Genitourinary Malignancies (see Table 13-1 for an overview of the features of testicular, bladder, prostate, and kidney cancers)
A. Includes malignancies of the male and female genitourinary tract.
B. Diseases are variable in genetic, environmental, and social risk factors.
C. Treatment and prognosis are unique to each diagnosis.
II.
Nursing Diagnoses, Interventions, and Outcomes for Testicular Cancer (Table 13-2)
A. Knowledge deficit related to early detection of testicular cancer
1.Problem: Testicular cancer is a treatable disease that is often 100% curable in early stages. Clinical studies demonstrate that few men practice testicular self-examination or undergo physical examination by their physicians. Increased rates of early detection would result in improved outcomes for men with testicular cancer.
2.Interventions
a. Teach patients, families, and the public the importance of early detection.
b. Provide information (discussions, pamphlets, seminars, media) about incidence, risk factors, screening, symptoms, diagnosis, prognosis, and treatment options.
c. Instruct all males, age 15 and older, in the correct technique and time for performing testicular self-examination (Box 13-1).
d. Provide support and encourage compliance with testicular self-examination and act as an advocate and liaison to ensure follow-up.
3.Desired outcome: The patient will demonstrate adequate knowledge of screening and early detection of testicular cancer as evidenced by:
a. Stating risk factors for the disease.
b. Demonstrating testicular self-examination and stating importance of monthly examination.
c. Returning for routine annual examinations.
b. Encourage patients to ask questions and express concerns.
c. See Chapters 6, 8, and 9 for details on chemotherapy, radiation, and surgical treatment.
B. Anxiety related to a diagnosis of testicular cancer and the potential for side effects of therapy
1.Problem: The diagnosis of cancer can produce anxiety about sexuality, fertility, survival, remission, and quality of life (QOL). All these factors can affect one’s self-concept.
2.Interventions
a. Educate about the disease, treatments, side effects (particularly sexuality and infertility), and overall prognosis.
b. Allow the patient to identify concerns and provide information accordingly.
c. Discuss potential alterations in sexual potency and fertility.
d. Discuss alternate ways of providing sexual gratification (see section on Prostate Cancer).
e. Discuss family planning and sperm banking if appropriate.
(1) Concerns about family planning may be subjugated to issues of treatment and prognosis; however, medical treatment may result in infertility. Accurate information helps the patient and partner consider alternative family planning.
(2) Sperm banking is a costly procedure (approximately $100.00 to $130.00 for initial counseling and sperm analysis, approximately $120.00 for each additional cryopreservation, in addition to monthly fees for storage). Patients are instructed to abstain from sex 3 to 7 days before providing a specimen for analysis. If sperm are of good quality, three specimens may be banked. Analysis takes approximately 7 to 10 days (see Box 13-2 for available resources).
3.Desired outcomes
a. Patient is able to cope with the diagnosis of testicular cancer as evidenced by:
(1) Participation in own care.
(2) Participation in treatment and follow-up.
b. Patient states that he feels a lessening sense of fear regarding diagnosis of testicular cancer and its implications.
c. Patient states that he is familiar with sperm banking and other reproductive technologies.
C. Pain related to disease or treatment of testicular cancer
1.Problem: Pain is frequently a problem in patients with testicular cancer. Growth of the tumor can cause pressure on nerve fibers, blood vessels, or other organs. Pain can also be associated with various treatments.
2.Interventions: Follow recommendations in Chapter 30.
3.Desired outcome: Pain is eliminated or controlled as described in Chapter 30.
D. Body image disturbance related to development of gynecomastia and scrotal changes
1.Problem: The body image of men with testicular cancer can be affected by breast enlargement or removal of one or both testicles (orchiectomy). Treatment may also alter sexual function (changes in ejaculation, orgasm, and libido). Young men may be particularly sensitive to these changes.
2.Interventions
a. Assess the patient’s perception of scrotal and breast changes.
b. Encourage open discussion about changes in body image between patient and partner.
c. Provide information about etiology of changes and treatment options.
TABLE 13-1 Overview of Genitourinary (GU) Cancers
Key Feature
Testicular Cancer
Bladder Cancer
Prostate Cancer
Kidney Cancer
Definition
Rare cancer <2% of all male cancers, most common solid malignancy in males 20-34 years old Cure rate almost 100% in early-stage disease Arise from testes as germ cell or non-germ cell tumors (see Table 13-2) Metastatic spread through lymphatics to lung, liver, viscera, bone, and brain
Second most common GU malignancy (6% of all male, 2% of female cancers in the US) Spreads by direct extension through submucosa and bladder wall Metastasis to lungs, liver, and bone
Most common male cancer of all male cancers: 33% incidence, 10% mortality in US Incidence increases in men over age 65, with median age at diagnosis 72 years Incidence is highest in African Americans, lowest in Japanese Prognosis is good for early-stage disease Screening and detection recommendations are not universally standard (see Table 13-7) Tumors arise from prostate and are adenocarcinomas Locally spreads to seminal vesicles, bladder, and perineum; distant spread is through lymphatics or hematologic routes Metastasizes to bone, lymph nodes (supraclavicular, scalene, retroperitoneal, pelvic, and periaortic); rare sites are mediastinum, lung, kidneys, or liver
˜3% of all male cancers, and <2% of all female cancers Average age at diagnosis is 55-70 years Prognosis is best in early stages Two classifications: cancers of the renal pelvis and ureters (˜4% to 5% of all GU cancers), renal cell carcinomas of the kidney parenchyma (˜85% of all kidney cancers) Metastasizes by direct extension to lung, liver, bone, lymph nodes, adrenal gland and contralateral kidney
Risk factors/etiologies
Etiology unknown Risk factors: family history of testicular cancer Cryptorchidism (failure of testicles to descend to scrotal sac) Exposure to estrogen in utero Trauma Inguinal hernia Klinefelter syndrome (congenital endocrine condition) Hermaphroditism (coexisting ovarian and testicular tissue) Degeneration, atrophy or torsion of testicles Vasectomy African-American descent Higher socioeconomic status
Cigarette smoking Exposure to arylamine used in dye, rubber, and leather industries and hair dye Excessive use of coffee, alcohol, saccharin, phenacetin Hypercholesterolemia Cyclophosphamide chemotherapy Pelvic irradiation Chlorination in water Exposure to Schistosoma hematobium (rare in US, common in Africa)
Etiology is unknown Risk factors: age >65 years, family history of prostate or breast cancer African-American heritage Increased testosterone Sexually transmitted infections Cadmium exposure (used in welding, electroplating, alkaline battery production) High-fat diet Vasectomy
Etiology is unknown Cigarette smoking Cadmium, asbestos, and lead exposure Excessive use of analgesics (aspirin, phenacetin, or acetaminophen) Obesity (in females) Estrogen History of adenomas Excessive use of caffeine or diuretics
Signs and symptoms
Painless enlargement of testicle; heaviness in scrotum, inguinal area, or lower abdomen Testicular nodule/mass Lumbar, abdominal, groin pain Weight loss secondary to metabolic changes Gynecomastia caused by elevation in serum human chorionic gonadotropin hormone (beta HCG) Supraclavicular mass due to lymph node metastases Cough, dyspnea, or hemoptysis from pulmonary metastases
Hematuria (gross or microscopic) Dysuria and urinary frequency and urgency Urinary hesitancy and decrease in force and caliber of stream Hydronephrosis Pain in suprapubic region, rectum, back or flank. Bone pain with skeletal metastases Lymphadenopathy Abdominal mass or hepatomegaly from metastasis Weight loss and decreased appetite Lower extremity edema due to obstruction Mental status changes and focal neurologic findings from brain metastases
Assess for prostate mass or nodule (asymmetry, induration), weight loss, back pain, urinary frequency, nocturia, dysuria, slow urinary stream, hematuria
Change in bowel patterns due to obstruction or compression Hematuria (gross or microscopic) Pain: flank pain, urethral pain related to obstruction or clots, metastatic pain Abdominal mass Fevers may be secondary to obstruction and infection or paraneoplastic syndrome Weight loss Anemia secondary to bone marrow depression, bleeding, or suppressed erythropoietin production secondary to renal dysfunction Acute dyspnea and edema secondary to obstruction of vena cava
Diagnostic tests
Serum tests: elevated HCG, alpha-fetoprotein (AFP), lactic acid dehydrogenase (LDH) Assess for enlargement of testes, scrotum, and lymph nodes Testicular ultrasound to detect a mass Excretory urogram (IVP) to assess displacement of ureter or kidney from a mass Chest radiographs to assess for pulmonary metastases CT scan of abdomen and pelvis to assess metastatic disease Liver, brain, and bone scans to evaluate metastases Surgical inguinal exploration with biopsy for tissue pathology
Serum tests: elevated carcinoembryonic antigen (CEA) Urine cytology to detect genetic or chromosomal changes Flow cytometry Cystoscopy to assess for a mass Transurethral resection (TUR) to assess for mass CT scan of abdomen, pelvis Magnetic resonance imaging (MRI) of abdomen/pelvis Chest x-ray to assess for metastases Bone scan to assess for metastasis Excretory urogram (IVP) to assess for tumor or obstruction
Serum tests: CBC (anemia may indicate bone marrow involvement), elevated acid phosphatase, elevated prostatic acid phosphatase, elevated alkaline phosphatase, elevated prostate specific antigen (PSA) Urine tests: cytology may show cancer cells, flow cytometry may show DNA changes Biopsy of prostate Cytology of prostate fluid, may show tumor cells Bone scan for skeletal metastasis (bone e-rays may show lytic vs blastic lesions) CT scan of abdomen and pelvis for lymph node and visceral involvement MRI to evaluate extent of disease and metastases Chest x-ray to evaluate pulmonary or pleural involvement Transrectal ultrasound (TRUS) to assess palpable mass Excretory urogram (IVP) may show hydroureteronephrosis related to obstruction
Serum tests: low serum iron and total iron binding capacity (TIBC) with anemia secondary to bleeding Elevated calcium secondary to paraneoplastic syndrome or bone metastases Elevated liver function tests secondary to paraneoplastic syndrome Elevated lactic acid dehydrogenase (LDH) with renal cell carcinoma Elevated renin in renal cell carcinoma Urine tests: urinalysis may reveal hematuria, bacteria, or pus. Cytology may reveal malignant cells. Flow cytometry for DNA content of cells Kidney, ureter, and bladder radiograph to assess for mass Excretory urogram (IVP) to assess for mass Retrograde urogram to assess for urethral obstruction Nephrotomograms to assess extra renal mass Renal ultrasound to assess mass MRI to assess mass/lymph node involvement CT of abdomen, chest, brain to assess for metastasis Cystoscopy, ureteroscopy, or nephroscopy with biopsy for definitive diagnosis
Treatment/Management
Prognosis and treatment depend on stage (see Tables 13-2 and 13-3) Radical orchiectomy (removal of one or both testes, epididymis, vas deferens, some lymphatics and blood supply) Radical lymph node dissection is stage dependent Chemotherapy or radiation therapy are dictated by type and stage of disease (see Table 13-3)
Prognosis and treatment depend on the depth of invasion into the bladder mass and histologic grade of the tumor (see Table 13-6)
Treatment depends on stage of disease: surgery, radiation therapy, hormonal therapy, chemotherapy or combinations of therapy (see Tables 13-7, 13-8, and 13-9)
Primary therapy is surgery with/without radiation therapy. Chemotherapy, hormonal therapy, and biotherapy may be used in advanced or recurrent disease (see Tables 13-11 and 13-12)
TABLE 13-2 Classification of Testicular Cancers
Germ Cell Tumors
Non-Germ Cell Tumors
Represent approximately 95% of all testicular malignancies
All males age 15 and older should perform testicular self-examination every month.
Perform testicular self-examination during or immediately after a warm shower.
Observe and compare each side of the scrotum. Note size and any differences in shape.
Hold scrotum in one hand. With the other hand, place the index and middle fingers on top of the scrotum and the thumb underneath. Gently roll each testicle between the fingers, noting any lumps or areas that seem hard or enlarged.
Locate the epididymis and note that it is soft and slightly tender. Examine the space between the front of the testis and back of the epididymis. Note any lumps.
Locate the spermatic cord and note that it is smooth, firm, and movable. Note any lumps.
Notify health care provider if any lumps or changes are noted.
BOX 13-2 Available Resources for Sperm Banking
Washington Fertility Study Center (phone: 202-333-3100)
American Cancer Society (ACS) (www.cancer.org/docroot/home/index.asp)
Cancer Information Service (phone: 1-800-4-CANCER)
Sperm Bank Directory (www.spermbankdirectory.com)
TABLE 13-3 TNM Staging Classification for Testicular Cancer
Primary Tumor (T)
Extent of tumor is assessed after radical orchiectomy.
PTX
Unable to assess primary tumor
PT0
No evidence of tumor
PTis
Intratubular tumor: preinvasive cancer
PT1
Tumor limited to the testis, including rete testis
PT2
Tumor invades beyond the tunica albuginea or into the epididymis
PT3
Tumor invades the spermatic cord
PT4
Tumor invades the scrotum
Regional Lymph Nodes (N)
NX
Unable to assess regional lymph nodes
N0
No regional lymph node metastasis
N1
Metastasis in a single lymph node, ≤2 cm in greatest dimension
N2
Metastasis in a single lymph node, >2 cm but <5 cm in greatest dimension
N3
Metastasis in a lymph node >5 cm in greatest dimension
BOX 13-1 Testicular Self-Examination Procedure
BOX 13-2 Available Resources for Sperm Banking
