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A partial fulfilment in our requirements in NCM106 – LECTURE

WRITTEN REPORT

IN

CANCER OF THE RENALPELVIS

Presented by:

Batch 2012

Cabigas, Cassandra A.

Presented to:

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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 peopleare diagnosed with this type of cancer in the UK each year. Cancer of the ureter andrenal 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 transitionalcell 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 asrenal cell cancer (RCC). The tests, investigations and treatment of RCC are verydifferent. 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 lymphaticsystem) 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 . Whencancer 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 isthought that smoking may increase the risk of developing these types of cancer. Peoplewho have been exposed to certain chemicals used in dye factories and chemicalindustries are also at a slightly increased risk.

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There may also be an increased risk in people who have papillary necrosis, acondition where parts of the kidney are damaged or have died off. This can sometimesoccur in people who have conditions affecting the kidney, such as diabetes or repeatedinfections.

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 mostlikely in people who were overexposed to pain killers containing phenacetin. Althoughthese pain killers have now been discontinued, phenacetin may be added to some illegalrecreational 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 socannot be passed on to other people. It is not caused by an inherited faulty gene, soother 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 thefollowing:

• 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 israre.

Sometimes the ureter may become blocked, either by cancer cells or by a bloodclot. This is known as ureteric obstruction. If this happens, the above symptoms maydevelop more quickly and may be more severe and often accompanied by a hightemperature.

The symptoms described may be caused by a number of conditions other thancancer of the ureter or renal pelvis. Symptoms which are severe and get worse, or thatlast for a few weeks, should always be checked by your doctor.

V. DIAGNOSTIC TESTS

1. A Series Of Urine and Blood Tests

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The urine sample will be sent to a laboratory to be checked under a microscopefor 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 andliver 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 diagnosisand, 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 toenable the doctor to look at the bladder. The doctor can also extend the tip of thecystoscope 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 localanesthetic.

If any abnormality that could be a cancer is seen, it has to be examined whileyou are under a general anaesthetic. The doctor will then take a sample of abnormalcells (biopsy), and these are examined in a laboratory under a microscope by apathologist.

Intravenous Urogram (IVU), Intravenous Pyelogram (IVP) or CT Urogram

These tests show up abnormalities in the urinary system. It is done in thehospital x-ray department and takes about an hour. A dye is injected into a vein, usuallyin 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 thisfeeling gradually disappears. You may feel some discomfort in your abdomen, but thiswill 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 hospitalscanning department. Before your test, you will be asked to drink plenty of fluid so thatyour bladder is full and a clear picture can be seen. Once you are lying comfortably onyour back, a special gel is spread over your abdomen. A small device, like amicrophone, is rubbed over the area. The echoes are converted into a picture by acomputer. This is a completely painless procedure and takes about 15-20 minutes. Oncethe scan is over, you will be allowed to empty your bladder.

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Retrograde pyelography

This is a special x-ray which involves inserting a catheter into the ureter at thetime 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 thecancer and whether or not it has spread beyond the ureter or renal pelvis. These mayinclude 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 usea small amount of radiation, which will be very unlikely to harm you and will not harmanyone 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 beseen 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 upa detailed picture of areas of your body. Before the scan you may be asked to completeand sign a checklist. This is to make sure that it's safe for you to have an MRI scan.

Before having the scan, you’ll 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 calleda 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 peoplefeel a bit claustrophobic during the scan. It’s also noisy, but you’ll be given earplugs or headphones.

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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 beyondthe ureter or renal pelvis.

The following stages are used for transitional cell cancer of the renal pelvis andureter.

• Localised The cancer is only in the area where it started and hasn't spreadoutside the kidney or ureter.

• Regional The cancer has spread to the tissue around the kidney or to nearbylymph nodes. Lymph nodes are bean-shaped structures that are foundthroughout the body. They produce cells to fight infection.

• Metastatic The cancer has spread to other parts of the body.

GradingGrading 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 healthand 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 withchemotherapy or occasionally radiotherapy. This is known as adjuvant treatment. Theaim of adjuvant treatment is to get rid of any remaining cancer cells and to reduce thechance of the cancer coming back. The effectiveness of adjuvant treatment for cancer of the ureter and renal pelvis is unknown.

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If surgery is not possible, other treatments may be more appropriate. These mayinclude chemotherapy or radiotherapy. The aim of these treatments is to reduce the sizeof 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 beremoved.

• Segmental ureterectomy resection is the removal of the affected part of theureter. The remaining parts are then rejoined. This procedure is usually onlypossible if the tumour is small, low-grade and contained within the ureter.

• Ureteroneocystomy (or reimplantation) is the removal of the lower part of theureter, 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 onlyin the lower part of the ureter.

Occasionally, a tumour may affect just the surface of the ureter. The cancer may beremoved either by laser treatment or electrosurgery. These two surgical treatments arein 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 thetumour.•

Electrosurgery An electric current is used to remove the cancer. The tumour andsurrounding area can be burned away. This treatment is sometimes done using auterescope or by making a small opening into the renal pelvis itself.

Radiotherapy

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

ChemotherapyChemotherapy 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 maybe given directly into the vein (intravenously).

FOLLOW-UP

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After treatment, you will have regular follow-up appointments with your specialistto monitor how you are recovering after treatment. Follow up will usually include aphysical examination. It may also involve taking some urine or blood samples. You willalso have regular cystoscopies to detect any changes in the ureter or bladder. About 3out 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 thebladder. The renal pelvis is the lower part of each kidney that connects to each ureter.

 

Structure of the kidneys

IX. NURSING MANAGEMENT

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Primary nursing diagnosis nursing care plans for Kidney Cancer  is altered urinaryelimination related to renal tissue destruction, Therefore the nursing interventionsassociated with Urinary elimination: Management; Fluid management; Medicationprescribing; 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 activityrestrictions.

• Maintain fluid balance.

Nursing interventions for Kidney Cancer 

•

Before surgery, assure the patient that the body will adequately adapt to the lossof a kidney.

• Administer prescribed analgesics as necessary. Provide comfort measures, suchas 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 riskof 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 organsto fill the dead space at the operative site, improving dependent drainage.

• If possible, assist the patient with walking within 24 hours of surgery.

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• Provide adequate fluid intake, and monitor intake and output.

• Monitor laboratory test results for anemia, polycythemia, and abnormal bloodchemistry values that may point to bone or hepatic involvement or may resultfrom 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 himduring 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 treatments.

• Before surgery, teach diaphragmatic breathing and effective coughingtechniques, such as how to splint the incision

• 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 thepatient. Provide and arrange for a home visit from nurses if appropriate.

• Refer the patient and family to hospital and community services such as supportgroups

• Reinforce any postoperative restrictions.

• Explain when normal activity can be resumed. Make sure the patient understandsthe 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 inrecovery e.g. Quit smoking, limit alcohol, eat more fruits, vegetables, and wholegrains and less animal fat; exercise once you are able.

• Explain the possible adverse effects of radiation and drug therapy.

• Advise the patient how to prevent and minimize these problems.

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• When preparing the patient for discharge, stress the importance of compliancewith prescribed outpatient treatment.

X. PREVENTION

• Follow your health care provider's advice regarding medications, including over-the-counter pain medicine.

• Stop smoking.

• Wear protective equipment if you may be exposed to substances that are toxic to

the kidneys.