon• Stimulate the immune system• Interferon-alpha is the type most often

used to treat cancer.C. Intravesical chemotherapy• Mitomycin and thiotepa are the drugs

used most often for intravesical chemotherapy. Other drugs that are used include valrubicin, doxorubicin, and gemcitabine.

CHEMOTHERAPY FOR BLADDER CANCER

• Cisplatin50 to 70 mg/m2 intravenously once every 3 to 4

weeks

• Cisplatin plus fluorouracil (5-FU)This consisted of cisplatin 15 mg/m(2) i.v. and 5-

fluorouracil (5-FU) 400 mg/m(2) i.v. in the mornings

• Mitomycin with 5-FU12mg/m2 IV Bolus (DAY 1 ONLY)• Gemcitabine and cisplatin gemcitabine dose of 1000 mg/m(2) and cisplatin

dose and schedule varied, with total doses ranging from 70 to 105 mg/m(2)

• Methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (called M-VAC)

• paclitaxel or docetaxel (for patients with poor kidney function)

Paclitaxel was given at a dose of 250 mg/m2 by 24-hour continuous infusion

RADIATION THERAPY FOR BLADDER CANCER

• External beam radiation therapy

PHOTODYNAMIC THERAPY

• A special light-sensitive drug is injected into the blood and allowed to collect in the tumor cells for a few days. Then a special type of laser light is focused on the inner lining of the bladder through a cystoscope. The light changes the drug in the cancer cells into a new chemical that can kill them.

TARGETED THERAPIES

Medication that blocks the growth of cancer cells by interfering with specific targeted molecules needed for carcinogenesis and tumor growth rather than by simply interfering with all rapidly dividing cells

• Eg-sunitinib,lapatinib ,Erlotinib, trastuzumab

GENE THERAPY

• The modified virus is put into the bladder and infects the bladder cancer cells

• When this infection occurs, the virus injects a gene into the cells for GM-CSF, an immune system hormone (cytokine) that may help activate immune system cells to attack the cancer

PROGNOSIS

• Stage 0 -- 98%.• For stage I -- 88%.• For stage II -- 63%.• For stage III -- 46%, depending on the size of

the cancer deposits present in the tissues next to the bladder and whether the cancer has spread to nearby organs.

• For stage IV -- 15%

CANCER OF KIDNEY

• Renal cell carcinoma (RCC), also known as renal cell cancer

• Adenocarcinoma, is by far the most common type of kidney cancer. About 9 out of 10 kidney cancers are renal cell carcinomas

INCIDENCE

• As per the Indian cancer registry data in men, it is the ninth most common cancer accounting for 3.9% of all cancer cases

• It is three times more common in men than in women, and 90% of the bladder tumors are transitional cell carcinoma (TCC)

TYPES OF KIDNEY CANCER

1. Papillary renal cell carcinoma• These cancers form little finger-like projections

(called papillae)

• Sometimes it is called chromophilic because the cells take in certain dyes and look pink under the microscope.

2. Chromophobe renal cell carcinoma• This subtype accounts for about 5% • The cells of these cancers are also pale, like

the clear cells, but are much larger

3. Collecting duct renal cell carcinomaThis subtype is very rare. The major feature is

that the cancer cells can form irregular tubes.

4.Transitional cell carcinoma• Transitional cell carcinomas don't start in the

kidney itself, but instead begin in the lining of the renal pelvis

• 5-10 % OF TOTAL RCC5. Wilms tumor (nephroblastoma)• Nephroblastomas, more commonly called

Wilms tumors, almost always occur in children. This type of cancer is very rare among adults

6. Renal sarcoma• That begin in the blood vessels or connective

tissue of the kidney.TOTAL 1%

STAGING/TNM CLASSIFICATION• Primary Tumor (T)• Tx-Primary tumor can not be assessed• T0-No evidence of primary tumor• T1a-Tumor 4 cm, confined to the kidney• T1b-Tumor 4 cm to < 7 cm, confined to the

kidney• T2a-Tumor ≥ 7 cm to < 10 cm, confined to the

kidney• T2b-Tumor ≥ 10 cm, confined to the kidney

• T3a-Tumor extends into the renal vein or its segmental branches or invades adrenal gland or perinephric fat but not beyond Gerota’s fascia

• T3b-Tumor extends into the vena cava below diaphragm

• T3c-Tumor extends into the vena cava above the diaphragm or invades the wall of vena cava

• T4-Tumor invades beyond Gerota’s fascia• Regional Lymph Nodes (N)• N1-Metastasis in 1 regional lymph node• N2-Metastasis in > 1 regional lymph node• Distant Metastases (M)• M1-Distant metastasis present

ETIOLOGY AND RISK FACTORS

• Smoking

• Obesity

• Workplace exposures

• Genetic and hereditary risk factors

von Hippel-Lindau disease

• People with this condition often develop several kinds of tumors and cysts (fluid-filled sacs) in different parts of the body

ETIOL …

• Hereditary papillary renal cell carcinoma• Hereditary leiomyoma-renal cell carcinoma• (FH) gene.• Hereditary renal oncocytoma• Family history of kidney cancer• High blood pressure

• Certain medicinesPhenacetin, Diuretics

• Advanced kidney disease• Gender• Race

PATHOPHYSIOLOGY Due to etiology

Loss of VHL protein(von-Hippel-Lindeau)tumour suppressor gene

Accumulate hypoxia-induced factor (HIF)

Transcriptional activation of multiple downstream targets

RCC

CLINICAL FEATURES• Blood in the urine (hematuria)• Low back pain on one side (not caused by

injury)• A mass (lump) on the side or lower back• Fatigue (tiredness)• Weight loss not caused by dieting• Fever that is not caused by an infection and

that doesn't go away after a few weeks• Anemia (low red blood cell counts)

Paraneoplastic Syndromes

1. Erythrocytosispromoting erythropoietin production from nonneoplastic renal tissue.

2. HypercalcemiaDue to production of a parathyroid hormone.

3. HypertensionDue to excess rennin production

4. Non metastatic hepatic dysfunctionElevation of alkaline phosphatase and bilirubin, hypoalbuminemia, prolonged prothrombin time, and hypergammaglobulinemia. It is known as Stauffer syndrome

DIAGNOSTIC MEASURES• Urine analysis• Complete blood count• Blood chemistry tests• CT scan• MRI scan• Ultrasound• Positron emission tomography (PET) scan• Intravenous pyelogram• Fine needle aspiration and needle core

biopsy

MANAGEMENT

–Surgery–Radiation therapy–Chemotherapy

SURGERY

• Radical nephrectomy• Partial nephrectomy (nephron-sparing

surgery)• Cryotherapy (cryoablation)• Radiofrequency ablation• Arterial embolization

RADIATION THERAPY FOR KIDNEY CANCER

• External beam therapy focuses radiation from outside the body on the cancer

CHEMOTHERAPY FOR KIDNEY CANCER

• Unfortunately, kidney cancer cells are usually resistant to chemo, and so chemo is not a standard treatment for kidney cancer.

• Some chemo drugs, such as vinblastine,floxuridine, 5-fluorouracil (5-FU), capecitabine, and gemcitabine

Targeted therapies

• Targeted drugs are proving to be especially important in diseases such as kidney cancer, where chemotherapy has not been shown to be very effective.

• These include drugs that stop angiogenesis (growth of the new blood vessels that nourish cancers) and drugs that target other important cell growth factors.

• EXAMPLES-Sorafenib ,Sunitinib Temsirolimus ,Everolimus ,evacizumab ,Pazopanib

Biologic therapy (immunotherapy)

• The goal of biologic therapy is to boost the body's immune system to fight off or destroy cancer cells more effectively.

• The main immunotherapy drugs used in kidney cancer are cytokines. The 2 cytokines most often used are interleukin-2 (IL-2) and interferon-alpha.

New approaches to local treatment

• High-intensity focused ultrasound is a fairly

new technique that is now being studied for

use in kidney cancer. It involves pointing very

focused ultrasound beams from outside the

body to destroy the tumor

NURSING MANAGEMENT• ASSESSMENT • Nursing Diagnosis • Preoperative nursing diagnosis• Anxiety related to diagnosis of cancer and

possibility of metastatic disease• Acute Pain and Hyperthermia related to

postinfarction syndrome• Anticipatory grieving related to loss; altered role

functioning• Disturbed body image and situational low self-

esteem related to changes in appearance, function,and roles

Nursing Interventions

• Reducing Anxiety Explain each diagnostic test, its purpose,

and possible adverse reactions Answer questions, and encourage more

thorough discussion with health care Assess patient's understanding about

diagnosis and treatment options

Controlling Symptoms of Postinfarction Syndrome

• Administer analgesics as prescribed • Encourage rest, and assist with positioning • Administer antiemetics as ordered• Restrict oral intake and provide • Obtain temperature every 4 hours,

• Post operative nursing diagnosis• Ineffective airway clearance related to the location

of the surgical incision• Ineffective breathing pattern related to surgical

incision and general anesthesia• Acute pain related to the location of the surgical

incision, the position the patient assumed on the operating table during surgery, and abdominal distention

• Urine retention related to pain, immobility, and anesthesia

• Risk for complications related to major surgical procedure

Nursing interventions

Monitoring And Managing Potential ComplicationsPromoting Urinary EliminationMaintaining Airway Clearance And Breathing

Patterns

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