A partial fulfilment in our requirements in NCM106 LECTURE

WRITTEN REPORT IN CANCER OF THE RENAL PELVIS

Presented by: Batch 2012 Cabigas, Cassandra A.

Presented to:

Mrs. Custodio, RN CANCER OF THE RENAL PELVIS

I. ALTERNATIVE NAMES: Transitional cell cancer of the renal pelvis or ureter II. INTRODUCTION Cancer of the renal pelvis or ureter is cancer that forms in the kidney's pelvis or the tube that carries urine from the kidney to the bladder. Cancers affecting the ureter and renal pelvis are rare. Approximately 400 people are diagnosed with this type of cancer in the UK each year. Cancer of the ureter and renal pelvis tends to affect more men than women, and is rare under the age of 65. The main type of cancer affecting the ureter and renal pelvis is called transitional cell carcinoma (TCC). This type of cancer develops in cells, known as transitional cells, which form the lining of the bladder, ureters and renal pelvis. Usually only one ureter or renal pelvis is affected. Another, more common, type of cancer that can affect the kidney, is known as renal cell cancer (RCC). The tests, investigations and treatment of RCC are very different. This information is only about TCC. The general information on kidney cancer covers the treatment of renal cell cancer. Very rarely, other types of cancer can start in the ureter or renal pelvis. These include some types of lymphoma (a cancer that starts from the cells of the lymphatic system) and sarcoma (a cancer that develops from the supporting tissues of the body, such as muscle or cartilage). Cancer that starts in the ureter or renal pelvis is known as primary cancer. When cancer spreads from another part of the body to the ureter it is known as secondary or metastatic cancer in the ureter or renal pelvis. III. CAUSES AND RISK FACTORS The exact causes of cancer of the ureter and renal pelvis are unknown. It is thought that smoking may increase the risk of developing these types of cancer. People who have been exposed to certain chemicals used in dye factories and chemical industries are also at a slightly increased risk.

There may also be an increased risk in people who have papillary necrosis, a condition where parts of the kidney are damaged or have died off. This can sometimes occur in people who have conditions affecting the kidney, such as diabetes or repeated infections. People who have kidney damage from long term use of certain pain killers may also have a higher risk of developing cancer in the renal pelvis. This risk is most likely in people who were overexposed to pain killers containing phenacetin. Although these pain killers have now been discontinued, phenacetin may be added to some illegal recreational drugs, such as cocaine, so regular users could still be at risk. Cancer of the ureter and renal pelvis, like other cancers, is not infectious and so cannot be passed on to other people. It is not caused by an inherited faulty gene, so other members of your family aren't likely to develop it.

IV. SIGNS AND SYMPTOMS The symptoms of cancer of the ureter and renal pelvis may include any of the following: blood in the urine (hematuria) passing blood clots in the urine unexplained weight loss mid back pain or cramps fatigue (tiredness and lack of energy) Anemia (if you have been passing blood in the urine for some time), but this is rare.

Sometimes the ureter may become blocked, either by cancer cells or by a blood clot. This is known as ureteric obstruction. If this happens, the above symptoms may develop more quickly and may be more severe and often accompanied by a high temperature. The symptoms described may be caused by a number of conditions other than cancer of the ureter or renal pelvis. Symptoms which are severe and get worse, or that last for a few weeks, should always be checked by your doctor.

V. DIAGNOSTIC TESTS 1. A Series Of Urine and Blood Tests

The urine sample will be sent to a laboratory to be checked under a microscope for any cancer cells. Samples of blood will also be taken to check your general health, the number of cells in your blood (blood count), and to see how well your kidneys and liver are working. Your GP will refer you to a urologist (a doctor who specializes in diseases of the urinary system) if further tests are needed. These tests will help to make the diagnosis and, if cancer is found, to check how far, if at all, the disease has spread.

Cystoscopy And Biopsy

A small, flexible, fibre-optic telescope (cystoscope) is passed up the urethra to enable the doctor to look at the bladder. The doctor can also extend the tip of the cystoscope up into the ureter: this procedure, known as ureteroscopy , can be done under a local or a general anaesthetic. In most cases this is done under a local anesthetic. If any abnormality that could be a cancer is seen, it has to be examined while you are under a general anaesthetic. The doctor will then take a sample of abnormal cells (biopsy), and these are examined in a laboratory under a microscope by a pathologist. Intravenous Urogram (IVU), Intravenous Pyelogram (IVP) or CT Urogram These tests show up abnormalities in the urinary system. It is done in the hospital x-ray department and takes about an hour. A dye is injected into a vein, usually in the arm, that travels through the bloodstream to the kidneys. The doctor can watch the passage of dye on an x-ray screen and pick up any abnormalities. The dye will probably make you feel hot and flushed for a few minutes, but this feeling gradually disappears. You may feel some discomfort in your abdomen, but this will only be temporary. You should be able to go home as soon as the test is over.

Ultrasound scan Sound waves are used to build up a picture of the inside of your body. You may have scans of your bladder and pelvis. The scan will be done in the hospital scanning department. Before your test, you will be asked to drink plenty of fluid so that your bladder is full and a clear picture can be seen. Once you are lying comfortably on your back, a special gel is spread over your abdomen. A small device, like a microphone, is rubbed over the area. The echoes are converted into a picture by a computer. This is a completely painless procedure and takes about 15-20 minutes. Once the scan is over, you will be allowed to empty your bladder.

Retrograde pyelography This is a special x-ray which involves inserting a catheter into the ureter at the time of ureteroscopy. Dye is then passed up the catheter to highlight the ureter and renal pelvis.

FURTHER TEST

If a cancer is found, you may be referred for other tests to find the size of the cancer and whether or not it has spread beyond the ureter or renal pelvis. These may include either of the following:

CT (computerised tomography) scan A CT scan takes a series of x-rays which builds up a three-dimensional picture of the inside of the body. The scan is painless but takes from 10-30 minutes. CT scans use a small amount of radiation, which will be very unlikely to harm you and will not harm anyone you come into contact with. You will be asked not to eat or drink for at least four hours before the scan. You may be given a drink or injection of a dye which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it's important to let your doctor know beforehand.

MRI (magnetic resonance imaging) scan This test is similar to a CT scan, but uses magnetism instead of x-rays to build up a detailed picture of areas of your body. Before the scan you may be asked to complete and sign a checklist. This is to make sure that it's safe for you to have an MRI scan. Before having the scan, youll be asked to remove any metal belongings including jewellery. Some people are given an injection of dye into a vein in the arm. This is called a contrast medium and can help the images from the scan to show up more clearly. During the test you will be asked to lie very still on a couch inside a long cylinder (tube) for about 30 minutes. It is painless but can be slightly uncomfortable, and some people feel a bit claustrophobic during the scan. Its also noisy, but youll be given earplugs or headphones.

The combination of tests will help the specialist to find out the stage and grade of the cancer. This will help the doctors to decide on the most appropriate treatment for you.

VI. STAGING AND GRADING Staging

Staging refers to the size of the cancer and whether or not it has spread beyond the ureter or renal pelvis. The following stages are used for transitional cell cancer of the renal pelvis and ureter. Localised The cancer is only in the area where it started and hasn't spread outside the kidney or ureter. Regional The cancer has spread to the tissue around the kidney or to nearby lymph nodes. Lymph nodes are bean-shaped structures that are found throughout the body. They produce cells to fight infection. Metastatic The cancer has spread to other parts of the body.

Grading Grading refers to how abnormal the cancer cells look under the microscope, and can give an idea of whether or not the cancer cells are slow-growing (low-grade) or faster-growing (high-grade).
VII. MEDICAL AND SURGICAL MANAGEMENT

Treatment will depend on a number of factors, including your age, general health and the position, type, stage and grade of the cancer. Surgery is the most common treatment for cancer of the ureter and renal pelvis. The extent of surgery will depend on many factors, such as the stage and the grade of the cancer. After surgery, sometimes further treatment may be recommended with chemotherapy or occasionally radiotherapy. This is known as adjuvant treatment. The aim of adjuvant treatment is to get rid of any remaining cancer cells and to reduce the chance of the cancer coming back. The effectiveness of adjuvant treatment for cancer of the ureter and renal pelvis is unknown.

If surgery is not possible, other treatments may be more appropriate. These may include chemotherapy or radiotherapy. The aim of these treatments is to reduce the size of the tumour and help control symptoms.

SURGERY Nephro-ureterectomy means the removal of the kidney, ureter and top part of the bladder. Sometimes the surrounding lymph glands, fat and tissue may also be removed. Segmental ureterectomy resection is the removal of the affected part of the ureter. The remaining parts are then rejoined. This procedure is usually only possible if the tumour is small, low-grade and contained within the ureter. Ureteroneocystomy (or reimplantation) is the removal of the lower part of the ureter, and sometimes a small part of the bladder. The remaining part of the ureter is then connected to the bladder. This is usually done if the tumour is only in the lower part of the ureter.

Occasionally, a tumour may affect just the surface of the ureter. The cancer may be removed either by laser treatment or electrosurgery. These two surgical treatments are in the early stages of development. Laser therapy A ureteroscope is passed through the bladder and into the ureter. A narrow beam of intense laser is then passed through the tube to destroy the tumour. Electrosurgery An electric current is used to remove the cancer. The tumour and surrounding area can be burned away. This treatment is sometimes done using a uterescope or by making a small opening into the renal pelvis itself.

Radiotherapy Radiotherapy treats cancer by using high-energy rays, which destroy the cancer cells and shrink the tumour while doing as little harm as possible to normal cells.

Chemotherapy Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy the cancer cells. They work by disrupting the growth and division of cancer cells. The chemotherapy may be given directly into the vein (intravenously).

FOLLOW-UP

After treatment, you will have regular follow-up appointments with your specialist to monitor how you are recovering after treatment. Follow up will usually include a physical examination. It may also involve taking some urine or blood samples. You will also have regular cystoscopies to detect any changes in the ureter or bladder. About 3 out of 10 (30%) people with cancer of the ureter or renal pelvis will develop a bladder cancer 5-10 years later. If you have any problems, or notice any new symptoms between your follow up appointments, let your doctor know as soon as possible.

VIII.

ANATOMY AND PHYSIOLOGY

The ureters are hollow muscular tubes that carry urine from the kidneys to the bladder. The renal pelvis is the lower part of each kidney that connects to each ureter.

Structure of the kidneys

IX. NURSING MANAGEMENT

Primary nursing diagnosis nursing care plans for Kidney Cancer is altered urinary elimination related to renal tissue destruction, Therefore the nursing interventions associated with Urinary elimination: Management; Fluid management; Medication prescribing; Urinary catheterization; Anxiety reduction; Pain management Nursing outcomes for nursing care plans for Kidney Cancer, Patient will:

Maintain urine specific agents within normal range Report increased comfort. Identify strategies to reduce anxiety. Express fears and concerns relating to his condition and prognosis. Maintain joint mobility and range of motion. Maintain ventilation. Communicate understanding of medical regimen, medications, diet, and activity restrictions. Maintain fluid balance.

Nursing interventions for Kidney Cancer

Before surgery, assure the patient that the body will adequately adapt to the loss of a kidney. Administer prescribed analgesics as necessary. Provide comfort measures, such as positioning and distractions, to help the patient cope with discomfort. After surgery, encourage diaphragmatic breathing and coughing.

Assist the patient with leg exercises, and turn him every 2 hours to reduce the risk of phlebitis. Check dressings often for excessive bleeding. Watch for signs of internal bleeding, such as restlessness, sweating, and increased pulse rate. Position the patient on the operative side to allow the pressure of adjacent organs to fill the dead space at the operative site, improving dependent drainage. If possible, assist the patient with walking within 24 hours of surgery.

Provide

adequate

fluid

intake,

and

monitor

intake

and

output.

Monitor laboratory test results for anemia, polycythemia, and abnormal blood chemistry values that may point to bone or hepatic involvement or may result from radiation therapy or chemotherapy Provide symptomatic treatment for adverse effects of chemotherapeutic drugs. Encourage the patient to express his anxieties and fears, and remain with him during periods of severe stress and anxiety.

Patient Teaching And Home Healthcare Guide for Kidney Cancer Tell

the

patient what to

expect from

surgery

and

other effective the

treatments. coughing incision

Before surgery, teach techniques, such

diaphragmatic as how

breathing and to splint

Be sure the patient understands what medications are to be taken at home, their effects, and dosages. Explain follow-up information, such as when the physician would like to see the patient. Provide and arrange for a home visit from nurses if appropriate. Refer the patient and family to hospital and community services such as support groups Reinforce any postoperative restrictions.

Explain when normal activity can be resumed. Make sure the patient understands the need to have ongoing monitoring of the disease. Annual chest x-rays and routine IVPs are recommended to check for other tumors. Emphasize and give understanding of the lifestyle choices that can aid in recovery e.g. Quit smoking, limit alcohol, eat more fruits, vegetables, and whole grains and less animal fat; exercise once you are able. Explain Advise the the possible patient adverse how to effects prevent of radiation and drug therapy. problems.

and

minimize

these

When preparing the patient for discharge, stress the importance of compliance with prescribed outpatient treatment.

X. PREVENTION

Follow your health care provider's advice regarding medications, including overthe-counter pain medicine. Stop smoking. Wear protective equipment if you may be exposed to substances that are toxic to the kidneys.