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Thread: sci nurse

  1. #1

    sci nurse

    please, some thoughts.

    there is an article in spinal cord journal my urologist has referenced by Dr. Claire Yang stating screening cystoscopies are not a good tool for early detection of bladder cancer in sci. the study is not available online unless you pay. though i have a copy of it. my urologist spent a long time talking to the author. http://www.nature.com/cgi-taf/DynaPa.../3100767a.html

    my urologist also found thru some research that alpha blockers such as flomax block dysreflexia and is wondering if that used a week ahead of time or so would allow her to do a cystoscopy in her office.

    in the meantime, we have scheduled a cystoscopy for 15 feb with a spinal. she has advised i take the flomax now. and detrol to avoid bladder spasms. but we are wondering for the future.

    is nitropaste good enough after the procedure and i am home? or would nefidipine be needed? thx.

    [This message was edited by cass on 02-10-05 at 03:25 AM.]

  2. #2
    You'll find some disagreement among the SCI nurses on the question of nifedipine. In the center where I work, we use nitropaste with great success. The backup drug (should the nitropaste fail) is hydralazine 10 mg by mouth (may be repeated x 1).

    KLD does not think that nitropaste works fast enough and her center still uses nifedipine.

    There are some reports of deaths with nifedipine so we don't like using it except as a last resort (and have not used it on anyone for more than five years now).

    When we do cystos with quads, we have anesthesia standing by to monitor blood pressure and respond to dysreflexia but I don't believe they routinely do spinals for the procedure.

    Dr. Yang is the urologist we work with here. The reason we do not do surveillance here is that bladder cancers are so fast growing that a person can be clear at one annual exam and have terminal cancer before the next one. The important thing is that you don't smoke. That greatly increases the occurrence of bladder cancer with indwelling catheters.

    We also use alpha blockers to prevent dysreflexia in people who have it at the drop of a hat. It would be a good drug to have on board before your cysto.

    RAB

  3. #3
    Cass,

    It seems sensible to use some kind of bladder antispasticity drug to prevent dysreflexia from cystoscopy. This depends in part on why they are doing the cystoscopy. Taking the drugs will blunt the response of the bladder to pressure and therefore you cannot tell much about the spasticity of the bladder. In order to see the bladder wall better, they must fill the bladder with fluid and this of course can kick off autonomic dysreflexia.

    As RAB pointed out, there is some differences of opinion concerning the best way to treat autonomic dysreflexia and the value of yearly cystoscopy. Because there is a risk of autonomic dysreflexia, it is important have appropriate facilities and people on standby to deal with it, if it occurs. In centers where they have good monitoring and backup, I agree that intravenous nifedipine treatment is probably the best way to control the blood pressure.

    Regarding surveillance for bladder cancer, I don't know how widely held Dr. Clair Yang's opinion is concerning the usefulness of surveillance. It is entirely possible that bladder cancer develops "so quickly" that yearly cystoscopy may not detect a majority of the cancers at a stage where they can be prevented. On the other hand, if it does so even in 10% of the patients, one would think that such surveillance would be worthwhile. To me, the more important issue is whether bladder cancer poses a sufficient risk to justify such expensive surveillance.

    Subramonian, et al (2004) studied 1324 patients and found four cases of bladder cancer. They found that the incidence of invasive bladder cancer is not statistically different from the general population. Groah & Lammertse (2003) took a different approach to the question. They asked the retrospective question whether people who do develop bladder cancer have a better survival rate if they had more intensive bladder surveillance. Their research suggests that death from bladder cancer in SCI people is related to risk factors such as age and smoking but increased surveillance of the bladders is not necessarily associated with better survival from bladder cancer.

    Hess, et al. (2003) concluded that gross hematuria warrants aggressive assessment for bladder cancer, that chronic indwelling catheter, smoking, and renal and bladder stones are important risk factors for bladder cancer. In an earlier study, West, et al. (1999) surveyed the charts of 130 patients who had developed bladder cancer out of a pool of 33,565 patients with SCI. The distribution of catheterization methods should be of interest.

    Wise.






    References

    1. Subramonian, K, Cartwright, RA, Harnden, P and Harrison, SC (2004). Bladder cancer in patients with spinal cord injuries. BJU Int. 93: 739-43. Department of Urology, Pinderfields Hospital, Aberford Road, Wakefield, West Yorkshire WF1 4DG, UK. ksubu2000@hotmail.com. OBJECTIVE: To evaluate the age-standardized incidence rate of bladder cancer in patients with spinal cord injury (SCI) and the overall risk for this population. PATIENTS AND METHODS: We reviewed 1334 patients with SCI whose dates of SCI, or first attendance at our centre, were between 1940 and 1998. The length of follow-up was calculated for each patient and age-specific incidence rates of bladder cancer calculated using 5-year age bands. This was used to calculate the overall incidence rate, using direct standardization with the European standard population. The cancers were analysed histochemically to characterize the phenotype. RESULTS: The 1324 patients contributed a total of 12 444 person-years of follow-up. There were four cases of bladder cancer, giving an age-standardized incidence rate of 30.7 per 100 000 person-years. Histochemistry showed areas were positive for cytokeratin 14, which was also positive in the undifferentiated areas. Immunohistochemical staining was positive for cytokeratin 14 and consistently negative for cytokeratin 20, suggesting a pure squamous phenotype. CONCLUSIONS: The age-standardized incidence of invasive bladder cancer in patients in our SCI unit is not statistically different from that of the general population. However, the incidence of invasive bladder cancer in the present study appears to be lower than that reported in other series. Histochemical analysis confirmed a squamous cell phenotype in these tumours.

    2. Groah SL and Lammertse DP (2003). Factors associated with survival after bladder cancer in spinal cord injury. J Spinal Cord Med 26: 339-44. OBJECTIVE: The purpose of this study was to evaluate factors influencing survival in individuals with spinal cord injury (SCI) and bladder cancer. We hypothesized that bladder cancer survivors would have undergone more intense genitourinary surveillance and would have had fewer risk factors for bladder cancer. DESIGN: Case-control study. PARTICIPANTS/METHODS: Eight participants with SCI who had survived at least 5 years (survivors) with bladder cancer were compared with 12 SCI controls who had died due to bladder cancer. Data was obtained retrospectively through medical record review and were analyzed using a two-tailed Mann-Whitney and Fisher's exact tests. RESULTS: The survivor and control groups were similar with regard to age at SCI, duration of SCI, age at bladder cancer diagnosis, and time utilizing an indwelling catheter. The proportion that developed squamous cell carcinoma was similar for the survivors and controls, at 37.5% and 44%, respectively. Survivors were more likely to be nonsmokers (P = 0.04), and have a history of squamous metaplasia (P = 0.05) and papillary cystitis (P = 0.03). Examining risk factors together, controls were more likely to have multiple risk factors for bladder cancer. The mean number of cystoscopies for the survivor and control groups, respectively, was 8.6 (range = 1-22, SE = 3.1) vs 18.9 (range = 4-48, SE = 6.6), and the mean number of bladder biopsies was 1.5 (range = 1-5, SE = 0.6) vs 4.2 (range = 1-11, SE = 2.0), respectively. CONCLUSION: Bladder cancer survivors were less likely to have multiple genitourinary risk factors. Fewer screening cystoscopies and biopsies were performed in survivors of bladder cancer than in those who died of bladder cancer. Department of Physical Medicine & Rehabilitation, National Rehabilitation Hospital, Washington, DC, USA. SuzanneL.Groah@Medstar.Net

    3. Hess MJ, Zhan EH, Foo DK and Yalla SV (2003). Bladder cancer in patients with spinal cord injury. J Spinal Cord Med 26: 335-8. OBJECTIVE: The incidence of bladder cancer in spinal cord injury (SCI) is 16 to 28 times higher than that in the general population. The objective of this study was to investigate the characteristics of bladder cancer that are unique to the SCI population. DESIGN: Retrospective review. METHODS: The charts of 16 patients diagnosed with bladder cancer from 1982 to 2001 were reviewed for type of cancer, exposure to risk factors, presenting symptoms, and survival time. RESULTS: The presenting manifestations were gross hematuria in 14 patients, papillary urethral growth in 1 patient, and acute obstructive renal failure in 1 patient. The diagnosis was made on initial cystoscopic evaluation in 16 patients; 3 patients required further evaluation. Eight of the 11 screening cytologies were suspicious for a malignancy prior to the diagnosis. Seven patients had transitional cell carcinoma, 6 patients had squamous cell carcinoma (SCCA), and 3 patients had both. The bladder wasmanaged with chronic indwelling catheter in 12 patients. Nine patients died of bladder cancer metastases and the remaining 3 patients died of other causes. Six patients survived 5 years or more; 4 were still alive at the completion of this study. CONCLUSION: Gross hematuria in individuals with SCI warrants aggressive assessment for bladder cancer. Chronic indwelling catheter, smoking, and renal and bladder stones are important risk factors for cancer. The incidence of SCCA in the SCI popullation is much higher than in the general population. Cystoscopic and cytologic evaluation in patients with advanced disease may fail to confirm the diagnosis in a high proportion of patients. SCI Department, VA Boston Healthcare System, West Roxbury Division, West Roxbury, Massachusetts 02132, USA. Marika.Hess@med.va.gov

    4. West DA, Cummings JM, Longo WE, Virgo KS, Johnson FE and Parra RO (1999). Role of chronic catheterization in the development of bladder cancer in patients with spinal cord injury. Urology 53: 292-7. OBJECTIVES: Patients with spinal cord injury (SCI) and chronic indwelling catheters are known to be at increased risk of bladder malignancy. "Decatheterization" by clean intermittent catheterization, external condom catheterization, or spontaneous voiding is thought to reduce the risk by decreasing the chronic mucosal irritation and rate of infection. We examined two Department of Veterans Affairs (DVA) data bases to test this theory. METHODS: A population-based retrospective analysis of invasive treatments for carcinoma of the bladder in all DVA hospitals was conducted using computerized inpatient files from fiscal years 1988 to 1992. RESULTS: One hundred thirty patients with bladder malignancy were identified from a pool of 33,565 patients with SCI (0.39%). All 130 patients underwent either radical cystectomy (n = 63, 48%) or transurethral resection of bladder tumor (n = 67, 52%). The 30-day perioperative mortality and overall 5-year survival rates were 2 (1.5%) and 49 (38%) of 130, respectively. Of the 130 patients analyzed, 42 (32%) had adequate data available regarding tumor pathologic findings and method of bladder management for analysis. The average age at diagnosis was 57.3 years. The histologic finding was transitional cell carcinoma in 23 (55%), squamous cell carcinoma in 14 (33%), and adenocarcinoma in 4 (10%) of 42. Bladder management was an indwelling urethral catheter in 18 (43%), suprapubic catheter in 8 (19%), clean intermittent catheterization in 8 (19%), and condom catheter in 6 (14%) of 42 patients. Squamous cell carcinoma was more common in patients with indwelling urethral catheters and suprapubic tubes (11 of 26, 42%) than in those using clean intermittent catheterization, condom catheterization, or spontaneous voiding (3 of 16, 19%). CONCLUSIONS: Bladder cancer was diagnosed in approximately 0.39% of this large SCI population during a 5-year period. Most cancers (55%) were transitional cell carcinomas. Squamous cell carcinoma was more common in patients with SCI and indwelling catheters than those without chronic catheterization. These data continue to suggest that avoidance of indwelling catheters, when feasible, is the preferred method of bladder management in patients with SCI. Department of Surgery, St. Louis University School of Medicine, and the John Cochran Veterans Affairs Medical Center, Missouri, USA.

  4. #4
    We are conducting a study comparing bladder biopsy results and simple urine cytology test. Data is not ready for analysis yet, but there is a trend that indicates that perhaps only annual urine cytologies (3 specimens) would be needed as we often see the abnormal cells here PRIOR to them being seen in biopsy. This is a much less expensive and invasive test, and if our study supports this, we may be considering a change in our practice in the future.

    If we can prevent one death due to bladder cancer, that is important to me. I have seen too many over the years.

    (KLD)

  5. #5
    thank you, rab, wise and kld very, very much. i was very surprised to see Dr. Yang's study.

    i will be providing my urologist all this info and esp. ty wise for the detailed references.

    rab...if you work with Dr. Yang, you must be in my area? seattle? or, perhaps i'm not allowed to ask that.

    one more question...do EKGs usually show normal for sci? they kept asking if i was in pain (i am) and when i questioned them and looked at the printout, they indicated the "noise" (my term) was muscle tremors. wouldn't that be normal for sci? they're calling it abnormal and making me do it again, potentially holding up my cystoscopy.

  6. #6
    SCI folks normally have similar EKG's to able-bodied folks except that quads and high paras have slower than normal heart rates.

    Your EKG was not really abnormal--it just wasn't technically "good enough" to see how your heart is working. How old are you? If you're younger than 40 an EKG may be a bit of overkill for a cysto. They could position the electrodes on other parts of your body rather than your arms, if they are what is trembling because of your pain.

    If a nurse or a doctor were to do your EKG it might be better because you may be too much of a challenge for the technician (who doesn't really have much training).

    Yes, I'm in Seattle. Post a private note and we'll talk.

    RAB

  7. #7
    ty RAB. i pt'd you.

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