CONFIRMING DIAGNOSIS Only cystoscopy and biopsy confirm bladder cancer. Cystoscopy should be performed when hematuria first appears. When it's performed under anesthesia, a bimanual examination is usually done to determine if the bladder is fixed to the pelvic wall. A thorough history and physical examination may help determine whether the tumor has invaded the prostate or the lymph nodes. (See Comparing staging systems for bladder cancer.)
The following tests can provide essential information about the tumor:
❑Urinalysis can detect blood in the urine and malignant cytology.
❑ Excretory urography can identify a large, early stage tumor or an infiltrating tumor, delineate functional problems in the upper urinary tract, assess hydronephrosis, and detect rigid deformity of the bladder wall.
❑ Retrograde cystography evaluates bladder structure and integrity. Test results help to confirm the diagnosis.
❑ Pelvic arteriography can reveal tumor invasion into the bladder wall.
❑ Computed tomography scan reveals the thickness of the involved bladder wall and detects enlarged retroperitoneal lymph nodes.
❑ Ultrasonography can detect metastasis beyond the bladder and can distinguish a bladder cyst from a tumor.
❑ Excretory urography evaluates the upper urinary tract for tumors or blockage.
Treatment
Superficial bladder tumors are removed by transurethral (cystoscopic) resection and fulguration (electrical destruction). This procedure is adequate when the tumor hasn't invaded the muscle.
Intravesicular chemotherapy is also used for superficial tumors (especially those that occur in many sites) and to prevent tumor recurrence. This treatment involves washing the bladder directly with antineoplastic drugs — most commonly, thiotepa, doxorubicin, mitomycin, or Bacillus Calmette-Guérin immunotherapy.
If additional tumors develop, fulguration may have to be repeated every 3 months for years. However, if the tumors penetrate the muscle layer or recur frequently, cystoscopy with fulguration is no longer appropriate.
Tumors too large to be treated through a cystoscope require segmental bladder resection to remove a full-thickness section of the bladder. This procedure is feasible only if the tumor isn't near the bladder neck or ureteral orifices. Bladder instillation of thiotepa, mitomycin-C, or doxorubicin after transurethral resection may also help control such tumors.
For infiltrating bladder tumors, radical cystectomy is the treatment of choice. The week before cystectomy, treatment may include external beam therapy to the bladder. Surgery involves removal of the bladder with perivesical fat, lymph nodes, urethra, the prostate and seminal vesicles (in males), and the uterus and adnexa (in females). The surgeon forms a urinary diversion, usually an ileal conduit. The patient must then wear an external pouch continuously. Other diversions include ureterostomy, nephrostomy, vesicostomy, ileal bladder, ileal loop, and sigmoid conduit.
Males are impotent following radical cystectomy and urethrectomy because these procedures damage the sympathetic and parasympathetic nerves that control erection and ejaculation. At a later date, the patient may desire a penile implant to make sexual intercourse (without ejaculation) possible.
Treatment of patients with advanced bladder cancer includes cystectomy to remove the tumor, radiation therapy, and systemic chemotherapy with such drugs as doxorubicin, methotrexate, vinblastine, and cisplatin. This combination sometimes is successful in arresting bladder cancer. Cisplatin is the most effective single agent.
Investigational treatments include photodynamic therapy and intravesicular administration of interferon-alfa and tumor necrosis factor. Photodynamic therapy involves I.V. injection of a photosensitizing agent such as hematoporphyrin ether, which malignant cells readily absorb. Then a cystoscopic laser device introduces laser energy into the bladder, exposing the malignant cells to laser light, which kills them. Because this treatment also produces photosensitivity in normal cells, the patient must totally avoid sunlight for about 30 days.
Special considerations
❑Before surgery, assist in selecting a stoma site that the patient can see (usually in the rectus muscle to minimize the risk of herniation). Do so by assessing the abdomen in various positions.
❑After surgery, encourage the patient to look at the stoma. Provide a mirror to make viewing easier.
❑To obtain a specimen for culture and sensitivity testing, catheterize the patient using sterile technique. Insert the lubricated tip of the catheter into the stoma about 2" (5.1 cm). In many facilities, a double telescope-type catheter is available for ileal conduit catheterization.
❑Advise the patient with a urinary stoma that he may participate in most activities, except for heavy lifting and contact sports.
❑When a patient with a urinary diversion is discharged, arrange for follow-up home health care or refer him to an enterostomal therapist, who will help coordinate the patient's care.
❑Teach the patient about his urinary stoma. Encourage his spouse, a friend, or a relative to attend the teaching session. Advise this person beforehand that a negative reaction to the stoma can impede the patient's adjustment.
❑First, show the patient how to prepare and apply the pouch, which may be reusable or disposable. If he chooses the reusable type, he'll need at least two.
❑To select the right pouch size, measure the stoma and order a pouch with an opening that clears the stoma with a 1/8" (3 mm) margin. Instruct the patient to remeasure the stoma after he goes home, in case the size changes. The pouch should have a drainage valve at the bottom. Tell the patient to empty the pouch when it's one-third full or every 2 to 3 hours.
❑To ensure a good skin seal, select a skin barrier that contains synthetics and little or no karaya (which urine tends to destroy). Check the pouch frequently to make sure that the skin seal remains intact. A good skin seal with a skin barrier may last for 3 to 6 days, so change the pouch only that often. Tell the patient that he can wear a loose-fitting elastic belt to help secure the pouch.
❑The ileal conduit stoma reaches its permanent size 2 to 4 months after surgery. Because the intestine normally produces mucus, mucus will appear in the draining urine.
❑Keep the skin around the stoma clean and free from irritation. After removing the pouch, wash the skin with water and mild soap. Rinse well with clear water to remove soap residue, and then gently pat the skin dry; don't rub. Place a gauze sponge soaked with vinegar-water (1 part to 3 parts) over the stoma for a few minutes to prevent uric acid crystal buildup. While preparing the skin, place a rolled-up dry sponge over the stoma to collect draining urine. Coat the skin with skin protectant, and cover with the collection pouch. If skin irritation or breakdown occurs, apply a layer of antacid precipitate to the clean, dry skin before coating with the skin protector.
❑The patient can level uneven surfaces on his abdomen, such as gullies, scars, or wedges, with various specially prepared products or skin barriers.
❑All high-risk people — for example, chemical workers and people with a history of benign bladder tumors or persistent cystitis — should have periodic cytologic examinations and learn about the danger of disease-causing agents.
❑Refer patients with ostomies to such support organizations as the American Cancer Society and the United Ostomy Association.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
Other Book Chapters Related to Bladder symptoms
Read excerpts from these other book chapters related to Bladder symptoms:
Medical Books Excerpts
- Urethral Discharge
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Bladder distention
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Bladder symptoms
» Next page: Lower urinary tract infection (Professional Guide to Diseases (Eighth Edition))
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