Wilm’s Tumour (Nephroblastoma)

This is one of the most common childhood tumours. The tumour is usually unilateral but may occasionally be bilateral. It is often malignant and spreads very rapidly. Metastasis tends to occur early in the lungs and prognosis is grave. However, if diagnosed early, about 4% are cured by surgical intervention, chemotherapy and deep x-ray therapy.

Clinical Features

When diagnosing a patient with nephroblastoma, the following characteristics should be kept in mind:

•       In early stages it is symptomatic

•       The condition occurs in the first three years of life

•       The child is usually brought to hospital because of gross abdominal enlargement and pain

•       Renal colic and haematuria

•       Urinary suppression and urinary infection

•       Anaemia and growth failure

•       Later there may be urethral obstruction

Diagnostic Investigations

Proper diagnostic investigations should always begin with accurate history taking. This should be followed by a careful physical examination, which should include an intravenous pyelogram, cystoscopy to exclude ureteric involvement, abdominal and chest x-ray to assess the extent of metastasis and blood tests for full blood count, haemoglobin, grouping and cross matching.

Management

The condition is best managed by a Nephrectomy or Nephrouterectomy.

Preoperative Care

This should be commenced as soon as the diagnosis is confirmed. The patient should be nursed on bed rest while the investigations and management are being organised. An intravenous pyelogram is aimed at detecting whether the renal pelvis is distorted and the kidney displaced. Abdominal palpation should be carried out carefully and kept to a minimum to prevent the systemic spread of cancer cells to the renal veins.

The patient is prepared for nephrectomy or nephro uterectomy, the latter being very extensive.
A blood transfusion should be given to correct anaemia before surgery and during the operation.

Postoperative Management

The nurse must make every effort to prevent infections, to accurately observe and record fluid intake and output and to selectively manage the patient’s dietary intake.

On return from the theatre, the child is nursed in semi prone position and the airway cleared to ensure adequate ventilation. After recovery, they should be nursed in recumbent and finally upright position to facilitate drainage from the nephrectomy bed. Clinical observations of TPR/BP and general appearance should be recorded every one to four hours as the condition improves. Specific observations include drainage from redivac, corrugated tube and wound. Strict urinary output is observed, recorded and reported to the doctor. A fluid balance chart should be accurately maintained.

If oedema or oliguria is found to be present, you should restrict fluid intake. If stones have formed in the renal system, or there is an onset of infection, you should increase the fluid intake. This however must be done in consultation with the doctor. The patient should be given low salt and low protein diet for oedematous and uraemic patients, while the carbohydrate intake should be increased.

Regular blood tests are necessary to monitor electrolyte levels, haemoglobin, blood urea and creatinine. Naso gastric tube aspiration in the early stages is necessary, especially when the patient feels nauseated. Oxygen therapy is recommended but only when necessary. Strict oral toilet should be maintained four hourly throughout. Physiotherapy and early ambulation should be encouraged to prevent complications.

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