Prostate brachytherapy, a technique of placing multiple tiny radioactive seeds into the prostate gland, has been one of the more promising recent advancements in prostate cancer therapy. These radioactive seeds are needle-placed directly within and adjacent to the prostate tumor, and they deliver a higher dose of radiation to the tumor than does the external beam technique.
This same-day-surgery technique uses fluoroscopic and biplanar-ultrasound guidance to enable the most-accurate interactive positioning of the insertion needles and the precise placement of an evenly spread 3D-grid of the radioactive seeds throughout the prostate gland.
Dr. Gordon Grado originally developed this treatment as an option for local prostate tumor recurrence following previous surgery or radiation therapy. Because of his success with locally recurrent cancers, however, this approach and technique were expanded to include early stage or locally advanced prostate cancer.
We are now able to treat patients with all sizes and shapes of prostate glands, including those with enlarged glands or who have previously undergone prostate surgeries such as a TURP procedure (transurethral resection of the prostate) for obstructive urinary symptoms.
Iodine-125 or Palladium-103 are the radioactive isotopes contained within these implantable seeds. These radioactive sources are placed into the prostate gland via pre-loaded needles or by using a specialized insertion “gun.” These isotopes release all their irradiation energy within a few months of being implanted.Because of the low energy of the x-rays released from these isotopes, radiation dose is deposited within millimeters of the seeds’ positions. Dose delivered to adjacent normal organs is minimal.
As only a small volume of prostate tissue is irradiated by each seed, many seeds must be evenly positioned throughout the prostate tissue to cover the entire prostate and the cancer site within the gland. The entire prostate gland is treated, because microscopic cancer cells may be present at multiple sites within the gland, even though the biopsy may have been positive in only one location. The number of seeds required for treatment depends on the size and shape of the prostate gland, as well as the activity strength of the seeds. On average, approximately 100 seeds may be implanted through 18 or so needles.
Before the procedure, the patient is carefully evaluated to make sure he is an appropriate candidate for prostate brachytherapy, which is defined by several staging tests.
Clinical History & Physical Exam
A detailed clinical history will be obtained for all patients regarding their general health, prostate cancer diagnosis, previous surgery or radiation treatment. This will be followed by a complete physical exam and detailed digital rectal exam.
Prostate Ultrasound Volume Study
CT Scan of the Pelvis
This high-resolution x-ray study of the pelvis is utilized to look for any pelvic lymph node enlargement or other evidence of cancer presence outside of the prostate region. The relationship of the prostate to other normal structures in the pelvis is identified, as well as its association to bony anatomy. Contraindications for the prostate seed implant may be detected by this x-ray exam.
Preparing for the Prostate Seed Implant
It is important to review with the physician all of the medications being taken, as some drugs, such as “blood thinner” medication, could adversely affect the procedure or cause an unnecessary delay in performing the procedure.
Any aspirin product or non-steroid anti-inflammatory medication should be discontinued 7 days prior to the implant. The day before the implant, a special diet and bowel prep will be started. This prep will remove fecal material from the lower bowel and rectum that could interfere with the ability to obtain a clear ultrasound image of the prostate at the time of surgery. The patient should not eat or drink anything after midnight the day before the procedure. Any prescription medications may be taken with a small sip of water. If you have diabetes, you should check with your doctor before taking medications that lower your blood sugar.
Prostate Seed Implant
This procedure is performed as an outpatient in a sterile operating room (O.R.). The patient will be asked to report 1-2 hours prior to the procedure for registration and preparation. The entire procedure lasts approximately one hour. After the patient is precisely positioned on the operating room table, an individual specializing in prostate ultrasound will place the biplanar ultrasound probe into the rectum to image the prostate. The ultrasound probe is carefully held in position by a stabilizing device that is attached to the O.R. table. Biplanar, transrectal ultrasound, along with fluoroscopy, gives a multi-dimensional view of the prostate gland on several video screens in the O.R. These images obtained are used to place the needles and space the radioactive sources accurately within the prostate gland. No surgical incision is required.
Needles are advanced through an area of skin called the perineum (behind the scrotum and in front of the rectum) into the prostate, with the aid of a template attached to the ultrasound probe and a computer plan designed specifically for the patient’s prostate gland size. Radioactive seeds are then deposited through the needle into the prostate gland, based on a precise map that was planned in advance and then re-checked and modified at the time of surgery. The dose needed is calculated by pre-implant dosimetry from the volume study. The seeds are permanently placed in the prostate gland and give off radiation over the seeds’ life span of 3 months to a year (depending on the radioactive seeds selected). Both the probe and needles are removed when the procedure is completed, and a Foley catheter is left in the bladder until the patient recovers. Cystoscopy at the completion of the procedure is rarely needed, except to evaluate the urethra and the bladder if necessary. The patient will then be transferred to the post-anesthetic care unit for an hour or more of recovery, where upon waking up will receive discharge instructions.
When the catheter is removed, the patient will be taught intermittent self-catheterization, should he have any voiding difficulty. Most patients, however, do not have to catheterize themselves. The patient’s urine may contain a small amount of blood for a short period of time. This is nothing to be alarmed about and should subside in 24-48 hours.
A CT scan of the prostate and PSA level check will be done prior to discharge. The CT scan and postoperative films will be utilized for evaluation of seed placement and to calculate the total dose delivered. Later in the day or in the morning following the procedure, the patient will have a post-op visit.
Discharge instructions will be provided. Antibiotics will be given for 5days following the procedure. If necessary, prescriptions for pain medications will be provided. Heavy lifting or strenuous activity should be avoided for 30 days after the procedure, but walking, swimming and golfing are fine. After that, the patient may return to a normal level of activity. A follow-up appointment will be scheduled in 2 to 3 months, which will consist of a PSA blood test, a physical exam, including a digital rectal exam, and an x-ray study of the seeds within the prostate gland, or ultrasound if necessary.
Iodine-125 and Palladium-103 are low energy, radioactive materials. This means that the radiation travels only a short distance, with the majority of radiation effects delivered within the prostate area, “shielded” by the surrounding body tissues. Exposure to family and friends is minimal, and special precautions are not indicated, unless otherwise advised by the doctor or nurse.
Short-Term Side Effects
Some patients experience burning or discomfort with urination that may last from a few days to several weeks. Patients may also experience some increased frequency and urgency with urination. These symptoms are due to swelling in the prostate that results from the placement of needles during surgery. Medications are available to decrease these side effects. When the swelling subsides, so do the side effects. Most of the side effects are gone within a few months.
Long-Term Side Effects
After receiving radiation to the prostate gland, any anticipated future surgeries to this region of the body should be first discussed with the Radiation Oncologist who was involved in the brachytherapy placement.
Procedures requiring caution include colonoscopy, proctoscopy, sigmoidoscopy, and cystoscopy. Most delayed, long-term side effects can be avoided by following careful instructions from the brachytherapy physician. The rate of impotency is small, and the rate of urinary incontinence is negligible, unless a previous surgical procedure to the prostate or a transurethral resection had been performed, or if hormonal deprivation therapy were utilized.
With the techniques and equipment now available, radioactive sources can be very carefully positioned throughout the prostate gland and the prescribed treatment delivered. We have developed specialized brachytherapy techniques for patients having undergone a TURP (transurethral resection of the prostate), had previous radiation to the prostate area, or have enlarged prostate glands. Radioactive sources can be positioned to deliver tumor-killing radiation doses, accounting for previous radiation delivered for prostate cancer or other malignancies.
Prostate gland size may present some problems, which can be accommodated. Gland sizes treated with this technique have ranged from 8 to 210 cc (cubic centimeters). Equipment development and expertise has allowed us to specialize in these more difficult patient problems.
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