bladder cancer

Bladder Cancer

Definition

Bladder cancer is a disease in which the cells lining the urinary bladder lose the ability to regulate their growth and start dividing uncontrollably. This abnormal growth results in a mass of cells that form a tumor.

Description

Bladder cancer is the sixth most common cancer in the United States. The American Cancer Society (ACS) estimated that in 2001, approximately 54,300 new cases of bladder cancer would be diagnosed (about 39,200 men and 15,100 women), causing approximately 12,400 deaths. The rates for men of African descent and Hispanic men are similar and are approximately one-half of the rate among white non-Hispanic men. The lowest rate of bladder cancer occurs in the Asian population. Among women, the highest rates also occur in white non-Hispanic females and are approximately twice the rate for Hispanics. Women of African descent have higher rates of bladder cancer than Hispanic women.The urinary bladder is a hollow muscular organ that stores urine from the kidneys until it is excreted out of the body. Two tubes called the ureters bring the urine from the kidneys to the bladder. The urethra carries the urine from the bladder to the outside of the body.Bladder cancer has a very high rate of recurrence. Even after superficial tumors are completely removed, there is a 75% chance that new tumors will develop in other areas of the bladder. Hence, patients need frequent and thorough follow-up care.

Causes and symptoms

Although the exact cause of bladder cancer is not known, smokers are twice as likely as nonsmokers to get the disease. Hence, smoking is considered the greatest risk factor for bladder cancer. Workers who are exposed to certain chemicals used in the dye industry and in the rubber, leather, textile, and paint industries are believed to be at a higher risk for bladder cancer. The disease also is three times more common in men than in women; caucasians also are at an increased risk. The risk of bladder cancer increases with age. Most cases are found in people who are 50-70 years old. In 2003, studies showed that hormone replacement therapy (HRT), a treatment used by many postmenopausal women, significantly increased the risk of bladder and other cancers.Frequent urinary infections, kidney and bladder stones, and other conditions that cause long-term irritation to the bladder may increase the risk of getting bladder cancer. A past history of tumors in the bladder also could increase one's risk of getting other tumors.One of the first warning signals of bladder cancer is blood in the urine. Sometimes, there is enough blood to change the color of the urine to a yellow-red or a dark red. At other times, the color of the urine appears normal but chemical testing of the urine reveals the presence of blood cells. A change in bladder habits such as painful urination, increased frequency of urination and a feeling of needing to urinate but not being able to do so are some of the signs of possible

Bladder cancer on the inner lining of the bladder. (Illustration by Argosy Inc.)bladder cancer. All of these symptoms also may be caused by conditions other than cancer, but it is important to see a doctor and have the symptoms evaluated. When detected early and treated appropriately, patients have a very good chance of being cured completely.

Diagnosis

If a doctor has any reason to suspect bladder cancer, several tests can help find out if the disease is present. As a first step, a complete medical history will be taken to check for any risk factors. A thorough physical examination will be conducted to assess all the signs and symptoms. Laboratory testing of a urine sample will help to rule out the presence of a bacterial infection. In a urine cytology test, the urine is examined under a microscope to look for any abnormal or cancerous cells. A catheter (tube) can be advanced into the bladder through the urethra, and a salt solution is passed through it to wash the bladder. The solution can then be collected and examined under a microscope to check for the presence of cancerous cells.A test known as the intravenous pyelogram (IVP) is an x-ray examination that is done after a dye is injected into the blood stream through a vein in the arm. The dye travels through the blood stream and then reaches the kidneys to be excreted. It clearly outlines the kidneys, ureters, bladder, and urethra. Multiple x rays are taken to detect any abnormality in the lining of these organs.The physician may use a procedure known as a cystoscopy to view the inside of the bladder. A thin hollow lighted tube is introduced into the bladder through the urethra. If any suspicious looking masses are seen, a small piece of the tissue can be removed from it using a pair of biopsy forceps. The tissue is then examined microscopically to verify if cancer is present, and if so, to identify the type of cancer.If cancer is detected and there is evidence to indicate that it has metastasized (spread) to distant sites in the body, imaging tests such as chest x rays, computed tomography scans (CT), and magnetic resonance imaging (MRI) may be done to determine which organs are affected. Bladder cancer generally tends to spread to the lungs, liver, and bone.

Treatment

Treatment for bladder cancer depends on the stage of the tumor. The patient's medical history, overall health status, and personal preferences also are taken into account when deciding on an appropriate treatment plan. The three standard modes of treatment available for bladder cancer are surgery, radiation therapy, and chemotherapy. In addition, newer treatment methods such as photodynamic therapy and immunotherapy also are being investigated in clinical trials.Surgery is considered an option only when the disease is in its early stages. If the tumor is localized to a small area and has not spread to the inner layers of the bladder, then the surgery is done without cutting open the abdomen. A cytoscope is introduced into the bladder through the urethra, and the tumor is removed through it. This procedure is called a transurethral resection (TUR). Passing a high-energy laser beam through the cytoscope and burning the cancer may treat any remaining cancer. This procedure is known as electrofulguration. If the cancer has invaded the walls of the bladder, surgery will be done through an incision in the abdomen. Cancer that is not very large can be removed by partial cystectomy, a procedure where a part of the bladder is removed. If the cancer is large or is present in more than one area of the bladder, a radical cystectomy is done. In this operation, the entire bladder and adjoining organs also may be removed. In men, the prostate is removed, while in women, the uterus, ovaries, and fallopian tubes are removed.If the entire urinary bladder is removed, an alternate place must be created for the urine to be stored before it is excreted out of the body. To do this, a piece of intestine is converted into a small bag and attached to the ureters. This is then connected to an opening (stoma) that is made in the abdominal wall. The procedure is called a urostomy. In some urostomy procedures, the urine from the intestinal sac is routed into a bag that is placed over the stoma in the abdominal wall. The bag is hidden by the clothing and has to be emptied occasionally by the patient. In a different procedure, the urine is collected in the intestinal sac, but there is no bag on the outside of the abdomen. The intestinal sac has to be emptied by the patient, by placing a drainage tube through the stoma.

Key terms

Biopsy — The surgical removal and microscopic examination of living tissue for diagnostic purposes.Chemotherapy — Treatment with anticancer drugs.Computed tomography (CT) scan — A medical procedure where a series of x rays are taken and put together by a computer in order to form detailed pictures of areas inside the body.Cystoscopy — A diagnostic procedure where a hollow lighted tube, (cystoscope) is used to look inside the bladder and the urethra.Electrofulguration — A procedure where a high-energy laser beam is used to burn the cancerous tissue.Immunotherapy — Treatment of cancer by stimulating the body's immune defense system.Intravenous pyelogram (IVP) — A procedure where a dye is injected into a vein in the arm. The dye travels through the body and then concentrates in the urine to be excreted. It outlines the kidneys, ureters, and the urinary bladder. An x ray of the pelvic region is then taken and any abnormalities of the urinary tract are revealed.Magnetic Resonance Imaging (MRI) — A medical procedure used for diagnostic purposes where pictures of areas inside the body can be created using a magnet linked to a computer.Partial cystectomy — A surgical procedure where the cancerous tissue is removed by cutting out a small piece of the bladder.Photodynamic therapy — A novel mode of treatment that uses a combination of special light rays and drugs are used to destroy the cancerous cells. First, the drugs, which make cancerous cells more susceptible to the light rays, are introduced into the bladder. Then the light is shone on the bladder to kill the cells.Radiation therapy — Treatment using high-energy radiation from x-ray machines, cobalt, radium, or other sources.Radical cystectomy — A surgical procedure that is used when the cancer is in more than one area of the bladder. Along with the bladder, the adjoining organs also are removed. In men, the prostate is removed, while in women, the ovaries, fallopian tubes and uterus may be removed.Stoma — An artificial opening between two cavities or between a cavity and the surface of the body.Transurethral resection — A surgical procedure to remove abnormal tissue from the bladder. The technique involves the insertion of an instrument called a cytoscope into the bladder through the urethra, and the tumor is removed through it.Urostomy — A surgical procedure consisting of cutting the ureters from the bladder and connecting them to an opening (see stoma) on the abdomen, allowing urine to flow into a collection bag.Radiation therapy that uses high-energy rays to kill cancer cells is generally used after surgery to destroy any remaining cancer cells that may not have been removed during surgery. If the tumor is in a location that makes surgery difficult, or if it is large, radiation may be used before surgery to shrink the tumor. In cases of advanced bladder cancer, radiation therapy is used to ease the symptoms such as pain, bleeding, or blockage. Radiation can be delivered by external beam, where a source of radiation that is outside the body focuses the radiation on the area of the tumor. Occasionally, a small pellet of radioactive material may be placed directly into the cancer. This is known as interstitial radiation therapy.Chemotherapy uses anticancer drugs to destroy the cancer cells that may have migrated to distant sites. The drugs are introduced into the bloodstream by injecting them into a vein in the arm or taking them orally in pill form. Generally a combination of drugs is more effective than any single drug in treating bladder cancer. Chemotherapy may be given following surgery to kill any remaining cancer cells. It also may be given even when no remaining cancer cells can be seen. This is called adjuvant chemotherapy. Anticancer drugs, including thiotepa, doxorubicin, and mitomycin, also may be instilled directly into the bladder (intravesicular chemotherapy) to treat superficial tumors. In 2003, the FDA was giving fast track designation to a form of paclitaxel, a common anticancer drug, that was shown effective in treating metastatic or locally advanced bladder cancer.A 2003 report stated that giving patients with bladder cancer chemotherapy followed by surgery may improve their outcomes. In the study of 307 patients, those with this combination of therapy lived two years longer than those treated with surgery only.Immunotherapy, or biological therapy, uses the body's own immune cells to fight the disease. To treat superficial bladder cancer, bacille Calmette-Guerin (BCG) may be instilled directly into the bladder. BCG is a weakened (attenuated) strain of the tuberculosis bacillus that stimulates the body's immune system to fight the cancer. This therapy has been shown to be effective in controlling superficial bladder cancer.Photodynamic treatment is a novel mode of treatment that uses special chemicals and light to kill the cancerous cells. First, a drug is introduced into the bladder that makes the cancer cells more susceptible to light. Following that, a special light is shone on the bladder in an attempt to destroy the cancerous cells.New treatments are continuously being investigated. Scientists have made great strides in gene mapping and research in the twenty-first century. In 2003, a type of gene therapy was being tested on patients with bladder cancer with success, but further enhancements were needed.

Prognosis

When detected in early stages, the prognosis for those with bladder cancer is excellent. At least 94% of people survive five years or more after initial diagnosis. However, if the disease has spread to the nearby tissues, the survival rate drops to 49%. If it has metastasized to distant organs such as the lung and liver, commonly only 6% of patients will survive five years or more. As newer treatment methods are developed, some prognoses improve. For example, neoadjuvant chemotherapy, or giving certain chemotherapy drugs following surgery, may help people live up to 31 months longer than previous treatments allowed.

Prevention

Since the exact causes of bladder cancer are not known, there is no certain way to prevent it. Avoiding risk factors whenever possible is the best alternative.Since smoking doubles one's risk of getting bladder cancer, avoiding tobacco may prevent at least half the deaths that result from bladder cancer. Taking appropriate safety precautions when working with organic cancer-causing chemicals is another way of preventing the disease. Women should discuss the risks vs. benefits of hormone replacement therapy with their physicians.If a person has had a history of bladder cancer, or has been exposed to cancer-causing chemicals, he or she is considered to be at an increased risk of getting bladder cancer. Similarly, kidney stones, frequent urinary infections, and other conditions that cause long-term irritation to the bladder also increase the chance of getting the disease. In such cases, it is advisable to undergo regular screening tests such as urine cytology, cystoscopy and x rays of the urinary tract, so that bladder cancer can be detected at its early stages and treated appropriately.

Resources

Periodicals

Good, Brian. "Battle Against Bladder Cancer." Men's Health 18 (December 2003): 32.Grossman, H. Barton, et al. "Neoadjuvant Chemotherapy Plus Cystectomy Compared With Cystectomy Alone for Locally Advanced Bladder Cancer." The New England Journal of Medicine (August 28, 2003): 859."HRT Increases Risk of Gallbladder, Breast, Endometrial, and Bladder Cancer." Women's Health Weekly (July 17, 2003): 31."Intravesical Gene Therapy Appears Safe for Those With Local Bladder Cancer." Cancer Weekly (July 8, 2003): 144."Tocosol Paclitaxel Receives Expedited Review for Bladder Cancer Indication." Biotech Week (November 26, 2003): 443.

Organizations

American Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA 30329-4251. (800) 227-2345. http://www.cancer.org.American Foundation for Urologic Disease. 300 W. Pratt St., Suite 401. Baltimore, MD 21201. Phone: (800)-828-7866.Cancer Research Institute. 681 Fifth Ave., New York, N.Y. 10022. (800) 992-2623. http://www.cancerresearch.org.National Cancer Institute. Building 31, Room 10A31, 31 Center Drive, MSC 2580, Bethesda, MD 20892-2580. (800) 422-6237. http://www.nci.nih.gov.Oncolink. University of Pennsylvania Cancer Center. http://cancer.med.upenn.edu.

Other

"Bladder Cancer." National Cancer Institute Page. http://www.nci.nih.gov.

bladder cancer

A malignant epithelial neoplasm arising in the transitional epithelium of the renal pelvis, ureter and urinary bladder; it is the 5th most common cancer of men in developed nations.

Statistics
±55,000 new cases/year (US); 90% 5-year survival; 9% if distant metastasis when diagnosed.

Clinical findings
Hematuria, increased urinary frequency.

Clinical types
Superficial (80% of total) throughout their entire clinical course; invasive ab initio.

Risk factors
Tobacco use (2- to 3-fold increased risk); occupational exposure to petrochemicals (benzene, exhaust fumes) and carcinogens in rubber, chemical and leather industries; schistosomiasis.

Diagnosis
History, PE, urine cytology, imaging; confirm by cystoscopy and biopsy.

Management
Depends on growth, size and location of tumour; for superficial UC, close follow-up is appropriate; for invasive BC, cystectomy, cystoprostatectomy and radical cystectomy may be needed; RT, neoadjuvant (preemptive) chemotherapy or bCG may be used.
Bladder cancer staging
Stage I—Cancer spreads to bladder mucosa but not to muscle wall.
Stage II—Cancer spreads to muscle wall of bladder.
Stage III—Cancer spreads through muscle wall to peritoneum and/or nearby reproductive organs.
Stage IV—Cancer spreads to abdominal wall, pelvis, to nearby lymph nodes, or metastasised.

bladder cancer

Cancer of urinary bladder Urology A malignant epithelial neoplasm of the urinary bladder; it is the 5^th most common cancer of ♂ in developed nations Statistics 52,300 new cases/1993–US; 90% 5-yr survival; 9% if distant metastasis when diagnosed Clinical types Superficial—80% of total—throughout their clinical course; invasive ab initio Risk factors Tobacco, occupational exposure to petrochemicals–benzene, exhaust fumes and carcinogens in rubber, chemical and leather industries, schistosomiasis Diagnosis History, PE, urine cytology, imaging; confirm by cystoscopy & biopsy Clinical Hematuria, ↑ urinary frequency Management Depends on growth, size, location of tumor; for superficial UC, close followup is appropriate; for invasive BC, cystectomy, cystoprostatectomy, and radical cystectomy may be needed; RT, neoadjuvant–preemptive chemotherapy, or bCG may be used

Bladder cancer staging

Stage I: Cancer spread to bladder mucosa but not to muscular wall
Stage II: Cancer spread to muscular wall of bladder
Stage III: Cancer spread through muscular wall to peritoneum and/or to the nearby reproductive organs
Stage IV: Cancer spread to abdominal wall, pelvis, to nearby lymph nodes, or it has metastasized

Bladder Cancer

DRG Category:	656
Mean LOS:	9.5 days
Description:	SURGICAL: Kidney and Ureter Procedures for Neoplasm With Major CC
DRG Category:	687
Mean LOS:	4.7 days
Description:	MEDICAL: Kidney and Urinary Tract Neoplasms With CC

Cancer of the urinary bladder is the second-most common genitourinary (GU) cancer after prostate cancer. It accounts for approximately 4% of all cancers and 2% of deaths from cancer in the United States. The American Cancer Society estimates that in 2013, there were 72,570 new cases of bladder cancer and 15,210 people died from the disease.

The majority of bladder tumors (> 90%) are urothelial or transitional cell carcinomas arising in the epithelial layer of the bladder, although squamous cell (4%), adenocarcinoma (1% to 2%), and small cell (1%) may occur. Urothelial tumors are classified as invasive or noninvasive and according to their shape (papillary or flat). Noninvasive urothelial cancer affects only the innermost layer of the bladder, whereas invasive urothelial cancer spreads from the urothelium to the deepest layers of the bladder. The deeper the invasion is, the more serious that the cancer is. Papillary tumors have fingerlike projections that grow into the hollow of the bladder. Flat urothelial tumors involve the layer of cells closest to the inside of the bladder.

Most bladder tumors are multifocal because the environment of the bladder allows for the continuous bathing of the mucosa with urine that contains tumor cells that can implant in several locations. The ureters, bladder neck, and prostate urethra may become obstructed. Direct extension can occur to the sigmoid colon, rectum, and, depending on the sex of the patient, the prostate or uterus and vagina. Metastasis occasionally occurs to the bones, liver, and lungs.

Bladder cancer is staged on the basis of the presence or absence of invasion and is graded (I to IV) on the basis of the degree of differentiation of the cell, with grade I being the best differentiated and slowest growing. Both the stage and the grade of the tumor are considered when planning treatment.

Causes

The cause of bladder cancer is not well understood; however, cigarette smoking and occupational exposure to aromatic amines (textile dyes, rubber, hair dyes, and paint pigment) are established risk factors. These cancer-causing chemicals enter the bloodstream, are filtered through the kidneys, become concentrated in the urine, and then damage the endothelial cells that line the inside of the bladder. Other associated factors include chronic bladder irritation and infection, vesical calculi, and exposure to cyclophosphamide (Cytoxan). Moderate to high amounts of caffeine could also possibly increase risk.

Genetic considerations

Although bladder cancer is generally considered to come from somatic (rather than germ line) mutations in bladder cells, mutations in several genes (e.g., HRAS, KRAS, RB1, and FGFR3) have been associated with susceptibility to bladder carcinogenesis.

Gender, ethnic/racial, and life span considerations

Bladder cancer occurs most frequently in persons over age 50, with more than half of the cases occurring in individuals over age 72. It is rare in persons under age 40. Bladder cancer is more common in men (1 in 30) than in women (1 in 90). Incidence is highest among European American men, with a rate twice that of African American men and four times that of European American women. Asians have the lowest incidence of bladder cancer. Younger men have reported less impotency following radical cystectomy than have older men. Persons living in urban areas are at higher risk for bladder cancer than persons living in rural areas.

Global health considerations

The global incidence is 8 per 100,000 males and 2.7 per 100,000 females. Developed countries have an incidence of bladder cancer from 6 to 10 times higher than developing countries. In North and South America, Europe, and Asia, transitional cell carcinoma is the most common type of bladder cancer.

Assessment

History

Gross, painless, intermittent hematuria is the most frequently reported symptom. Occult blood may be discovered during a routine urinalysis. Dysuria and urinary frequency are also reported. Burning and pain with urination are present only if there is infection. The patient may not seek medical attention until urinary hesitance, decrease in caliber of the stream, and flank pain occur. Other symptoms may include suprapubic pain after voiding, bladder irritability, dribbling, and nocturia.

Physical examination

The physical examination is usually normal. A bladder tumor becomes palpable only after extensive invasion into surrounding structures.

Psychosocial

After a diagnosis of cancer, treatment with radical cystectomy and creation of a urinary diversion system can threaten the sexual functioning of both men and women. The procedure can cause impotence in men and psychological problems similar to those that accompany a hysterectomy and oophorectomy in women. In addition, a portion of the vagina may be removed, thus affecting intercourse. The psychological impact of a stoma and external urinary drainage system can cause changes in body image and libido.

Diagnostic highlights

General: Urinalysis generally reveals gross hematuria and occasionally pyuria.

Test	Normal Result	Abnormality With Condition	Explanation
Cystoscopy/biopsy	Normal view of bladder, free of growths	Suspicious growths are seen; a small piece is removed and biopsied	Biopsy confirms the malignancy
Serum carcinoembryonic antigen (CEA) level	< 2.5 ng/dL in nonsmokers; < 5 ng/mL in smokers	Approximately 50% of patients with late-stage bladder cancer have moderately elevated CEA levels	Useful in monitoring response to treatment and extent of disease
Urine cytology	Normal type and amount of squamous and epithelial cells of urinary tract	Abnormal cells are seen under the microscope (tumor and pretumor cells)	Evidence of urinary tract neoplasm

Other Tests: Urine culture, urinalysis with microscopy, intravenous pyelogram, ultrasonography, pelvic computed tomography scan, magnetic resonance imaging, bone scan, complete blood count, liver and kidney function tests, alkaline phosphatase (bony fraction)

Primary nursing diagnosis

Diagnosis

Risk for altered urinary elimination related to the obstruction of urinary flow

Outcomes

Urinary continence; Urinary elimination; Knowledge: Disease process and treatment regime; Self-care: Toileting; Self-esteem

Interventions

Urinary elimination management; Urinary incontinence care; Teaching: Individual; Fluid monitoring; Urinary catheterization; Anxiety reduction; Infection control; Skin surveillance; Tube care: Urinary

Planning and implementation

Collaborative

Patients with higher stage invasive disease are usually treated with radical curative surgery, whereas patients with lower stage noninvasive disease can be controlled with more conservative measures. Papillary tumors, even when noninvasive, have a high rate of recurrence. Carcinoma in situ (CIS) is usually multifocal and also has a high rate of recurrence.

conservative.

Superficial bladder tumors can be treated effectively with conservative measures that consist of surgical removal of the tumor by transurethral resection of the bladder (TURB) followed by electrical destruction or fulguration, intravesical instillation of chemotherapy or immunotherapy, and frequent follow-up cystoscopic examination. Superficial bladder tumors can also be destroyed with the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser. Patients with multiple superficial bladder tumors receive intravesical instillation of chemotherapy and immunotherapy, such as bacillus Calmette-Guérin (BCG) vaccine. This vaccine is made from a strain of Mycobacterium bovis and helps to prevent a relapse.

surgical.

Partial or segmental cystectomy may be recommended for patients with diffuse, unresectable tumors or tumors that fail to respond to intravesical therapy. Because tumors are likely to continue to spread and metastasize to distant sites, procedures such as radical cystectomy with creation of a urinary diversion, external radiation therapy, or a combination of preoperative radiation therapy followed by radical cystectomy and urinary diversion are recommended.

The Bricker ileal conduit is the most popular method for creating the urinary diversion. In this procedure, the ureters are implanted into an isolated segment of the terminal ileum. The proximal end of the ileal segment is closed, and a stoma is formed by bringing the distal end out through a hole in the abdominal wall. An external pouch for the collection of urine is worn continuously. Ureteral stents, which are left in place up to 3 weeks after surgery, may be placed during the procedure to promote the flow of urine.

postoperative.

Postoperatively, direct nursing care toward providing comfort, preventing complications from major abdominal surgery, and promoting urinary drainage. Monitor the patient’s vital signs, dressings, and drains for symptoms of hemorrhage and infection. Monitor the color of the stoma, as well as the amount and color of the urine in the collection pouch, every 4 hours. Urine should drain immediately. Some stomal edema is normal during the early postoperative period, but the flow of urine should not be obstructed.

radiation.

External beam radiation therapy can be used as both adjuvant and definite treatment for bladder cancer. High-dose, short-course therapy consisting of 16 to 20 Gy can be delivered preoperatively to decrease the size of the tumor(s) and prevent spread during surgery. Radiation therapy with a curative intent may be a treatment option for patients who are opposed to a cystectomy and urinary diversion. Unfortunately, 50% of patients with invasive bladder cancer eventually relapse.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Thiotepa, mitomycin, doxorubicin	Varies with drug	Intravesical chemotherapy	Reduce recurrence in those who had complete transurethral resection
M-VAC (methotrexate, vinblastine, adriamycin, cisplatin) MCV (methotrexate, cisplatin, vinblastine) GemCIS (gemcitabine, cisplatin)	Varies with drug	Combination systemic antineoplastic chemotherapy	Combination systemic chemotherapy may be effective in prolonging life but is rarely curative

Independent

For patients who require radical cystectomy with urinary diversion, offer support and reinforcement of the information. Ensure that the patient knows what to expect. Involve another family member in the preoperative education. If it is needed, arrange a preoperative visit by someone who has adjusted well to a similar diversion.

If any type of stoma is to be created, arrange for a preoperative visit from the enterostomal therapist. The enterostomal therapist can assist in the selection and marking of the stoma site (although the stoma site is somewhat contingent on the type of urinary diversion to be performed) and can introduce the patient to the external urine collection pouch and related care. Suggest involvement with community associations such as the United Ostomy Association and the American Cancer Society.

postoperative.

Encourage the patient to look at the stoma and take an active part in stoma care as soon as possible. Allow him or her to hold the equipment, observe the amount and characteristics of urine drainage, and empty the urine collection pouch. Implement care to maintain integrity of the skin around the stoma or urinary diversion that has been created. Empty the urinary drainage pouch when it is about one-third full to prevent the weight of the pouch from breaking the skin seal and leaking urine onto the skin. Depending on the type of urinary diversion created, begin teaching stoma care and care of the system 2 to 3 days after surgery.

Be sensitive to the patient’s feelings about the potential for altered sexual functioning after radical cystectomy. Listen attentively and answer any questions honestly. Encourage the patient and his or her partner to explore alternative methods of sexual expression. Consider referral to a sex therapist. If appropriate, suggest that men investigate the possibility of a penile prosthesis with their physician.

Evidence-Based Practice and Health Policy

Mohamed, N.E., Herrera, P.C., Hudson, S., Revenson, T.A., Lee, C.T., Quale, D.Z., …Diefenbach, M.A. (2013). Muscle invasive bladder cancer: Examining survivor burden and unmet needs. The Journal of Urology. Advanced online publication. doi 10.1016/j.juro.2013.07.062

Investigators of one study explored unmet needs among a sample of 30 patients who underwent cystectomy and urinary diversion for treatment of bladder cancer. They found that patients experiencing bladder cancer have varying informational, medical, and psychological needs along the cancer trajectory.
At the point of diagnosis, 57% of patients felt the information they received was insufficient and indicated they needed more information on postoperative self-care, the healing process, and finances and medical insurance. Only 20% of patients reported receiving information about possible changes in sexual function, and 33% of patients reported feeling severely depressed when diagnosed but none received a referral for care.
Postoperatively, 53% of patients received support at home from a visiting nurse. However, 30% of these patients reported needing more support in stomal or continent reservoir care.
At survivorship (6 to 72 months postoperatively), 43% of patients experienced changes in sexual function; however, only 17% of these patients received advice on sexual dysfunction. Similar to the time of diagnosis, 33% of patients reported feeling depressed; however, less than 7% received professional assistance for depressive symptoms.

Documentation guidelines

Description of all dressings, wounds, and drainage collection devices
Physical findings related to the pulmonary assessment, abdominal assessment, presence of edema, condition of extremities, bowel and bladder patterns of voiding
Response to and side effects experienced related to intravesical instillations of chemotherapy or BCG; systemic chemotherapy
Teaching performed, the patient’s understanding of the content, the patient’s ability to perform procedures demonstrated

Discharge and home healthcare guidelines

patient teaching.

Following creation of an ileal conduit, teach the patient and significant others how to care for the stoma and urinary drainage system. If needed, arrange for follow-up home nursing care or visits with an enterostomal therapist.

Teach the patient the specific procedure to catheterize the continent cutaneous pouch or reservoir. A simple stoma covering made from a feminine hygiene pad can be worn between catheterizations. Stress the need for the patient to wear a medical ID bracelet.

Following orthotopic bladder replacement, teach the patient how to irrigate the Foley catheter. Suggest the use of a leg bag during the day and a Foley drainage bag at night. Once the pouch has healed and the Foley catheter, ureteral stents, and pelvic drain have been removed, teach the patient to “push” or “bear down” with each voiding. Instruct the patient on methods for performing Kegel exercises during and between voidings to minimize incontinence. Suggest wearing incontinence pads until full control is achieved. Also instruct the patient on self-catheterization techniques in case the patient is unable to void. Instruct patients where to obtain ostomy pouches, catheters, and other supplies. Teach the patient how to clean and store catheters between use following the clean technique.

care of skin in external radiation field.

Encourage the patient to verbalize concerns about radiation therapy and reassure the patient that she or he is not “radioactive.” Instruct the patient to wash skin gently with mild soap, rinse with warm water, and pat the skin dry each day but not to wash off the ink marking that outlines the radiation field. Encourage the patient to avoid applying any lotions, perfumes, deodorants, or powder to the treatment area. Encourage the patient to wear nonrestrictive soft cotton clothing directly over the treatment area and to protect the skin from sunlight and extreme cold. Stress the need to maintain the schedule for follow-up visits and disease surveillance as recommended by the physician.