Introduction

Several types of carcinoma arise on the urothelial surface. The most

common is transitional cell carcinoma (TCC), which can arise anywhere in
the urinary tract but is usually found in the urinary bladder. Depending on
the genetic alterations that occur, they may follow different pathways in the
expression of their phenotype..
Incidence
Each year, 40,000-50,000 patients are diagnosed with bladder cancer in the
United States, and most of these occur in men, with a male-to-female ratio of
3:1. CIS represents only 10% of cancers in this population.
Etiology:
- The development of most bladder cancers is related to environmental
factors. A history of smoking is present in 75% of bladder cancer
patients. Secondhand smoke has also been implicated as a risk factor.
- Risk is high in those who consume artificial sweeteners, coffee or
aromatic amines and who are exposed to cyclophosphamides.
- Patients who are exposed to chemicals because of their occupation are at
increased risk for developing bladder cancer. Petrochemical workers, tire
manufacturers, beauticians, leather workers, printers, textile workers,
and workers in similar industries are at increased risk. Bladder
carcinogens include benzidine, nephelines, aromatic amines,
nitrosamines, local radiation therapy, various dyes and solvents, and
some chemotherapeutic drugs.
Pathophysiology:
CIS is thought to arise because of an early mutation or deletion in the cell
cycle regulator, p53. Mutation or deletion in the 9p chromosome arm may
also be present in CIS.
Of all bladder carcinomas:
- 90% are transitional cell carcinomas
- 5% are squamous carcinoma
- 2% are adenocarcinomas
- 80% of TCCs are superficial (CIS) and well differentiated and associated
with good prognosis.
- 10- 20% of TCCs are high-grade and muscle invasive
and associated with poor prognosis.
Tumours are classified into four growth patterns: in situ (noninvasive);
papillary; infiltrating; and combined papillary and infiltrating.

For malignant bladder tumours, the staging system most commonly used
today is TNM classification.
Tis : In-situ disease
Ta
: Epithelium only
T1 : lamina propria invasion
T2 : Superficial muscle invasion
T3a : Deep muscle invasion
T3b : Perivesical fat invasion
T4aN1-3
: tumor metastasis within the pelvis with lymph nodes
T4aN4M1 : tumor metastasis beyond the pelvis
Grade of tumour also important
G1 Well differentiated
G2 Moderately well differentiated
G3 Poorly differentiated
Clinical manifestations
:Patients with CIS may present with gross hematuria, microscopic
hematuria, or irritative bladder symptoms. 80% present with painless
haematuria
Also present with treatment-resistant infection or bladder irritability
and sterile pyuria, urinary frequency, urgency, and dysuria.
Diagnosis is often delayed because symptoms are attributed to urinary tract
infection.
Diagnosis
Physical examination : unlikely to reveal any abnormalities associated
with CIS. If a large coexistent bladder cancer is present, a mass may
be palpable in the suprapubic area or on rectal examination.
Lab Studies:
Urinalysis
- This routine test is used to evaluate the presence of RBCs, WBCs, and
protein.
- Urine for culture and sensitivity: Prior to performing an endoscopic
examination or initiating any therapy, the urine should be free of
infection.
Urine cytology
- At least 100 cc of a freshly voided specimen, not an overnight sample, is
usually sufficient to check the presence of malignant cells.
Urine tumor markers

- A number of molecular tumor markers have been identified in the urine

of patients with bladder cancer- BTA stat ([bladder tumor antigen]
Polymedco) and the NMP22 ([nuclear matrix protein] Matritech)
- Bladder cancer antigen (BCA) measures cytokeratins 8 and 18, while
CYFRA 21-1 detects cytokeratin 19.
- epithelial growth factor
CBC count: The presence of anemia or an elevated WBC count Chemistry
panel
Liver function test -One of the intravesical agents used to treat CIS is BCG.
Systemic absorption of this agent can produce an acute hepatitis
KFT
patients with marginal or abnormal renal function may have obstruction or
some type of renal disease that may worsen with intravesical therapy.
Serum tumor markers- Carcinoembryionic antigen
Imaging Studies:
CT urogram
This is becoming the preferred to the IVP. The CT urogram combines a CT
scan with intravenous contrast to provide anatomic details of the kidneys,
regional lymph nodes, and other abdominal organs that may be affected by
this disease.
Intravenous pyelogram: This study involves the intravenous injection of
contrast with a series of radiographic images of the abdomen.
Ultrasonography: This is useful to detect obstruction and large tumors.
Transurethral and transrectal US, higher frequency transducers allow better
spatial resolution
Definitive Diagnostic Procedures:
A definitive diagnosis of CIS is made using cystoscopy with bladder
biopsies. This is generally performed under general anesthesia,
TREATMENT
Evaluation of anatomical extent of disease must include determination of the
site, number, and growth pattern of individual bladder tumours, as well as
depth of muscular and perivesical fat invasion and presence or absence of
lymph node extension.
Medical therapy

- BCG is the principle immunotherapeutic agent used for the eradication

of CIS. Interferon alfa (IFN-alfa) may be used in conjunction with BCG,
but it has not been effective as monotherapy. BCG is activated by
dissolving the powder in 1 cc of sterile water and diluting the mixture
with 30-50 cc of saline. The solution is instilled into the bladder through
a catheter. The patient voids the solution after 1-2 hours.
Once in the bladder, the live organisms enter macrophages, where they
induce the same type of histologic and immunologic reaction as found in
patients with tuberculosis. BCG also has a predilection for entering bladder
cancer cells, where the proteins are broken down and fragments are
combined with histocompatibility antigens and displayed on the cell surface.
This induces a cytokine and direct cell-to-cell cytotoxicity response, which
targets these cells for destruction.
In order for BCG to be effective, the host should be immunocompetent,
tumor burden should be small, direct contact with the tumor should occur,
and the dose should be adequate to incite a reaction. To induce this reaction,
multiple instillations of BCG are required.
- Chemotherapeutic agents that can be administered intravesically to treat
CIS include mitomycin C, thiotepa, Adriamycin, cis-platinum, and
valrubicin.
- Photodynamic therapy has been shown to be effective, but it has limited
usefulness because of adverse effects. This treatment involves the
intravenous injection of a porphyrin derivative followed 24 hours later
with exposure of the bladder surface to laser light, activating the
cytotoxic agent, which has preferentially concentrated within the cancer
cells. The laser is introduced through a cystoscope. The major adverse
effect is severe photosensitivity, which can last for several months.
Surgical therapy
Patients who do not respond to intravesical immunotherapy or chemotherapy
are candidates for radical cystectomy.
- Trans urethral resection
- Partial cystectomy- a segment is removed. Up to half can be removed.
- Radical cystectomy and urinary diversion.
o Creation of an ileal conduit (Brickers procedure): An ileal
bladder is created using a segment of intestine. One end of the
segment is closed and the other end is brought to an artificial
opening made in abdominal wall. Ureters are connected to the

ileal bladder. An appliance is placed to collect urine. Intestinal

anastamosis is done to maintain the continuity.
o Kock Pouch or continent- an internal pouch is created from a
segment of ileum or ascending colon. Ureters are implanted
into it. Ileal segment is connected from pouch to the skin
surface. Catheter is used to drain urine intermittently.
o Indiana pouch Larger pouch than kock pouch.
o Neobladder: If urethra is spared the reservoir will be emptied
through urethra.
Palliative procedures : to drain urine
o Percutaneous nephrostomy or Pyelostomy
o Ureterosyomy
o Vesicostomy
Superficial TCC
- Requires transurethral resection and regular cystoscopic follow-up
- Consider prophylactic chemotherapy if risk factor for recurrence or
invasion (e.g. high grade)
Consider immunotherapy-BCG = attenuated strain of Mycobacterium bovis
reduces risk of recurrence and progression
Carcinoma in-situ
- 50% patients progress to muscle invasion
Consider immunotherapy
- If fails patient may need radical cystectomy
Invasive TCC
1.
Radical cystectomy and urinary diversion
- Valve rectal pouch
- Modified ureterosigmoidostomy
- Ileal conduit
- Neo-bladder
2. Radiotherapy after surgery
3.Chemotherapy after surgery
Nursing Management
Risk for injury related to chemotherapy and radiotherapy
- Increase fluid intake
- Antibiotics for cystitis.
- Protect fro infections

- Report the side effects related to chemotherapy.

- Place the client on radiotherapy in a private room.
- Disinfect urine before discarding
Hemorrhage related to hematuria and surgery.
- Intermittent bladder irrigation to prevent clots
- High intake of fluid
- Strict intake and output chart.
- Monitor for bleeding at the wound site
- Monitor drainage for excessive collection.
Body image disturbances
- Emotional support.
- Preoperative counseling
- community and ostomy associations.
- Encourage them to accept the stoma as a part of their body
- Proper method of covering the stoma and p[ouch
Risk for infection
- Strict aseptic techniques
- Avoid contact with persons with some infections.
- Clean intermittent catheterization
- Avoid overcrowding
- Nutritious diet.
- Soap and water cleaning of stoma
- Antibiotics as prescribed.
- Proper hand washing.
Risk for impaired skin integrity related to irritation to peristomal skin
- Check the PH of urine as alkaline urine causes irritation
- Antibiotics for UTI.
- Do not change the pouch very frequently, leave it in place as long as
possible.
- Leave the skin surrounding stoma to fresh air as long as possible.
- Nystatin powder or cream, if pt is having yeast infection.
Altered sexuality pattern
- Pre and post operative counseling
- Other methods of sexual satisfaction
Occlusion of urinary drainage bag
- Check for bladder retention or abdominal pain
- Care of SPC as it will be there for 2 weeks
- Strict output charting
- Intermittent irrigation to prevent block

Paralytic ileus, stomal ischemia and blockage of urinary catheters

- Routine monitoring of vital signs.
- Intake and output
- Inspection of stoma and wound
- Check the RT aspiration.
- Assess bowel sounds.
- Care of catheter which drain urine through stoma
- Care of stomal pouch.
Knowledge deficit.
- Right application of pouch over the stoma.
- Avoid contact of urine with stoma.
- Clean the stoma with a mild soap and water and dry thoroughly before .
- Change at morning when less urine production is there.
- Adequate fluid intake.
- Maintain proper hygiene.
- Reusable appliances should be washed thoroughly in luke warm water.
- Keep a gauze over the stoma while removing the pouch and cleaning
- Demonstrate the stomal care to them
- Provide written instructions to client and relatives.
- Teach the method of intermittent catheterization to a client with
continental or Kock or Indiana pouch.
Follow-up care
Following successful treatment of initial or recurrent CIS with intravesical
BCG and/or chemotherapy, patients are monitored at regular intervals with
cystoscopy and urine cytology. This usually occurs at a frequency of every 3
months for the first 1-2 years and every 6 months thereafter. IVP is usually
performed every 6-12 months as well. This follow-up continues for a
minimum of 5 years.
Following cystectomy and urinary diversion, cytology is performed every 3
months for the first 1-2 years and every 6 months thereafter. For patients
with a urostomy or continent diversion, a catheterized specimen is obtained
from the stoma, not the urostomy bag, because contact with the bag and the
stagnant nature of urine in the bag confounds the cytologic findings. If the
patient did not undergo a urethrectomy, a urethral wash for cytology should
also be performed on this schedule. Patients with an intestinal neobladder
should provide a voided specimen. An IVP or loopogram should be

performed every 6-12 months to evaluate the upper urinary tract, as should a
CT scan, chest radiograph, and serum chemistries to rule out metastatic
disease. After 2-3 years, a vitamin B-12 level should be checked because
many of these patients develop deficiency of this vitamin.
Complications
o Hematurea.
o Bladder distention
o Stomal stenosis
o Recurrence
o Small bowel obstruction
o Wound infection
o Small bowel fistulas
o Wound dehiscence
o Ureterocutaneous fistula
Prognosis
Superficial tumours are usually low grade and associated with a good
prognosis
Muscle invasive tumours are of higher grade and have a poorer prognosis
Disease-specific survival rates of 63% at 15 years in patients treated with
BCG therapy and cystectomy early in the course of their disease.
Results associated with chemotherapy regimens are not as favorable.
Local recurrence rates after surgery are approximately 15% and after
radiotherapy alone 50%
Pre-operative radiotherapy is no better than surgery alone
Adjuvant chemotherapy may have a role