Treatment

Permanent Seed Prostate Brachytherapy is a very effective technique for treating early stage prostate cancer, using tiny radioactive seeds of Iodine that are inserted permanently into the prostate gland. 'Brachy' means close and, in this treatment, the radioactivity is inserted directly into the cancerous organ. Brachytherapy provides a higher, more localised radiation close to the prostate and minimises the effects on the surrounding tissues, such as the rectum and bladder.

Your specialist team at Urology Bay of Plenty will advise you whether your prostate cancer is suitable for treatment by brachytherapy.  At your clinic visit, you will have a  rectal examination to assess the stage of the cancer. You will also undergo a painless transrectal ultrasound (TRUS) to assess the size of the prostate. Your urinary symptoms will be assessed, and you will need to come to the clinic with a comfortably full bladder so a flow rate can be performed.

Prostate brachytherapy is carried out as a two-stage technique, with Stage 1 being The Volume Study.  Stage 2 is the The Implantation Process of the seeds, which is carried out approximately 4 weeks later.

The Volume Study

This is a detailed transrectal ultrasound, normally performed as a day-case procedure under general anaesthetic.

During the Volume Study, aerated gel is placed in the water pipe (urethra) whilst under anaesthetic. This will help to identify this structure during the procedure. The prostate volume is outlined on the ultrasound images, including the position of the urethra. A three-dimensional model is then constructed by the brachytherapy planning computer and a dose plan produced. This plan will be unique to each patient and will determine the position and number of seeds needed.

Occasionally, if the prostate is gland is too large, medication destined to reduce the size of the prostate gland may be necessary in order to shrink the prostate down to a size that will then be suitable for the seed implant. 

The outcome of the Volume Study will be discussed with you by your surgeon, Mark Fraundorfer.

The Implantation Process

You will be admitted on the day of the procedure. As for the Volume Study bowel preparation would have taken place on the day before the implant. The implantation Process involves the insertion of radioactive seeds, under transrectal ultrasound guidance, using needles that pass through the skin between the legs behind the scrotum (the perineum). Most of the seeds implanted are woven into a strand of absorbable material to help maintain their position and they will remain in place permanently. The strand material 'dissolves'. X-rays are taken throughout the procedure, to check the position of the seeds. A catheter is placed into the urethra whilst you are under anaesthetic. This remains in place overnight until the effect of the anaesthetic have fully worn off.  Generally, most patients are able to go home the day after surgery and will be followed up at regular intervals by the team at Urology Bay of Plenty.

What happens if the cancer returns?

Whilst the success rate of brachytherapy seems to be as high as for surgery, neither treatment option can guarantee cure. Should the cancer return in the prostate gland, a radical prostatectomy, or cryotherapy are possible further treatment options that can still provide cure.

Your Consent

Following your initial visit, if you are suitable for brachytherapy and are happy to proceed with this as a treatment option for your prostate cancer, we will be able to schedule your dates.

We will need your permission for your operation to go ahead. Before you sign the consent form it is important that you understand the risks and effects of the operation and anaesthetic. These will be discussed with you by your doctor and the nurse, should you have any questions, your nurse or doctor would be happy to answer these.

About Your Anaesthetic

You will NOT be allowed to eat or drink anything for at least six hours before your surgery. This includes chewing gum and sweets.

Both the Volume Study and Implantation Process will be performed under General Anaesthetic.

• General Anaesthetic: You will be asleep throughout the operation and remember nothing of it.

You must not drive any vehicle or operate any machinery for 24 hours after having an anaesthetic. You will have to arrange for someone to drive you home if you go home within 24 hours of your surgery.

Your Operation

The Volume Study

You will need to have bowel preparation the day before the procedure, to ensure that the rectum is empty, so that clear ultra sounds images of the prostate can be obtained.

The Implantation Process

You will be admitted on the day of the procedure. As for the Volume Study bowel preparation would have taken place on the day before the implant. Prior to the procedure you may be shown how to catheterise yourself in case you cannot pass urine after the procedure.

The procedure is performed under general anaesthetic in the operating theatre.

After Surgery

The Volume Study

You may find that you pass some jelly from the penis after the scan and you may notice some slight discomfort during the first time that you pass urine.

The Implantation Process

Immediately after the operation, you may notice some bruising beneath the scrotum and tenderness between the legs.

Once the catheter has been removed, you may notice some discomfort when passing urine. You may pass seeds in the urine, although this is uncommon and usually will happen within the first 24 hours following implant.

We will ensure that you are able to pass urine satisfactorily before you are discharged home.

Going Home

A small number of patients will need to self catheterise after the procedure. This will be fully discussed prior to discharge.

It is quite common to see some blood in the urine for a day or two after the procedure. This is quite normal, so do not be alarmed. There can also be blood in the semen.

After the brachytherapy implant, all patients will receive:

• An alpha-blocker. This tablet relaxes the muscle within the prostate gland and helps to reduce the narrowing of the water pipe as it runs through the swollen prostate, so reducing urinary symptoms. This is best taken in early evening. You will be encouraged to take this tablet until your urinary symptoms settle.
• An anti-inflammatory painkiller. This tablet has two benefits. It is an effective painkiller Adan is also useful in reducing the inflammation from the prostate gland, so helping to relieve urinary symptoms. You will receive a one-month supply of this tablet and we encourage you to take this medication for at least three weeks.
• A course of antibiotics. You will receive a course of antibiotics. These will help to prevent infection following the implant. They are safe to take with an alcoholic drink if desired.

Once Home

You should be able to resume normal activities (e.g. work, shopping) within a few days. However, we would normally advise you to avoid heavy lifting or strenuous activity for the first two weeks after your implant.

Radiation protection

Many patients are concerned about whether an implant poses any potential radiation exposure to their family and friends. It is important to remember that although the seeds are radioactive, you are not. Objects that you touch or items that you use do not become radioactive. Other people may use linen, clothing, tableware or dishes after you without special precautions. Your bodily waste (urine and stool) are not radioactive.

There are no formal restrictions on your activities when you return home. However, we recommend that the following precautions are followed for the first 2 months after the implant, after which time the radiation levels reduce significantly and you may resume life as normal.

1. Women who are pregnant should not sit very close to you (e.g. on the same sofa or bed) for more that a few minutes a day. However, you may con tine to greet or hug them as you would have done before the implant and spend as long as you wish in the same room as them.
2. Do no sit children on your lap for long periods. As explained above, you may briefly cuddle them for a few minutes and they may stay in the same room as you for as long you wish.
3. Other adult family, friends and colleagues are not at risk and restrictions on time and activities are not necessary.

Family relations

You may sleep in the same bed as your partner, provided she is not pregnant. Sexual intercourse, using a condom, may be resumed once you feel comfortable to do so. Initially, a condom should be used, because there is a very small risk that a seed may be passed in the semen.

Your semen may be discoloured dark brown or black. This is normal and is a result of bleeding that have occur ed during the implant. Following 2-3 ejaculations, it will not be necessary to use a condom.

Water intake

For one week after the implant, you are encouraged to drink plenty of water to flush through any small blood clots that may develop out of the bladder. Thereafter, you should return to a normal drinking pattern and your daily intake should not normally exceed 1.5 litres per day. Alcohol, in moderation is fine.

After the implant, it is common for patients to notice a gradual worsening of their urinary symptoms. Often, patients will find that they do not have too many problems during the first couple of weeks following implant. Symptoms will then peak at around 4-6 weeks post-implant, but improve over the ensuing months. For this reason, we would normally advise you keep your catheter handy for about six weeks.

Typically patients complain of a slow stream, with urinary frequency and urgency during the day and night. There may also be a feeling of incomplete emptying of the bladder, with the need to strain. Most often, the symptoms are worse at night and during periods of inactivity.

These side-effects are due to the swelling of the prostate following the procedure and irritation of the prostate and bladder lining due to radiation from the seeds. They are temporary and will settle in time.

We would normally expect that by 6-9 months following implant a patient's urinary symptoms will have returned to how they were before treatment began.

Urinary Retention

As mentioned, approximately 1 in 20 patients may have temporary difficulty in emptying their bladder after the implant and this can result in urinary retention.

The symptoms of urinary retention are inability to pass urine and lower abdominal discomfort, usually with a constant desire to urinate. Normally we teach patients to catheterise themselves, using single-use disposable catheters, which most patients find is easier and more convenient. This avoids having a permanent, indwelling catheter. The inability to pass urine is usually transient and, within a few weeks, you will find that your bladder starts to empty properly again and the need for catheterisation will stop. 

Bowels

Some patients find that, immediately following the implant, their bowels tend towards constipation. This can usually be relieved by an increase in fresh fruit, vegetables and fibre.

Occasionally, patients can experience troublesome rectal symptoms following their implant, such as frequency of opening their bowels or diarrhoea. This symptom is more common following additional external beam radiotherapy than with a brachytherapy implant alone.

The symptoms are usually self-limiting and can often be managed by changing one's diet slightly, by reducing the roughage, i.e. decreasing fruit and fibre intake. Immodium medication can further reduce any urgency or discomfort. Very occasionally, steroid suppositories are required. These symptoms tend to start 6 months after the implant.

Erectile dysfunction

Erection of the penis may be affected by brachytherapy. The risk is lower in younger men who have had no previous difficulties obtaining an erection and it tends to affect about 15% of our patients following treatment.

Current research suggests that the risk is lower than with other treatments, such as radical prostatectomy. Treatment with PDE5 inhibitors (Viagra, Cialis, Levitra) is usually effective in approximately 80% of patients should difficulties in achieving and maintaining an erection occur.

Some men notice a decreased or dry ejaculate following brachytherapy. This is a common, temporary side-effect of some of the alpha-blockers, but can also occur as a result of the brachytherapy itself.

Follow-up

Normally you will be reviewed by your urologist approximately a month after the implant. PSA will be first checked 3 months after the implant. Usually, it will then be checked every 3 months for the first two years and every 6 months thereafter. Approximately 25% of patients will experience a temporary small rise in PSA (a 'PSA bounce'), typically anywhere between 6 months -2 years after the procedure. This is quite common, with the PSA dropping again after a few months. The reasons for this bounce phenomenon are unclear, but it does not have any effect on the overall success of the treatment.

While you are in hospital we will do everything we can to make your stay as comfortable as possible. The nursing and medical staff are always available to help with whatever needs you have. If you are worried about anything before or after your surgery, or if you have any further questions or would like more information, please do not hesitate to ask your nurse who will be more than happy to help.