(RADIOACTIVE SEED IMPLANTATION)
Brachytherapy (more commonly known as "seed implantation") is a procedure in which small radioactive seeds are placed in the prostate to kill prostate cancer cells. It is a procedure in which both a urologist and a radiation oncologist (doctor who specializes in radiation treatment for cancer) may be involved. Seed implantation does not require a skin incision because the seeds are placed through small needles in the perineum (area behind the scrotum and in front of the anal region).
When considering all studies from around the world, it appears that prostate cancer cure rates from surgery, external radiation, or seed implantation may be equal at less than 10 years from the date of treatment. Until we have longer follow-up of seed implant patients, however, surgery will still be considered "the gold standard" to which all other therapies must be compared.
The small metallic pellets are called "seeds" because they actually look like tiny flower seeds. Once implanted, they will remain there forever (much like a filling in a tooth cavity), but the radioactive effect quickly wears off. Although there are different types of radioactivity associated with the seeds, the most commonly used isotopes (radioactive material) are Iodide, Palladium, and Gold. Each type of isotope has a different energy level and its own "half-life." The half-life is the rate at which the seed loses its radioactivity (i.e. the time it takes for the seed to "burn out"). We are able to tell you how long it will take before the seeds are no longer active. The type used will depend on the parameters of your particular cancer, as well as on the preference of the physicians managing your care. The number of seeds implanted will depend on the size and shape of your prostate gland.
Seed implantation can be done as monotherapy (the only treatment) or may be combined with external beam radiation therapy. External beam therapy is a type of radiation that is delivered from completely outside the body (almost like having an X-ray). In combination, there is more total radiation delivered to the cancer. While this may seem to be a desired result, the decision is not always so straightforward. Many cancers will be effectively treated with monotherapy, and higher doses of radiation may sometimes be associated with more frequent side effects and complications. This decision will be made by both the radiation oncologist and your surgeon after you fully understand the pros and cons of each approach. By the time you are scheduled for your seed implantation, you will already know if you are having monotherapy or combination therapy. For combination therapy, you can have the external beam first followed weeks later by the seed implant, or vice-versa.
The reason we perform this operation is to cure the patient of prostate cancer. In other words, when we do this procedure, we make the assumption that the cancer is still in the prostate and has not traveled out beyond the walls of the prostate or to distant areas in the body. Despite all modern technology, there is no way to guarantee this before the operation.
Our decision to proceed is based on a combination of any of the following depending on your particular circumstances:
- The prostate specific antigen or PSA value (prostate blood test) and the way the prostate feels on digital rectal examination (DRE).
- The grade of the cancer: this is a scoring system (called the Gleason score) that pathologists (doctors who examine the biopsy specimens) use to determine how aggressive a specific tumor may be.
- A bone scan (special nuclear X-ray of the entire skeleton) if it is indicated.
- A CT scan (computerized tomography) or MRI (magnetic resonance imaging) when they are indicated. Neither of these sophisticated tests are very accurate in helping to stage (determine if cancer is localized or spread) prostate cancer.
There are instances when we may suggest radiation therapy even when we know that there is a high likelihood that the cancer has already begun to spread beyond the prostate. Although no curative, it would be to try to achieve "local control" of the tumor.
If you have any significant medical problems, we may send you for an updated general physical and note of "medical clearance" from your primary physician. This is precautionary and for your own protection.
It is necessary, as with any procedure or operation requiring anesthesia, that you have not eaten for at least 8 hours prior to the scheduled time. We will ask you to clean out your colon the night before. You should plan a light lunch and light, early dinner (perhaps around 5-6:00 p.m.) the evening prior. Approximately 2 hours before bed, you will give yourself an enema.
If the results were suboptimal, we request that you repeat a second enema approximately one hour before bed. We may also request that you administer a third enema when you awaken the morning of your procedure.
As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood ("blood thinners, aspirin, anti inflammatory medicines, etc."). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
The duration of the operation is different for every patient mostly reflecting difference in the prostate size, and consequently, the number of seeds that must be placed. The general range is 1-2 hours. You will be in lithotomy position (on your back with your legs elevated in stirrups much like the position for an exam at the gynecologist.
The type of anesthesia used will reflect the suggestion of the anesthesiologist as well as contributions from your preferences as well as that of your surgeon. General anesthesia (complete sleep) or a spinal are typically used and acceptable for this procedure.
A catheter is placed into your urethra and into the bladder. The bladder may be filled with a contrast dye so that we can see the outline of your bladder using X-ray. An ultrasound probe is placed in the rectum just like the one placed during your original prostate biopsy. A special needle guide is then placed against the perineum (areas of your body between your scrotal sac and anal region). Using a combination of X-ray and ultrasound guidance (or ultrasound alone) the needles are carefully placed through the skin and into very specific areas of the prostate. These needles are hollow, and the seeds are placed into the prostate when pushed through using a special instrument. The placement of the seeds will correspond to a "dosimetry plan."
This is a sophisticated computerized program used to determine how the dose of radiation should be distributed in your individual prostate gland. We are able to confirm the position of the seeds using ultrasound and possibly X-ray as well.
After all the seeds are placed, the catheter is removed. We may then place a cystoscope (small telescope) into the bladder and perform an examination. We check for abnormalities of the bladder or urethra, and that no seeds migrated into the bladder itself. At this point, the procedure is over.
After the procedure, you will be in the recovery room until you are ready to be discharged home. In rare instances, a patient may be kept overnight for observation.
Depending on what we discussed with you prior to the procedure, you may have no catheter in your bladder when you awaken, or you may. Depending on your history (if you have a history of problems urinating due to your prostate), the catheter may be removed prior to your discharge home, or we may instruct you to keep the catheter in for one or more nights. If you are being discharged with the catheter, it will be attached to a small bag that straps to one of your legs. In this regard, it is easily concealed under your clothing and nobody knows it is there. You will get instructions on how to empty the bag and switch it to a larger bag for overnight use when you are sleeping. It sound complicated but is quite easy...we assure you.
The catheter or the procedure itself may give you a sensation that you need to urinate. This sensation typically disappears after a few days. The urine may be crystal clear or appear blood tinged for a few days. You may have a little blood from the rectum for a day or two, especially if you have a history of hemorrhoids.
You will be discharged with instructions for follow-up in our office. Other than your regular medications, we may give you an antibiotic and a pain medication (severe pain is uncommon).
Occasionally we prescribe other medications such as anti-inflammatory medicine, or pills that help the prostate relax to improve urination. We will discuss this with you if it applies to your particular circumstances.
It is normal to feel a bit tired for a few days. We typically tell patients that they will be out of work for one week, although many patients do return within a few days. The perineum may have minor swelling as well as black-and-blue discoloration. We suggest that you apply ice compresses intermittently (20 minutes on and 20 off) to the area for the first 24 hours.
Expectations of Outcome
Most patients feel just fine within a day or two after the procedure. If you completed the external beam radiation therapy in the prior months, you are more likely to be symptomatic after the seed implantation due to residual swelling of the tissue. The symptoms associated with radiation may progress over the next few weeks to months or they may seem severe in the early weeks and slowly go away. Alternatively, they may seem mild for months and then progress. The scenario is somewhat different in each patient. While the radioactivity of the seeds will burn out in weeks to a few months (depending on the isotope used), there may be ongoing tissue changes for over a year. As a result, it is not possible to determine the success of the treatments or the full degree of side effects for quite some time. We usually do not re-check your PSA level for several months after you are finished with all of your treatments. Research has demonstrated that it could take as long as two years before your PSA reaches it nadir lowest value.
It is not possible to completely protect surrounding organs (i.e. bladder and rectum) from some of the radiation dose. Almost every patient undergoing prostate radiation will have changes in the bladder wall that cause any one or a combination of these symptoms: frequency (urinating often), urgency (a sensation that one has to urinate often or urgently), nocturia (awakening at night to urinate), and dysuria (burning while urinating). The symptoms may be very mild and not bothersome. Alternatively, they can be quite severe and troublesome. Although most decrease over time, they less commonly persist indefinitely. Many symptoms are partially or completely improved with medications.
Changes to the rectum are less common but may result in tenesmus (a frequent urge to have a bowel movement), diarrhea (frequent, often loose bowel movements), discomfort and bleeding.
Possible Complications of the Procedure
ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned.
*Before listing the specifics, there are two important considerations: The first is that combined therapy (seed implantation and external radiation therapy) is almost always associated with a higher rate and a more severe degree of each complication compared with seed implantation monotherapy. The second is that each patient's tissue reacts to radiation in a somewhat unpredictable fashion. Two patients undergoing the exact same radiation treatment (total dose, timing, etc.) may have very different rates and severity of complications or side effects. Aside from anesthesia complications, it is important that you be made aware of all possible outcomes, which may include, but are not limited to:
- Incontinence (Involuntary Loss of Urine): As discussed, with time, many patients may develop bothersome urinating symptoms. While incontinence is far less common, it is possible. Urge incontinence is the most common and refers to the loss of urine when the bladder uncontrollably squeezes. Stress incontinence would be the loss of urine with a cough, sneeze, or heavy lifting, and is a rare complication following radiation therapy. Total incontinence is the constant dripping of urine and is associated with the extremely rare conditions of fistula formation or urethral necrosis (see below).
- Impotence (Erectile Dysfunction): You may be under the impression that radiation therapy is not associated with erectile dysfunction. That is not always the case. While there is very rarely "immediate" damage to the nerves controlling erectile function, delayed radiation effects may result in impaired erectile function or complete impotence. The long-term prognosis will depend on your pre-radiation erectile function, the total dose of radiation administered, as well as the way in which your tissue reacted to the radiation.
- Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids and observation. This problem is more common in diabetics, patients on long-term steroids, or in patients with disorders of the immune system.
If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
- Urinary Retention: Retention is the inability to empty the bladder. If the prostate becomes very swollen from the effects of the seed implantation, it can obstruct the flow of urine. We may need to place a catheter for a few days or until further treatment is considered appropriate. Usually, this problem resolves with time. In patients with very large prostates or a prior history of urinary problems, another type of procedure (to unblock the prostate cannel) could be necessary.
- Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation (especially longer operations), you can develop a clot in a vein of your leg (DVT).
Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
Bladder Neck Contracture/Urethral Stricture/Urethral Necrosis: Due to the effects of the radiation, any portion of the urethra can form a stricture or contracture (scars that narrow a passageway). If the flow of urine becomes significantly obstructed, it may be necessary to undergo a future minimally-invasive procedure to open the scar. Once a stricture forms following radiation, the problem can often be recurrent. Multiple procedures to correct this problem could ultimately affect urinary continence. Urethral necrosis is an extreme form of obstruction. In this instance, the tissue lining of the urethra inexplicably continues to break down from the radiation. The tissue sloughs off (peels away) and can obstruct the urethra. If certain portions of the urethra are affected, it can result in total incontinence.
- Hemorrhagic Cystitis (Radiation Cystitis): Weeks, months or years after radiation, the tissue of the bladder can become severely inflamed. The inflammation can cause generalized discomfort or dysuria (burning sensation during urination). Radiation cystitis can also cause episodes of hematuria (blood in the urine). The bleeding can be minor or significant. Sometimes clots form and result in urinary retention (inability to empty the bladder). Although quite uncommon, bleeding can be severe enough as to warrant transfusion.
- Wound Infection: Although quite uncommon, an infection can occur in the tissue where a needle was placed. This would present with unusual redness, swelling and/or drainage (white to yellow thick fluid).
- Fistula Formation: In very rare instances, tissue exposed to radiation can break down until a fistula (abnormal communication passage) forms between the affected organ and an adjacent space or organ. The most common example is a fistula between the prostate and the rectum. Less commonly, the bladder and prostate are involved. In this instance, a patient may be totally incontinent of urine. Stool incontinence could result as well. Treatment may be difficult, and require one or more reconstructive surgeries involving the colon and or urinary tract.
- Chronic Pain: While unusual, any patient can develop chronic pain in an area that was subject to surgery. The cause is not always forthcoming. While this usually resolves with time, consultation with a pain specialist may be necessary.
- Death: The incidence of death during or shortly after this procedure is extremely unusual, and occurs less than 1%. It is usually a result of an unexpected cardiac (heart) event or a pulmonary (lung) event.
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medicalevaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.
Delta Medix, P.C.