presented by:Nr.Kabiru Abdullahi
updated By: abubakar usman
Date:17/july/2021
Introduction
Cancer is the growth of abnormal cells in the body. Bladder cancer typically begins in the inner lining of the bladder, the organ that stores urine after it passes from the kidneys. Most bladder cancers are caught early, when treatments are highly successful and the disease has not spread beyond the bladder. But bladder cancer tends to come back, so regular check-ups are important.
REVIEW OF THE RELATED ANATOMY AND PHYSIOLOGY
The urinary bladder, or the bladder, is a hollow organ in the pelvis. Most of it lies behind the pubic bone of the pelvis, but when full of urine, it can extend up into the lower part of the abdomen.
Its primary function is to store urine that drains into it from the kidney through tube-like structures called the ureters.
The ureters from both the kidneys open into the urinary bladder. The bladder forms a low-pressure reservoir that gradually stretches out as urine fills into it.
In males, the prostate gland is located adjacent to the base of the bladder where urethra joins the bladder. From time to time, the muscular wall of the bladder contracts to expel urine through the urinary passage (urethra) into the outside world. The normal volume of the full bladder is about 400 ml-600 \ml.
The layers of the bladder
The bladder consists of three layers of tissue.
☆. The innermost layer of the bladder, which comes in contact with the urine stored inside the bladder, is called the "mucosa" and consists of several layers of specialized cells called "transitional cells," which are almost exclusively found in the urinary system of the body. These same cells also form the inner lining of the ureters, kidneys, and a part of the urethra. These cells form a waterproof lining within these organs to prevent the urine from going into the deeper tissue layers. These cells are also termed urothelial cells, and the mucosa is termed the urothelium .
☆. The middle layer is a thin lining known as the "lamina propria" and forms the boundary between the inner "mucosa" and the outer muscular layer. This layer has a network of blood vessels and nerves and is an important landmark in terms of the staging of bladder cancer (described in detail below in the bladder cancer staging section).
The outer layer of the bladder (the "muscularis") comprises of the "detrusor" muscle. This is the thickest layer of the bladder wall. Its main function is to relax slowly as the bladder fills up to provide low-pressure urine storage and then to contract to compress the bladder and expel the urine out during the act of passing urine. Outside these three layers is a variable amount of fat that lines and protects the bladder like a soft cushion and separates it from the surrounding organs such as the rectum and the muscles and bones of the pelvis.
Definition
Bladder cancer is an uncontrolled abnormal growth and multiplication of cells in the urinary bladder, which have broken free from the normal mechanisms that keep uncontrolled cell growth in check.
: Types
♧ Urothelial carcinoma (previously known as "transitional cell carcinoma") is the most common type and comprises 90%-95% of all bladder cancers. This type of cancer has two subtypes: papillary carcinoma (growing finger-like projections into the bladder lumen) and flat carcinomas that do not produce fingerlike projections. Urothelial carcinoma (transitional cell carcinoma) is strongly associated with cigarette smoking
♧ Adenocarcinoma of the bladder comprises about 1%-2% of all bladder cancers and is associated with prolonged inflammation and irritation. Most adenocarcinomas of the bladder are invasive.
♧ Squamous cell carcinoma comprises 1%-2% of bladder cancers and is also associated with prolonged infection, inflammation, and irritation such as that associated with longstanding stones in the bladder. In certain parts of the Middle East and Africa (for example, Egypt), this is the predominant form of bladder cancer and is associated with chronic infection caused by Schistosoma worm (a blood fluke, that causes schistosomiasis, also termed bilharzia or snail fever ).
Other rare forms of cancer found in the bladder include small cell cancer (arising in neuroendocrine cells), pheochromocytoma (rare), and sarcoma (in muscle tissue).
Risk factors
Factors that may increase bladder cancer risk include:
☆Smoking. Smoking cigarettes, cigars or pipes may increase the risk of bladder cancer by causing harmful chemicals to accumulate in the urine. When you smoke, your body processes the chemicals in the smoke and excretes some of them in your urine. These harmful chemicals may damage the lining of your bladder, which can increase your risk of cancer.
☆Increasing age. Bladder cancer risk increases as you age. Though it can occur at any age, most people diagnosed with bladder cancer are older than 55.
☆Exposure to certain chemicals. Your kidneys play a key role in filtering harmful chemicals from your bloodstream and moving them into your bladder. Because of this, it's thought that being around certain chemicals may increase the risk of bladder cancer. Chemicals linked to bladder cancer risk include arsenic and chemicals used in the manufacture of dyes, rubber, leather, textiles and paint products.
☆Previous cancer treatment. Treatment with the anti-cancer drug cyclophosphamide increases the risk of bladder cancer. People who received radiation treatments aimed at the pelvis for a previous cancer have a higher risk of developing bladder cancer.
Chronic bladder inflammation. Chronic or repeated urinary infections or inflammations (cystitis), such as might happen with long-term use of a urinary catheter, may increase the risk of a squamous cell bladder cancer. In some areas of the world, squamous cell carcinoma is linked to chronic bladder inflammation caused by the parasitic infection known as schistosomiasis.
☆Personal or family history of cancer. If you've had bladder cancer, you're more likely to get it again. If one of your blood relatives — a parent, sibling or child — has a history of bladder cancer, you may have an increased risk of the disease, although it's rare for bladder cancer to run in families. A family history of Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer (HNPCC), can increase the risk of cancer in the urinary system, as well as in the colon, uterus, ovaries and other organs.
BLADDER CANCER STAGING
Bladder cancer is staged using the tumor node metastases (TNM) system developed by the International Union Against Cancer (UICC) in 1997 and updated and used by the American Joint Committee on Cancer (AJCC). In addition, the American Urologic Association (AUA) has a similar staging system that varies slightly from that used by the AJCC. The combination of both staging systems appears below. This staging gives your physician a complete picture of the extent of the person's bladder cancer.
The T stage refers to the depth of penetration of the tumor from the innermost lining to the deeper layers of the bladder.
The T stages are as follows:
Tx - Primary tumor cannot be evaluated
T0 - No primary tumor
Ta - Noninvasive papillary carcinoma (tumor limited to the innermost lining or the epithelium)
Tis - Carcinoma in situ (flat tumor)
T1 - Tumor invades connective tissue under the epithelium (surface layer)
T2 Tumor - invades muscle of the bladder
T2a - Superficial muscle affected (inner half)
T2b - Deep muscle affected (outer half)
T3 - Tumor invades perivesical (around the bladder) fatty tissue
T3a - Microscopically (visible only on examination under the microscope)
T3b - Macroscopically (for example, visible tumor mass on the outer bladder tissue)
T4 - Tumor spreads beyond fatty tissue and invades any of the following: prostate, uterus, vagina, pelvic wall, or abdominal wall
The presence and extent of involvement of the lymph nodes in the pelvic region of the body near the urinary bladder determines the N stage.
The N stages are as follows:
Nx - Regional lymph nodes cannot be evaluated
N0 - No regional lymph node metastasis
N1 - Metastasis in a single lymph node < 2 cm in size
N2 - Metastasis in a single lymph node > 2 cm, but < 5 cm in size, or two or more lymph nodes < 5 cm in size
N3 - Metastasis in a lymph node > 5 cm in size and/or to lymph nodes along the common iliac artery
The metastases or the M stage signifies the presence or absence of the spread of bladder cancer to other organs of the body.
Mx - Distant metastasis cannot be evaluated (This stage is not used by some clinicians.)
M0 - No distant metastasis
M1 - Distant metastasis
Staging allows proper classification of patients into groups for research studies and study of newer treatments.
Grading
♤Grade 1 cancers (or low grade or well differentiated cancers) have cells that look very much like normal cells. They tend to grow slowly and are not likely to spread.
♤Grade 2 cancers have cells that look more abnormal. They are called medium grade or moderately differentiated and may grow or spread more quickly than low grade.
♤Grade 3 cancers have cells that look very abnormal. They are called high grade or poorly differentiated and are more quickly growing and more likely to spread.
♤Grade 4 cancers are so abnormal that they have no distinguishing features to say that they even started as bladder cells. They are undifferentiated.
Diagnosis
Bladder cancer is most frequently diagnosed by investigating the cause of bleeding in the urine that a patient has noticed. The following are investigations or tests that come in handy in such circumstances:
Urinalysis: A simple urine test that can confirm that there is bleeding in the urine and can provide an idea about whether an infection is present or not. It is usually one of the first tests that a physician requests. It does not confirm that a person has bladder cancer but can help the physician in short-listing the potential causes of bleeding.
Urine cytology: A health care professional performs the test on a urine sample that is centrifuged. Then a pathologist examines the sediment under a microscope. The idea is to detect malformed cancerous cells that may pass into the urine from a cancer. A positive test is quite specific for cancer (for example, it provides a high degree of certainty that cancer is present in the urinary system). However, many early bladder cancers may be missed by this test so a negative or inconclusive test does not effectively rule out the presence of bladder cancer.
Ultrasound: An ultrasound examination of the bladder can detect bladder tumors. It can also detect the presence of swelling in the kidneys in case the bladder tumor is located at a spot where it can potentially block the flow of urine from the kidneys to the bladder. It can also detect other causes of bleeding, such as stones in the urinary system or prostate enlargement, which may be the cause of the symptoms or may coexist with a bladder tumor. An X-ray examination may rule out other causes of symptoms.
: CT scan/ MRI: A CT scan or MRI provides greater visual detail than an ultrasound exam and may detect smaller tumors in the kidneys or bladder than can be detected by an ultrasound. It can also detect other causes of bleeding more effectively than ultrasound, especially when intravenous contrast is used.
Cystoscopy and biopsy: This is probably the single most important investigation for bladder cancer. Since there is always a chance to miss bladder tumors on imaging investigations (ultrasound/CT/MRI) and urine cytology, it is recommended that all patients with bleeding in the urine, without an obvious cause, should have a cystoscopy performed by a urologist as a part of the initial evaluation. This entails the use of a thin tube-like optical instrument connected to a camera and a light source (cystoscope).
: CLINICAL MANIFESTATIONS
Bladder cancer signs and symptoms may include:
●Blood in urine (hematuria), which may cause urine to appear bright red or cola colored, though sometimes the urine appears normal and blood is detected on a lab test
●Frequent urination
●Painful urination
●Back pain
medical Management
Chemotherapy
Chemotherapy involves drugs designed to kill cancer cells. These drugs may be given before surgery to shrink tumors, making them easier to remove. Chemotherapy is also used to destroy any cancer cells left after surgery and to lower the chances that the cancer will return. Hair loss, nausea, loss of appetite, and fatigue are common side effects. The drugs can be given by vein or directly into the bladder.
Immunotherapy
This type of treatment stimulates immune system to identify and attack cancer cells. One treatment, bacillus Calmette-Guerin therapy, sends in helpful bacteria through a catheter directly to your bladder that trigger the immune system. Another type of therapy, immune checkpoint inhibitors, targets certain proteins on cancer cells.
Radiation
Radiation uses invisible, high-energy beams, like X-rays, to kill cancer cells and shrink tumors. It's most often given from outside the body by machine. Radiation is often used in tandem with other treatments, such as chemotherapy and surgery. For people who can't undergo surgery, it may be the main treatment. Side effects can include nausea, fatigue, skin irritation, diarrhea, and pain when urinating.
FGFR Inhibitors
These newer drugs target cancer differently than other treatments like chemotherapy do. FGFRs (fibroblast growth factor receptors) are proteins on bladder cancer cells. They can turn faulty and feed cancer growth. FGFR inhibitors block that action. They are tablets you take by mouth. Their use is reserved for metastatic/advanced bladder cancer. Some people with advanced cancer who have not been helped by other treatments may respond to FGFR inhibitors
Several new treatments may prove useful in treating bladder cancer. Photodynamic therapy, used in early stage cancers, uses a laser light to activate a chemical that kills cancer cells. Some gene therapies use lab-created viruses to fight cancer. And targeted therapies aim to control the growth of cancer cells. You may be eligible to participate in a clinical trial of these or other cutting-edge treatments.
Surgery
Transurethral surgery is most often done for early-stage cancers. If cancer has invaded more of the bladder, the surgeon will likely perform a total cystectomy, removing the entire bladder and nearby lymph nodes. For men, the prostate and seminal vesicles may also be removed. For women, the uterus, fallopian tubes, ovaries, and part of the vagina may also be removed.
Nursing management
♡ Evaluate and be aware of painful effects of particular therapies (surgery, radiation, chemotherapy, biotherapy).
♡ Provide information to patient about what to expect.
♡Provide nonpharmacological comfort measures (massage, repositioning, backrub) and diversional activities (music, television)
♡ Encourage use of stress management skills or complementary therapies (relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and therapeutic touch).
♡. Use touch during interactions, if acceptable to patient, and maintain eye contact.
♡. Note evidence of conflict; expressions of anger; and statements of despair, guilt, hopelessness, “nothing to live for.”
♡. Encourage verbalization of thoughts or concerns and accept expressions of sadness, anger, rejection. Acknowledge normality of these feelings.
♡. Provide cutaneous stimulation (heat or cold, massage).
♡. Evaluate pain relief and control at regular intervals. Adjust medication regimen as necessary.
♡. Inform patient the expected therapeutic effects and discuss management of side effects
♡. Encourage discussion of concerns about effects of cancer and treatments on role as homemaker, wage earner, parent, and so forth.
Nursing diagnosis
1. Anticipatory Grieving
2. Situational Low Self-Esteem
3. Acute Pain
4. Altered Nutrition: Less Than Body Requirements
5. Risk for Fluid Volume Deficit
6. Fatigue
7. Risk for Infection
8. Risk for Altered Oral Mucous Membranes
9. Risk for Impaired Skin Integrity
10. Risk for Constipation/Diarrhea
11. Risk for Altered Sexuality Patterns
12. Risk for Altered Family Process
13. Fear/Anxiety
Prevention
■The best way to prevent bladder cancer is to avoid exposure to agents that cause the disease.
■People who don't smoke are three to four times less likely to get bladder cancer as compared to smokers. Continuing to smoke after the diagnosis of bladder cancer portends a poorer outcome and increases the chance of the disease coming back after treatment.
■Avoidance of occupational exposure to cancer-causing chemicals such as aniline dyes may also be important.
Conclusion
Despite research in this area no medication or dietary supplement has been conclusively demonstrated to decrease the risk of bladder cancer in normal individuals. However, recent studies of patients taking atorvastatin ( Lipitor ) to lower cholesterol have suggested the drug may lower the risk of prostatic cancer and by inference, bladder cancer, but this needs further study.