Brachytherapy

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Brachytherapy is often offered as an excellent option for the treatment of prostate cancer. At Urology Centers of Alabama, we utilize permanent seed implantation (brachytherapy), either alone or in combination with external radiation and/or hormonal blockade. The therapy or combination of therapies depends on the stage, extent, and aggressiveness of the individual’s prostate cancer. The outpatient procedures are performed at Trinity Medical Center or Baptist Hospital Princeton in Birmingham. Since the beginning of our Prostate Brachytherapy program in 1996, we have performed seed implants for prostate cancer at these hospitals.

About Brachytherapy

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Brachytherapy, which is derived from the Greek words for short distance (brachy) and treatment (therapy), is also referred to as seed implantation. Radioactive “seeds” are carefully placed inside of the cancerous tissue to attack the cancer at close range. Each radioactive seed is about the size of a grain of rice, and gives off radiation which travels only a few millimeters to kill nearby cancer cells.

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Multiple seeds are generally implanted depending on the size of the area needing to be treated. With permanent implants the radioactive seeds lose strength, or “decay” over time. The seeds remain permanently implanted, but are no longer radioactive.. Brachytherapy has been proven to be very effective and safe, providing a good alternative to surgical removal of the prostate while reducing the risk of certain long term side effects.

Benefits of Brachytherapy

The benefits of brachytherapy include a quicker recovery time, less time spent in the hospital, and a reduced risk of postoperative infections. Other benefits of using brachytherapy in the treatment of early stage prostate cancer are quite pronounced. There is a lower incidence of impotence and incontinence than occurs with a radical prostatectomy, and most men resume walking within a few hours of the procedure and other normal activity within a few days.

Brachytherapy has been proven to be comparably effective in the treatment of prostate cancer, and patients often suffer fewer side effects compared to when the employment of external radiation therapy or surgery is used.

Length of Radioactivity

With seed implants, the “seeds”, or sources of radiation,  remain in the body permanently, but the radioactive materials are specially selected such that the energy of the radiations emitted are so low that there is a negligible risk to others who come into contact with the brachytherapy patient.  It is, however, recommended that the patient avoid close contact with children and pregnant women for several months.  There are two types of seeds that we use for brachytherapy, Iodine-125 and Palladium-103.   Iodine-125 seeds decay, or lose their energy, at a rate of 50% every 60 days. After 10 months, their radioactivity is nearly exhausted. Palladium-103 seeds decay much quicker, losing half their energy every 17 days. They are nearly inert after only 3 months.

Candidates for Radiation Seed Implants

In general, men who have small, early stage prostate cancers may be considered for a radiation seed implant. Several tests are necessary to ensure that radiation seed implantation is an appropriate treatment for your prostate cancer. With more advanced cancer some patients are candidates for a combination treatment consisting of seed implantation and the addition of external beam radiation with or without hormone blockade.

Before the Prostate Brachytherapy Procedure

Prior to implantation, your physician will order an ultrasound to help determine the size and shape of your prostate. This is often done at the time of the biopsy.   This can also help determine the location and extent of the cancer. The ultrasound will help in planning your treatment and in determining the number of radioactive seeds to be ordered for the procedure.

At the time of your procedure, your doctor will locate your prostate with a rectal ultrasound, and take measurements showing the exact location and size of your prostate. These images help your doctor to determine the number of seeds needed and their location, to most effectively treat your cancer.

You generally will have preadmission testing at the hospital before the brachytherapy procedure. These tests may include blood tests, and electrocardiogram (EKG), and chest x-rays. Your doctor will determine which tests are necessary. The results are used by anesthesiologists to determine what kind of anesthesia to use for brachytherapy procedure.

A few days before your procedure you will be given specific instructions about preparation, including diet and enemas. These instructions are very important to follow in order to make sure that the ultrasound image of your prostate will be clear.

During the Procedure

Brachytherapy is usually an outpatient procedure, which means you most likely will not have to be admitted or spend the night at the hospital. The implant procedure is done under general anesthesia and the procedure last approximately 1-2 hours. Once the anesthesia takes effect, a catheter will be inserted into your bladder to drain urine, and an ultrasound probe will be placed into the rectum.

Using images provided by the ultrasound probe, your physician inserts long, thin needles through the skin between the scrotum and rectum (perineum) into and around the prostate. These needles carry the radioactive seeds, which contain either Palladium 103 or Iodine-125. The seeds are actually rice-sized titanium cylinders that have the radioactive substance sealed within them. As the needles are removed, the seeds are deposited and left behind. They remain in your prostate permanently. When all the seeds are placed, the rectal ultrasound probe is removed. At the end of the procedure, a scope may be passed through the urethra into the bladder to determine if any seeds slipped into the bladder. The urinary catheter is normally removed from the bladder before the patient wakes up.

After the Procedure

Immediately after the procedure you are taken to the recovery room until the anesthesia wears off, which usually takes 45 minutes to 1 hour.  Once you are awake and able to eat, drink, and urinate, you will be discharged home.  Occasionally, a patient will be kept overnight in the hospital for observation after anesthesia.

Activity Restrictions

  • Avoid strenuous activity for one month. Walking, swimming, and golf are okay. Riding a bicycle or a stationary bicycle is prohibited. After one month, you may return to your regular activities, but in the unlikely event the needle-entry site (perineum) remains tender, please avoid activities that irritate the area.
  • DO NOT strain or push during urination or bowel movements. This may cause bleeding.

 

Diet

You may resume a regular diet unless instructed otherwise. Some foods can be irritating to the bladder causing frequent urination, discomfort, and possibly a slower urine stream. If you develop any of these urinary symptoms you may need to decrease your intake of the following foods:

Beverages

Foods/vitamins

Alcoholic Beverages

Apples

Apple juice

B complex vitamins

Carbonated drinks

Cantaloupe

Coffee

Chocolate

Cranberry juice

Chili peppers/spicy foods

Grape juice

Citrus

Tea

Cranberries

Grapes

Guava

Peaches

Pineapple

Plums

Strawberries

Tomatoes

Vinegar

Vitamin C

Medications

Take your usual medications unless you are instructed otherwise. After the implant procedure your physician may prescribe one or more of the following medications.

  • Antibiotics-You may receive a prescription for an antibiotic to prevent infection. Take the antibiotic as prescribed until all the medication is gone. If you develop symptoms such as itching, hives, and/or shortness of breath, discontinue the antibiotic at once and call your physician.
  • Pain medication-Medication for discomfort will be available if necessary. Take acetaminophen (Tylenol™, Aspirin Free Anacin™) for discomfort. Any pain not relieved by acetaminophen, do not hesitate to contact your physician. Avoid the use of aspirin and aspirin containing products for one week after your procedure as they may increase the likelihood of bleeding.
  • Stool Softener-It may be helpful to use a stool softener for 1-2 weeks to prevent straining during bowel movements.
  • Alpha blocker-you may be prescribed a medication to help empty your bladder such as Flomax™, Rapaflo™, or Hytrin™.

Avoid all over the counter medications that contain antihistamines and/or decongestants (ask your pharmacist if you are unsure). These may cause urinary retention.

Early Side Effects

“Early” side effects are those that occur within the first 30 days of the procedure. They may include:

  • Discomfort-It is not unusual to have some tenderness and/or bruising between the scrotum and rectum. There may be slight bleeding from this area for the first 2 weeks. If this persists or amounts to more than an ounce of blood within 24 hours, contact your physician.
  • Blood in urine-There may be blood in the urine for several days following implantation. However, if large clots are passed with urine, or if it is difficult to urinate, call your physician. Drinking plenty of fluid can help move liquids through the bladder, thus decreasing or preventing clots from forming.
  • Burning and difficulty with urination-After the urinary catheter is removed (usually within the first 24 hours) some men have difficulty urinating. You will be instructed on how to catheterize your bladder in the event you are unable to urinate. If you have the urge to urinate and cannot, or you are unable to do self-catheterization, you will need to go to an emergency room for evaluation and care. You may also have burning during urination. If this becomes a problem for you, please contact your physician.
  • Ejaculation - You will probably experience diminished, discolored, delayed and/or dry ejaculate for several months to a year, which may be permanent in nature. This may happen immediately, or be delayed, but it is considered to be a common side effect after seeding.

Late Side Effects

“Late” side effects occur after the first 30 days have passed and are almost always related to the radiation given off by the seeds in the prostate. Late side effects include, but are not limited to:

  • Difficulties with urination-Inflammation and swelling in the prostate may result in frequent urination, burning during urination, the urgent need to urinate and/or a weaker urine stream. These symptoms are usually temporary, typically lasting anywhere from one month to a year or more. Avoiding foods and beverages that contain caffeine may help lessen these symptoms.
  • Rectal irritation-Some patients may feel pain in the rectal area or pass blood with bowel movements, although it is not common.
  • Impotence-Sexual potency in men can be influenced by a number of factors including age, medication use, tobacco use, and overall health (including cardiovascular problems, diabetes, and hypertension). Because many factors affect potency it is difficult to measure the precise affect that seed implantation has on a man’s sexual potency. Studies done on impotence following seed implantation show varied results. Current figures indicate that from 10 to 50 percent of men may have impotence following seed implantation. Impotence can be temporary or long lasting. Discuss this possible side effect with your physician.

Follow Up

You will be scheduled to return to the hospital radiation oncology department one month after the implant for a CT scan.  This is to document seed placement and allow calculation of the radiation dose to the prostate and other tissues achieved by the implant. An additional follow up with the radiation oncologist will be scheduled shortly after the CT scan.

If additional radiation is planned after the brachytherapy procedure, treatment usually will begin 2 months after the implant. Some patients will require hormone blockade treatment in addition to the radiation treatment.

Your doctor will tell you how often you need to be seen after the brachytherapy procedure. You need to be checked for treatment progress, treatment side effects, and to make sure that the cancer has not recurred. The schedule will often be more frequent during the first several years following treatment.