Brachytherapy Procedure & Information

Visitor No: ©Mr B Potluri

Following prostate biopsy, CT scan and Bone scan we have found that you have a prostate cancer, which is confined to the prostate. Currently the three main treatments for this cancer are: 1.Radical Prostatectomy, is a common treatment for early stage of prostate cancer, involving major surgery to remove the prostate gland. 2.External beam radiotherapy: Where Radiation to stop the growth of cancer cells is concentrated on the prostate using a linear accelerator that emits a beam of radiation from outside the body tissue. This is given in small doses over a long period to minimise damage to normal tissue. 3.Brachytherapy or Prostate Radiation Seed Implant, tiny seeds of radioactive medication, such as Oncoseed (Iodine 125) are permanently implanted directly into the cancer where they give off cancer killing radiation continuously for six weeks. In fast growing cancer this is supplemented by small dose of external beam radiotherapy. You have chosen to undergo Brachytherapy as a monotherapy (seed implantation alone) Potential Risks and Inconvenience of Brachytherapy Immediately after the operation you may notice following, which usually settles in day or two: Slight bleeding beneath the scrotum Bruising and tenderness between legs Blood in the urine Later side effects, which usually start two weeks and may last upto eight weeks, this is due to swelling of the prostate caused by radiation from seeds 1.Frequency of urination 2.Burning with urination 3.Urgency and weaker urinary stream 4.Catheter dependency 5.Loss of sexual potency 6.Very small possibility of seed could leave your prostate and lodge in other site usually the lungs. It is unlikely that this will cause you any harm. The intensity of these symptoms varies from patient to patient and cannot be predicted in advance.  What is Brachytherapy and how does it work? Prostate radiation seed implant (brachytherapy) is one curative form of treatment for early stage prostate cancer (i.e. confined to the prostate as far as we can tell).  In this procedure, high dose radioactive seeds are permanently implanted into the prostate and the inverse square law (the law that states that when a ship at sea doubles its distance from a lighthouse the intensity of the beam quarters) protects the other pelvic organs.  Not all patients are suited to this procedure and the appropriateness for any individual may only be confirmed after a 'volume study' or some initial anti-hormone therapy-particularly for patients with larger glands at the outset. What does a volume study involve? This is a transrectal ultrasound assessment to determine the size and shape of your prostate such that we may calculate the dose and distribution of the seeds to be implanted. This is performed in a similar method to the transrectal biopsy. You will be asked to attend Rivers Hospital. The procedure duration is half an hour. You will be placed on an operating table and your legs will be supported on stirrups. An ultrasound probe will be inserted in the back passage (rectum). Serial ultrasound scan pictures will be taken to assess shape and size of the prostate. You will also be required to have a bowel preparation prior to the study. How is the implant done? You will be admitted to hospital on the morning of the operation. You would have had your bowel preparation the day before and you may need low rectal enema prior to the procedure if necessary. You are requested to fast for six hours (midnight before the morning of the procedure). You should be off anticoagulant (blood thinning) medications and off aspirin for four days before the procedure. If you are diabetic you should let this fact be known early in the consultation process, and other medical conditions that might influence the safety of a small operative procedure under general anaesthesia should also be declared.  This leaflet gives you some general information about the side effects that you might experience following the seed implant into your prostate gland.   It also gives information on diet and exercise and suggests precautions that are advisable because of the radioactive nature of the seeds. When you return from the operation, a urinary catheter will be in place and your perineum may be sore. Are there any side effects? Immediately after the operation, you might notice slight bleeding beneath the scrotum, blood in the urine and bruising and tenderness between the legs.  The operation and the seeds mainly cause these side effects.  If you have marked discomfort, please let the nursing staff know. During the operation, a catheter will be placed in your bladder to drain any urine away.  It is usually removed a few hours later, but sometimes it is left in overnight.   It is normal to see some blood in the urine draining from the catheter.  After the catheter is removed you will probably experience some burning when passing urine.   If you become unable to pass urine, and your bladder feels full or uncomfortable, please let the nursing staff know if you are still in hospital or telephone us if you are at home. Later on, you may experience frequent urination, burning with urination, sense of urgency and a weaker urinary stream.  Most of these side effects are due to the radiation from the seeds, which cause swelling and irritation of the prostate, and produces these symptoms.   Drinking plenty of fluids and avoiding caffeine-containing beverages may help to relieve these symptoms.  If they cause distress, medication may be helpful.  Please contact your GP for advice. How long will I have to stay in hospital? You will normally be allowed home on the day after the operation.  You might notice a trace of blood in your urine for several days after the operation.  This is quite normal so do not be alarmed.  However, if the bleeding becomes severe or there are blood clots please telephone us immediately or contact your G.P.  Drinking plenty of water helps prevent blood clots and flushes the bladder. Antibiotics are given after the implant to prevent infection.  You should take them as prescribed until you have used them all.   If you develop an allergic reaction, such as a skin rash, you should contact the Rivers Hospital.   You will also be prescribed a drug called Flomax MR, which will improve urination and flow of urine. Will I have to change my diet? You should take a normal diet, unless you are on a special diet for other reasons.  Drink plenty of fluids for a few days after the operation. What about resuming physical activities? Avoid heavy lifting or strenuous activity for the first two days after leaving hospital.  After that, you may return to your normal activity level.  Sexual intercourse may be resumed after two weeks, but please refer to the following section. How safe is the radiation treatment? Radiation safety is a concern of many patients.   However, Iodine 125 seeds are low energy radioactive materials and most of the radiation that they emit is absorbed by the body tissues.   Also, the strength of the seeds reduces with time.   The radiation level outside your body, arising from the seeds, is not much greater than the normal background level that exists in the natural environment.  The risk to other people around you is therefore very low and very far below the legal level at which you would need to be in a designated hospital radioisotope room (but see 'Sensible precautions' regarding proximity to pregnant women and children - below).   Are there any extra precautions I should take? There is a small risk that you will pass a seed in your urine for one or two days immediately following their implantation.   Because of this there are some precautions that will be taken whilst you are in hospital, and we ask for your co-operation with these minor restrictions.   These are: - 1. Your room's toilet and shower facilities will be isolated once you have had your implant. They may, of course, be used up to the time of your implant. 2.  You will be provided with a urinal bottle - such that any loose seed is collected. 3.  Please do not use any other toilet or shower in the hospital. 4.  Please stay in your room until you have changed into your own clothes.   Once you have changed into your own clothes, you may circulate around the hospital as you wish (as long as you do not use any of the toilets or showers). 5.  Visiting is unrestricted whilst you are in hospital, but please observe the guidelines in the paragraphs that follow. Sensible precautions! Whilst there are no formal restrictions on your activities when you return home, we suggest that you comply with the following guidelines for a period of two months after your operation, for you and your family's peace of mind. A.  Women who are (or may be) pregnant should not sit very close to you, on the same settee for example.  Apart from this there is no need for you to treat them any differently as to how you would have done before having the implant.   You may greet them as you normally would and they may stay in the same room as you for as long as you wish. B.  Do not nurse children on your lap or sit very close to them for long periods of time (as above).   You may cuddle or hold them for a few minutes each day and they may stay in the same room as you for as long as you wish. There is no need to place any restriction on the time you spend, or activities you undertake with other family members, friends or colleagues. What if I do release a seed? Iodine 125 seeds are sealed sources, and the radioactive material does not escape from them.  Objects that you touch or use do not become radioactive and your normal body wastes are not radioactive. If you pass a seed in your urine or find one in your clothing it should be sealed in a container which is provided and returned to Meadow Ward, Rivers Hospital. Sexual intercourse may be resumed two weeks after the implant, but condoms must be used for the first two months after the operation.  This is because there is a small risk that a seed might be contained in the ejaculate.   Your semen may be discoloured brown or black.   This is normal in this procedure and is a result of bleeding that may have occurred during the operation and is now being released into the ejaculate.  Condoms should be disposed of by double wrapping them and placing in the dustbin. PROSTATE SEED IMPLANT - THE PROCEDURE DAY OF SURGERY 1.You will usually arrive on the morning of your scheduled surgery.  The nurse will prepare you for the procedure and take you to the surgery holding area. 2.Once you are in the operating theatre, you will receive regional (spinal or epidural) or general anesthesia.  The Consultant Anesthetist in charge will discuss this. 3.In the operating theatre, your legs will be positioned in the same position as they were in the prostate ultrasound study, which you had performed previously. 4.There will be a prostate ultrasound probe placed in your rectum during the procedure.  To assist in placement of radioactive seeds into your prostate an x-ray machine (fluoroscopy) may also be utilised to visualise the prostate better. 5.The procedure itself takes approximately 60 minutes to perform.  This also includes examination of the bladder by a telescope called cystoscopy.  Implant procedure is performed without the need of an incision.  A template is placed on the perineal space between scrotum and rectum and attached to the ultrasound machine.  The needles are placed through the template into the prostate to facilitate in implanting radioactive seeds.  There is very little blood loss associated with this procedure.  You may notice some oozing of blood after the procedure along with bruising in that general area.  For the majority of patients, there is minimal to no discomfort after the procedure. 6.Once the procedure(s) are finished you will be taken into the recovery room where you will stay (approximately one hour) until you are ready to be transferred to the ward. 7.The first x-ray will be obtained the following morning before you are discharged home. 8.Once you arrive on the ward, you will usually have to remain on bed rest for a short period of time, if you have had spinal or epidural anesthesia performed.  This is due to the possibility of developing severe headache, which may last for several days, if you get up too soon after the procedure.  Your nurse will tell you how long you need to stay in bed. 9.You may see a yellow sign on the door to your room, and on your urine and drainage bag.  This is a notification sign that signifies you have had radioactive seeds placed in your prostate and that your urine needs to be monitored by the nurse. 10.Once you are able to get out of bed, you may ambulate in your room and in the halls, if desired. 11.You will have no diet restrictions once you arrive to the ward, unless you have had general anesthesia. 12.You will have a Foley catheter in your bladder with an attached drainage bag, which will stay in place until the following morning.  The nurse is required to monitor all drainage in the urine bag for the presence of any seeds.  It is not uncommon for the seed to be passed in the urine and be present in the drainage bag.  If this should occur, the nurse will follow certain procedures to obtain the passed radioactive seed.  At no time should you empty your own urine drainage bag. 13.You are not considered to be radioactive or giving off radiation to any person who may come in your room (either nurses or visitors).  However, if the iodine seed is passed in the urine drainage bag, then only the urine in the bag is considered to be radioactive and is handled appropriately by the nurse. A single seed or two poses little concern.  14.You should continue to take your regular medication (ie: heart medication, diabetic medication etc) and we will also prescribe a five-day course of antibiotics. DAY 2 (DISCHARGE) 1.In the early hours of the morning, the nurse will remove your Foley catheter from your bladder.  The nurse will still need to monitor your urine for the presence of any seeds that you may have passed, so you will be given a urinal to save your urine for the nurse to check prior to discarding.  Do not urinate in the toilet.  Again, your urine is not considered to be radioactive unless there is a seed present. 2.The nurse will give you written discharge instructions.  Usually you will receive antibiotics to prevent potential infection and, possibly a short course of steroidal anti-inflammatories that usually is not started until five days following your implant. 3.Since the number of seeds implanted into the prostate varies from man to man, due to numerous factors, do not be concerned if you do or do not receive some of the above stated prescriptions. 4.In general, expect some urinary changes to occur 7-10 days following your implant.  These are usually mild to moderate and are managed effectively with a variety of medications.  5.You should have a scheduled follow up appointment approximately two weeks following your implant.  At four weeks time, you will have your seed localisation by a short CT scan of the seed implant.  Sometimes we may ask you to come in prior to your scheduled appointment to carry out x-rays for localisation of these seeds. 6.You may be discharged in the early part of the morning, provided that you are urinating adequately. 7.Once home, you may utilise sitting in warm water 2-3 times daily for any persistent oozing of blood or rectal/perineal discomfort or bruising.  These are temporary effects and will disappear within a few days to a couple of weeks. Follow-up Commitments Follow up is extremely important after your treatment.  You will need an examination and a PSA test every 3 months for the first two years after any implant and then every 6 months.  You understand that if you do not come for your follow up appointments that side effects are harder to take care of.  If you do not come back for follow up appointments then if the cancer should come back it will be much harder to treat and could cause severe problems or even death.   GLOSSARY OF TERMS Anaesthesia: The loss of all sensation in a specific area of the body (local) or throughout the entire body (general) Antibiotics: A medication used to prevent or treat infection Biopsy: Removal of small sample of living body tissue for purpose of examination under microscope Bone scan: Study of bones by injection of radioactive material to detect cancer deposits Catheter: A flexible tube inserted through the urethra CT scan: Study of Body structure by a rapid sequences X-ray pictures. Clinical Oncologist: A Doctor, specialist in the treatment of cancer Dysuria: Painful urination Frequency: A need to urinate often. Haematuria: Blood in the urine Hesitancy: Delayed start of urine flow after the need to urinate is felt and the person wishes to urinate. Incontinence: The inability to control the flow of urine from the body, resulting in the involuntary passage of urine. Perineum: The region of body between the anus and the scrotum Radiographer: Person who is skilled in radiography Radiotherapy: Treatment of disease by X-rays and similar forms of radiation. Urethra: The tube that drains urine from the bladder, through the penis, and outside the body Urgency: A strong desire to urinate immediately Voiding: Urination