8.13 Bladder and Prostate Cancer

This section will provide an overview of two common cancers affecting the urinary tract – bladder cancer and prostate cancer.

Bladder Cancer

Bladder cancer is the most common malignancy affecting the urinary system. Bladder cancer is classified as non-muscle invasive, muscle-invasive, or metastatic, with treatment and prognosis based on the severity of the disease.^[1]

Signs and Symptoms

Clients with bladder cancer typically have hematuria and some may have frequency, urgency, dysuria, and nocturia.^[2]

Diagnostic Testing

The presence of hematuria requires diagnostic testing that usually begins with cystoscopy and biopsy of suspicious tissue or tumors. Read more about cystoscopy in the “General Urinary System Assessment” section of this chapter.

If tumors are found on cystoscopy, a transurethral resection of bladder tumor (TURBT) is typically performed to remove the tumor(s) and stage the cancer. If bladder cancer is diagnosed, additional diagnostic testing for staging the cancer includes CT, MRI, and PET scans.^[3]

Medical Treatment

Treatment is based on biopsy results that indicate if the cancer has invaded the bladder muscle tissue. For clients with bladder cancer that has not invaded the bladder muscle tissue, conservative treatment typically includes removal of the tumor with a TURBT followed by chemotherapy administered directly into the bladder, referred to as intravesical therapy. This conservative treatment is used to maintain a functional bladder.^[4]

Muscle-invasive bladder cancer is treated with radical cystectomy, meaning removal of the bladder and regional lymph nodes. In males, radical cystectomy also includes the removal of the prostate and seminal vesicles. When a client’s bladder is removed, urinary flow must be redirected, referred to as urinary diversion. Three common types of urinary diversion include the following^[5]:

• Ileal conduit: A diversion is created for the urine to flow from the ureters through a segment of bowel (usually the ileum) to a stoma on the skin surface, where it is collected using an external appliance.
• Cutaneous continent reservoir: A reservoir is constructed under the skin and the client self-catheterizes at regular intervals to empty the reservoir. This option avoids the need for an external appliance.
• Orthotopic neobladder: A neobladder is formed from a segment of the bowel and attached to the urethra, enabling the client to void through the urethra.

If a client is diagnosed with metastatic cancer, they are typically treated with chemotherapy,  immunotherapy, or targeted therapies.

Chemotherapy

Chemotherapy uses medications to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body.^[6]

Targeted Therapy

Targeted therapy uses medications or other substances to identify and attack specific cancer cells. Targeted therapies usually cause less harm to normal cells than chemotherapy or radiation therapy.^[7]

Immunotherapy

Immunotherapy uses the client’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer.^[8]

Prostate Cancer

Cancer of the prostate gland is the second most common cancer occurring in men. In the U.S., about 1 out of 8 men will be diagnosed with prostate cancer. Prostate cancer usually grows very slowly, so treating it before symptoms occur may not improve men’s health or help them live longer.^[9] Prostate cancer tends to grow on the peripheral edges of the gland first and, therefore, often does not result in urinary symptoms initially.

Signs and Symptoms

Symptoms of prostate cancer are initially similar to benign prostatic hypertrophy (BPH), such as trouble starting a urine stream and frequent urination, especially at night, and trouble emptying the bladder. Symptoms of advanced prostate cancer that have metastasized to other areas of the body include pain in the back, hips, or pelvis that doesn’t go away, shortness of breath, fatigue, fast heartbeat, dizziness, pale skin caused by anemia, hematuria, blood in the semen, dysuria, and erectile dysfunction.^[10]

A health care provider may assess for prostate cancer by performing a digital rectal exam, which entails inserting a lubricated, gloved finger into the rectum and palpating the prostate through the rectal wall to assess size, lumps, or other abnormal areas.^[11]

Diagnostic Testing

Diagnostic testing for prostate cancer may include the following^[12]:

• Prostate-specific antigen (PSA): A test that measures the level of PSA in the blood, a substance made by the prostate that may be found in higher-than-normal amounts in the blood of men who have prostate cancer. PSA levels may also be elevated in men who have BPH or prostatitis, so it is not a very reliable test.
• Pelvic lymphadenectomy: A surgical procedure to remove the lymph nodes in the pelvis. A pathologist views the tissue under a microscope to look for cancer cells.
• PSMA PET scan: An imaging procedure that is used to help find prostate cancer cells that have spread outside of the prostate into bone, lymph nodes, or other organs. For this procedure, a cell-targeting molecule linked to a radioactive substance is injected into the body and travels through the blood. It attaches to a protein called prostate-specific membrane antigen (PSMA) that is found on the surface of prostate cancer cells. A PET scan detects high concentrations of the radioactive molecule and shows where the prostate cancer cells are in the body.
• Seminal vesicle biopsy: The removal of fluid from the seminal vesicles using a needle that is then viewed under a microscope by a pathologist to look for cancer cells.
• Transrectal ultrasound: A procedure in which a probe that is about the size of a finger is inserted into the rectum to check the prostate. The probe is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. Transrectal ultrasound may also be used during a biopsy procedure called transrectal ultrasound guided biopsy.
• Transrectal MRI: A procedure that uses a strong, magnet radio waves and a computer to make a series of detailed images to determine if the cancer has spread outside the prostate into nearby tissues. Transrectal MRI may also be used during a biopsy procedure. This is called transrectal MRI guided biopsy.
• Transrectal biopsy: During this procedure, tissue is removed from the prostate by inserting a thin needle through the rectum and into the prostate. This procedure may be done using transrectal ultrasound or transrectal MRI to help guide where samples of tissue are taken. A pathologist views the tissue under a microscope to look for cancer cells.

If prostate cancer is diagnosed, additional testing to check for metastasis may include bone scan, MRI, or CT scans.

Medical Treatment

There are several types of treatment for clients with prostate cancer, depending on the stage of the cancer and if it has metastasized^[13]:

• Watchful waiting
• Surgery
• Radiation therapy and radiopharmaceutical therapy
• Hormone therapy
• Bisphosphonate therapy
• Chemotherapy
• Targeted therapy
• Immunotherapy

Watchful waiting refers to treatment used for older men whose prostate cancer is found during a screening test, but do not have signs or symptoms. Watchful waiting means closely monitoring a client’s condition without any treatment unless signs or symptoms appear, or test results change. Treatment is provided to relieve symptoms and improve quality of life.

Surgery

There are many types of surgeries performed to treat prostate cancer^[14]:

• Radical prostatectomy: A surgical procedure to remove the prostate, surrounding tissue, and seminal vesicles. Removal of nearby lymph nodes may be done at the same time to check for possible metastasis. The main types of radical prostatectomy are as follows:
  • Open radical prostatectomy: An incision (cut) is made in the retropubic area (lower abdomen) or the perineum (the area between the anus and scrotum). Surgery is performed through the incision.
  • Radical laparoscopic prostatectomy: Several small incisions (cuts) are made in the wall of the abdomen. A laparoscope (a thin, tube-like instrument with a light and lens for viewing) is inserted through one opening to guide the surgery. Surgical instruments are inserted through the other openings to do the surgery.
  • Robot-assisted laparoscopic radical prostatectomy: Several small cuts are made in the wall of the abdomen, as in radical laparoscopic prostatectomy. The surgeon inserts an instrument with a camera through one of the openings and surgical instruments through the other openings using robotic arms. The camera gives the surgeon a three-dimensional view of the prostate and surrounding structures. The surgeon uses the robotic arms to do the surgery while sitting at a computer monitor near the operating table.
  • Pelvic lymphadenectomy: Lymph nodes are removed from the pelvis for examination under a microscope by a pathologist who looks for cancer cells. If the lymph nodes contain cancer, the doctor may not remove the prostate and may recommend other treatment.
  • Transurethral resection of the prostate (TURP): TURP is a surgical procedure to remove tissue from the prostate using a resectoscope (a thin, lighted tube with a cutting tool) inserted through the urethra. This procedure is done to treat benign prostatic hypertrophy, and it is sometimes done to relieve symptoms caused by a tumor in the prostate gland before other cancer treatment is given. TURP may also be done in men who cannot have a radical prostatectomy because their tumor is only in the prostate.

Radiation Therapy and Radiopharmaceutical Therapy

Radiation therapy uses high-energy X-rays or other types of radiation to kill cancer cells or keep them from growing. There are different types of radiation therapy^[15]:

• External radiation therapy uses a machine outside the body to send radiation toward the area of the body with cancer. A computer may be used to make a three-dimensional (3-D) picture of the tumor and shape the radiation beams to fit the tumor. This allows a high dose of radiation to reach the tumor and causes less damage to nearby healthy tissue.
• Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. Oftentimes these items may be left in place permanently. In early-stage prostate cancer, radioactive seeds are placed in the prostate using needles that are inserted through the skin between the scrotum and rectum. The placement of the radioactive seeds in the prostate is guided by images from transrectal ultrasound or computed tomography (CT). The needles are removed after the radioactive seeds are placed in the prostate.
• Radiopharmaceutical therapy uses a radioactive substance to treat metastatic prostate cancer that has spread to the bone.

Hormone Therapy

Hormone therapy, also referred to as anti-androgen therapy, reduces the amount of testosterone or blocks its action to stop prostate cancer cells from growing. Hormone therapy includes medications, surgery, or other hormones. Orchiectomy is the surgical removal of one or both testicles, the main source of testosterone, to decrease the amount of hormone being made.^[16]

Bisphosphonate Therapy

Bisphosphonate therapy uses medications to reduce bone disease when prostate cancer has metastasized to the bone. Men who are treated with hormone therapy or orchiectomy are at an increased risk of bone loss and fractures.^[17]

Nursing Diagnoses

Nursing diagnoses for clients with bladder and prostate cancer focus on addressing the unique challenges and needs associated with this condition. The nursing priorities are centered around providing comprehensive care, managing symptoms, and enhancing the client’s overall well-being while preventing complications.

Common nursing diagnoses for clients with prostate cancer include the following:

• Decreased Activity Tolerance
• Disturbed Body Image
• Fear
• Imbalanced Nutrition: Less Than Body Requirements
• Powerlessness
• Risk for Spiritual Distress

Outcome Identification

Outcome identification includes setting short- and long-term goals and creating expected outcome statements customized for the client’s specific needs. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions.

Sample expected outcomes for common nursing diagnoses related clients being treated for bladder or prostate cancer are as follows:

• After the teaching session, the client will report symptoms to promptly report to the health care provider.
• The client will verbalize three positive coping strategies before discharge from the hospital.

Nursing Interventions

Nursing interventions for bladder and prostate cancer are designed to provide comprehensive care, symptom management, and emotional support. The goal is to improve the client’s quality of life, assist with treatment-related side effects, and promote overall well-being.

Medication Management

Nurses administer medications as prescribed for symptom control. Nurses monitor and help manage the client’s pain and other discomfort through pharmacological and nonpharmacological interventions, based on the client’s preferences.

Specially trained oncology nurses administer chemotherapy. Nurses play an important role in monitoring for side effects and adverse effects, reporting concerns to the health care team, and advocating for symptom control and quality of life.

Clients are taught and encouraged to use energy conservation techniques to manage fatigue associated with the disease process and medical interventions.

Client Education

Clients undergoing specific cancer treatments typically require reinforced health teaching about the intervention and the ability to ask questions. If undergoing chemotherapy or surgical intervention, clients must also be instructed to monitor and report signs of infection.

Psychosocial Support

Emotional distress commonly occurs in clients diagnosed with cancer, as well as their family members. Side effects and adverse effects associated with the disease and medical treatments can compound the emotional distress. Most people experience feelings of grief and loss when cancer is diagnosed. They may experience spiritual distress with a common question being, “Why me?” Nurses can play an important role in helping clients find spiritual support and a feeling of hope, even in the midst of terminal cancer.

In addition, the emotional burden of coping with an ostomy or other long-term consequences of treatment may be devastating for some clients and may affect their self-esteem, body image, quality of life, and ability to be intimate. For example, it is common for clients with ostomies to struggle with body image and their altered pattern of elimination. Nurses can promote healthy coping by ensuring the client has appropriate referrals to an appropriate nurse specialist, a social worker or case manager, and support group.

Nurses offer emotional support, empathy, and active listening to help clients and their family members cope with feelings resulting from the diagnosis, treatment, and changes in role performance. Information is reinforced as needed on medical treatments, and information is provided regarding available resources, counseling, and support groups. Nurses assess for signs of anxiety and depression and refer clients and family members to counseling as needed. Relaxation techniques and mindfulness practices are encouraged as positive coping strategies. Palliative care services are offered to manage symptoms, relieve pain, and enhance the client’s quality of life. Nurses also initiate discussions about advance care planning and end-of-life preferences.

Evaluation

During the evaluation stage, nurses determine the effectiveness of nursing interventions for a specific client. The previously identified expected outcomes are reviewed to determine if they were met, partially met, or not met by the time frames indicated. If outcomes are not met or only partially met by the time frame indicated, the nursing care plan is revised. Evaluation should occur every time the nurse implements interventions with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with other members of the interprofessional team.