Urinary Tract Cancers
The American Cancer Society (2002) estimates increases in both the incidence and death rates of all urinary tract cancers over pre-vious reports; however, while the rate of estimated new cases of bladder cancer has increased, there has been a slight decrease in the rate of new cases of kidney and renal pelvis cancer in the last few years. Urinary tract cancers include those of the urinary blad-der, kidney and renal pelvis, ureter, and other urinary structures, such as the prostate. Tobacco use continues to be a leading cause of all urinary tract cancers.
Cancer of the kidney accounts for about 3.7% of all cancers in adults in the United States. It affects almost twice as many men as women. The most common type of renal tumor is renal cell or renal adenocarcinoma, accounting for more than 85% of all kid-ney tumors (Hock et al., 2002). These tumors may metastasize early to the lungs, bone, liver, brain, and contralateral kidney. One third of patients have metastatic disease at the time of diag-nosis. The incidence of all stages of kidney cancer has increased
in the last two decades in the United States. Although enhanced imaging techniques account for improved detection of early-stage kidney cancer, it is unknown why the rate of late-stage kidney cancers is higher (Hock, Lynch & Balaji, 2002) (Chart 45-13).
Many renal tumors produce no symptoms and are discovered on a routine physical examination as a palpable abdominal mass. The classic triad of signs and symptoms, which occurs in only 10% of patients, comprises hematuria, pain, and a mass in the flank. The usual sign that first calls attention to the tumor is pain-less hematuria, which may be either intermittent and microscopic or continuous and gross. There may be a dull pain in the back from the pressure produced by compression of the ureter, exten-sion of the tumor into the perirenal area, or hemorrhage into the kidney tissue. Colicky pains occur if a clot or mass of tumor cells passes down the ureter. Symptoms from metastasis may be the first manifestations of renal tumor and may include unexplained weight loss, increasing weakness, and anemia.
The diagnosis of a renal tumor may require intravenous urography, cystoscopic examination, nephrotomograms, renal angiograms, ultrasonography, or a CT scan. These tests may be exhausting for patients already debilitated by the systemic effects of a tumor as well as for elderly patients and those who are anxious about the di-agnosis and outcome. The nurse assists the patient to prepare physically and psychologically for these procedures and monitors carefully for signs and symptoms of dehydration and exhaustion.
The goal of management is to eradicate the tumor before metas-tasis occurs (Kirkali, Tuzel & Munga, 2002).
A radical nephrectomy is the preferred treatment if the tumor can be removed. This includes removal of the kidney (and tumor), adrenal gland, surrounding perinephric fat and Gerota’s fascia, and lymph nodes. Radiation therapy, hormonal therapy, or che-motherapy may be used along with surgery. Immunotherapy may also be helpful. For patients with bilateral tumors or can-cer of a functional single kidney, nephron-sparing surgery (par-tial nephrectomy) may be considered. Favorable results have been achieved in patients with small local tumors and a normal contra-lateral kidney.
Nephron-sparing surgery is increasingly being used to treat patients with solid renal lesions. The technical success rate of nephron-sparing surgery is excellent, and operative morbidity and mortality are low. For renal cell carcinoma, long-term cancer-free survival is comparable to that after radical nephrectomy, par-ticularly for low-stage disease (Uzzo & Novick, 2001). Although laparoscopic nephroureterectomy is a lengthier surgical proce-dure, it has the same efficacy and is better tolerated by patients than open nephroureterectomy for upper tract transitional cell carcinoma. As more experience is gained with this type of surgery, surgical time will be reduced (Chen & Bagley, 2000; Jabbour, Desgrandchamps, Cazin et al., 2000; Shalhav, Dunn, Portis et al., 2000).
Renal Artery Embolization. In patients with metastatic renal car-cinoma, the renal artery may be occluded to impede the blood supply to the tumor and thus kill the tumor cells. After angio-graphic studies are completed, a catheter is advanced into the renal artery, and embolizing materials (Gelfoam, autologous blood clot, steel coils) are injected into the artery and carried with the arterial blood flow to occlude the tumor vessels mechanically. This decreases the local blood supply, making removal of the kid-ney (nephrectomy) easier. It also stimulates an immune response because infarction of the renal cell carcinoma releases tumor-associated antigens that enhance the patient’s response to meta-static lesions. The procedure may also reduce the number of tumor cells entering the venous circulation during surgical manipulation.
After renal artery embolization and tumor infarction, a char-acteristic symptom complex called postinfarction syndrome oc-curs, lasting 2 to 3 days. The patient has pain localized to the flank and abdomen, elevated temperature, and GI symptoms. Pain is treated with parenteral analgesic agents, and acetaminophen is administered to control fever. Antiemetic medications, restric-tion of oral intake, and intravenous fluids are used to treat the GI symptoms.
Currently, no pharmacologic agents are in widespread use for treating renal cell carcinoma. Depending on the stage of the tumor, percutaneous partial or radical nephrectomy may be fol-lowed by treatment with chemotherapeutic agents. The use of bi-ologic response modifiers such as interleukin-2 (IL-2) and topical instillation of bacillus Calmette-Guerin (BCG) in the renal pelvis continue to be studied, with both treatments currently used in clinical practice (Hvarness, Krarup & Eldrup, 2001; Nonomura, Ono, Nozawa et al., 2000; Okubo, Ichioka, Matsuta et al., 2001).
Patients may be treated with IL-2, a protein that regulates cell growth. This may be used alone or in combination with lymphokine-activated killer cells, which are WBCs that have been stimulated by IL-2 to increase their ability to kill cancer cells. Inter-feron, another biologic response modifier, appears to have a direct antiproliferative effect on renal tumors. The study of these biologic agents and new biologic response modifiers is a priority because nearly half of all patients with renal cell carcinoma die within 5 years of diagnosis (Pizza, De Vinci, LoConte et al., 2001).
The patient with a renal tumor usually undergoes extensive diag-nostic and therapeutic procedures, including surgery, radiation therapy, and medication (or systemic) therapy. After surgery, the patient usually has catheters and drains in place to maintain a patent urinary tract, to remove drainage, and to permit accurate measurement of urine output. Because of the location of the sur-gical incision, the position of the patient during surgery, and the nature of the surgical procedure, pain and muscle soreness are common.
The patient requires frequent analgesia during the postopera-tive period and assistance with turning. Turning, coughing, use of incentive spirometry, and deep breathing are encouraged to prevent atelectasis and other pulmonary complications. The pa-tient and family require assistance and support to cope with the diagnosis and uncertainties about the prognosis.
Teaching Patients Self-Care. The patient is taught to inspect andcare for the incision and perform other general postoperative care. Additionally, the patient learns about activity and lifting restric-tions, driving, and use of pain medications. Instructions are provided about follow-up care and when to notify the physician about problems (fever, breathing difficulty, wound drainage, blood in the urine, pain or swelling of the legs).
The patient is encouraged to eat a well-balanced diet and to drink adequate liquids to avoid constipation and to maintain an adequate urine volume. Education and emotional support are pro-vided related to the disease process, treatment plan, and continu-ing care because many patients are concerned about the loss of the other kidney, the possible need for dialysis, or the recurrence of cancer.
Continuing Care. Follow-up care is essential to detect signs ofmetastases and to reassure the patient and family about the pa-tient’s status and well-being. The patient who has had surgery for renal carcinoma should have a yearly physical examination and chest x-ray because late metastases are not uncommon. All sub-sequent symptoms should be evaluated with possible metastases in mind.
If follow-up chemotherapy is necessary, the patient and fam-ily are informed about the entire treatment plan or chemother-apy protocol, what to expect with each visit, and how to notify the physician. Periodic evaluation of remaining renal function (creatinine clearance, serum BUN and creatinine levels) may also be carried out periodically. A home care nurse may monitor the patient’s physical status and psychological well-being and coor-dinate other services and resources needed by the patient.