Caring for a patient with a fungating malignant lesion in a hospice setting: reflecting on practice.

This article attempts to demonstrate the process of using experiential learning to reflect on nursing practice. This will be discussed in relation to the Atkins and Murphy's model of reflection. A case study will be used to demonstrate the complex issues of symptom management and the implications for improving and maintaining a consistent quality of holistic care within a hospice. The case of 'Sylvia', a 68-year-old woman with a diagnosis of incurable cancer, will be discussed in relation to the management of a fungating malignant lesion, pain management, the control of malodour, and maintaining dignified and respectful care and optimizing self-esteem and quality of life.

Trichosporon asahii fungemia in a patient with non-hematological malignancy.

Trichosporon fungemia is usually seen in neutropenic patients with underlying hematological malignancies. In this report we describe a fatal case of Trichosporon asahii fungemia in a non-neutropenic patient with a non-hematological malignancy. For 1 week the patient exhibited hematuria, weakness, easy fatigability and headaches. At admission she had anemia, renal failure and evidence of right hydronephrosis and bladder wall masses as detected by CT scan. She did not have a history of tobacco abuse, contact with urinary carcinogens or Schistosoma infestation; her clinical picture was suggestive of bladder cancer. After some investigations the patient underwent radical cystectomy and ileal conduit surgery because of transitional cell carcinoma in the urinary bladder. After an initial uneventful improvement postoperatively the patient deteriorated and died of septic shock despite all reanimation efforts and antibiotherapy including fluconazole. The blood culture obtained 4 days before the patient died revealed T. asahii, which was isolated on the day she died and found to be resistant to fluconazole and caspofungin. This report suggests that clinicians remain aware that T. asahii fungemia may develop in clinically deteriorated patients even if they do not have a hematological malignancy.

Synchronous solitary metastasis of transitional cell carcinoma of the bladder to the testis.

Primary tumors known to metastasize to the testis, in order of decreasing frequency, are prostate, lung, gastrointestinal tract, melanoma, and kidney tumors. Metastasis from bladder cancer to the testis is extremely rare, occurs with advanced and metastatic disease, and is usually a finding at autopsy. We report a rare, and probably the first, case of solitary and synchronous metastatic transitional cell carcinoma of the bladder to the testis, discovered on the preoperative workup. An incidentally discovered testicular mass in a man with high-grade, invasive bladder cancer should be considered a metastatic lesion until proven otherwise.

First clinical experience with new transurethral bipolar prostate electrosurgery resection system: controlled tissue ablation (coblation technology).

BACKGROUND AND PURPOSE: Bipolar transurethral resection of the prostate (TURP) can allow transurethral debulking of the adenoma with a lower potential for complications from systemic absorption of hypotonic irrigant. We evaluated a new bipolar double-loop resection system with a dedicated controlled ablation (Coblation) generator in this context. PATIENTS AND METHODS: In our series of 36 patients, 32 underwent transurethral bipolar loop resection, of whom 12 had prostates >50 cc (range for entire series 30-126 cc) on transrectal ultrasonography. Ten men had indwelling catheters because of urinary retention. The four other patients underwent transurethral resection of bladder tumors. After an initial learning curve of eight TURPs, some minor technical modifications were made, both to the bipolar-loop resection technique and to the hardware. The modified Vista Coblation system was subsequently evaluated by 18 other urologists in 17 other centers throughout the U.S. RESULTS: The median resected dry weight was 22 g, and the median operating-room time was 48 minutes, giving a median resection rate of approximately 1 g every 2 minutes. Two of the eight men in our learning curve required treatment for delayed bleeding problems (clot obstruction of catheter), and one of these received a blood transfusion. Transfusion was not required subsequently regardless of prostate size, even in men with larger glands. One of the patients treated for bladder tumor had a minor perforation of the posterior bladder wall, which healed with conservative management. In the multicenter experience in the U.S., there were 59 evaluable patients. The median resected weight was 23 g, and the median resection time was 55 minutes. Two men required conversion to monopolar roller coagulation for intraoperative bleeding. Most patients (80%) were discharged from hospital within 24 hours. No adverse neuromuscular stimulation occurred. CONCLUSION: This first single-center and international multicenter experience with Coblation technology for bipolar double-loop saline TURP confirms the feasibility and safety of this procedure. Subjective evaluation showed the four most important perceived benefits of bipolar over monopolar TURP to be smoother cutting action, elimination of TUR syndrome, less tissue burning (and no smell), and reduced bleeding. The results of randomized studies with this technology are awaited, while its role in bladder tumor resection remains unclear.