Longwood Urological Associates

Seed Implantation for the Treatment of Prostate Cancer

Brachytherapy

Frequently Asked Questions

What is seed implantation?

Prostate Brachytherapy involves the placement of radioactive seeds (Iodine-125) directly into the prostate gland for the treatment of prostate cancer. The advantage of brachytherapy is the ability to specifically irradiate an organ that contains tumor while protecting the normal tissue of other organs. The goal of seed implantation is to deliver radiation to the prostate in such a way as to gain control of the cancer while minimizing side effects from treatment. Seed implantation represents a minimally invasive treatment for prostate cancer as it only requires a one day hospital stay and patients can return to their normal level of activity three days after the procedure.

Is seed implantation new?

The concept of insertion of radioactive sources into the prostate for the treatment of prostate cancer has a long history and dates back to the turn of the century. Many patients with prostate cancer were treated by this method in the 1960s and 1970s. At that time the radioactive seeds were placed in the prostate through an open surgical incision in the lower abdomen. Because of the uncertainty of seed placement by this method, this technique was abandoned.

By the late 1980s, technologic and scientific advances in trans-rectal ultrasound imaging had revived interest in seed implantation for the treatment of prostate cancer. The introduction of trans-rectal ultrasound probes made possible real time interactive placement of radioactive seeds into the prostate. In addition, the development of 3-D simulation software ( similar to 3D glasses used for film viewing) allows accurate determination of the dose delivered to the prostate and surrounding structures, bladder, urethra and rectum. These new tools have permitted the refinement of interstitial brachytherapy for prostate cancer and have resulted in a more accurate method of delivering the dose to the prostate gland.

Who is a candidate for seed implantation?

Men with clinically localized prostate cancer (stages A and B) are candidates for seed implantation for treatment of their disease. Because interstitial therapy is localized to the prostate, patients who have disease outside the prostate (stages C and D) should not be treated with an implant alone. Consultation with the physicians at the New England Baptist Hospital will be helpful in determining whether seed implantation is an option for treatment of the patient's prostate cancer.

During this consultation, the doctors will explain all treatment options available for clinically localized prostate cancer. They will present the existing data (including results, complications, risks and benefits) of these treatment options and outline a course of treatment specific to the patient's situation and disease. Significant others will also be given the information with the patient to support and assist with their decision and care at home.

How is seed implantation performed?

You must first undergo a planning trans-rectal ultrasound volume study which will be arranged by your urologist. This test is done a few weeks prior to the actual brachytherapy procedure. The shape of the prostate is measured to determine the number of seeds for treatment to be placed in the prostate and their location.

Approximately two weeks later, the seed implantation is performed. The procedure requires either a general or spinal anesthetic and takes between one and two hours to complete. Needles are placed into the prostate through the perineum (the area between the scrotum and rectum). The number of I-125 seeds implanted will depend on the size and shape of the prostate gland and treatment protocol. The seeds are placed into the prostate through special needles. The needles which hold multiple seeds are placed while visualizing the prostate using the trans-rectal ultrasound. After all the seeds are placed (between 50 to 100+ seeds) the needles are removed. No incision or sutures (stitches) are required. The perineum will have antibiotic cream placed on it where the needles were inserted and a foley catheter (a tube placed through the urethra to drain the bladder of urine) remains in place after the procedure. The foley is removed the morning after the procedure. The urologist will give you medication to help with the ease of bowel movements and any minimal discomfort you may experience after the procedure.

You will remain in the hospital the night of the procedure and be discharged from the hospital the following day. It is required that you have a ride home.

Who performs the seed implantation?

Seed implantation at New England Baptist Hospital is performed as a team approach by both a urologist and radiation oncologist. Both physicians are present throughout the procedure and communicate as an adjunctive team during the surgery.

Are the seeds removed?

The type of seeds (Iodine-125) used at the New England Baptist are permanent implants and are not removed. The half life of the seeds is

approximately 60 days. Therefore, only fifty per cent of the activity will remain two months after the procedure. For practical purposes, all activity has ceased by one year after the procedure.

Do any radiation precautions need to be followed after the procedure?

Radiation safety is a concern of many of our patients. Iodine-125 is a low energy radioactive material and loses its activity very quickly at short distances from the seeds. The low energy of the seeds means that their radiation is contained within the prostate gland, for the most part. Objects that the patient touches or items the patients uses are not radioactive. Bodily wastes (urine and stool) are not radioactive.

The Nuclear Regulatory Commission (NRC) has determined that no radiation precautions need to be taken for patients who undergo prostate seed implantation with I-125 seeds. The NRC states that these patients do not represent any risk to the people around them, including young children and pregnant women. However, we do ask patients to follow a few common sense guidelines. They are:

1. Children should not sit on the patient's lap for the first two months after the procedure
2. Pregnant (or possibly pregnant) women should avoid prolonged close contact with the patient for the first two months after the procedure
3. She can greet the patient briefly and then move to a distance of six feet or more away
4. At a six foot distance, there is no limit to the length of time she can be in the same room with the patient.

How about diet and activity after the procedure?

The patient's usual diet can be resumed the day after the procedure. We ask that the patient avoid heavy lifting or strenuous physical activity for the first two days after the procedure. After that, normal activity (including driving) can be resumed.

How successful is the procedure?

If patients are properly selected for the procedure, approximately 80-85% of patients will have their prostate cancer controlled by seed implantation. Cancer control is defined by a non-rising PSA that is less than 1.0 ng/Ml. These results are obviously very encouraging. However, when evaluating these results we must remember that the technique of ultrasound guided seed implantation has only been practiced for approximately six years. Because prostate cancer is generally a slow growing cancer, at least ten to fifteen years of follow up is necessary to adequately compare the results for seed implantation with the results of other treatment options for clinically localized prostate cancer.

What are the complications?

The rate of urinary incontinence (dribbling, inability to hold urine) after seed implantation is less than 2%. The most common complication after this procedure is irritation to the urethra as a result of the radiation. This can result in frequent urination and burning on urination in some men who undergo seed implantation. A weak urinary stream and difficulty emptying the bladder can occur due to swelling of the prostate. These symptoms are usually most prominent during the first two months after the procedure. If these problems do occur, they can be improved with medication. Please notify your physician if you experience any of these symptoms, so that you can be relieved of them.

Urinary retention (the inability to urinate) occurs in approximately 10% of men who undergo the procedure. This usually resolves by the first six weeks after the procedure. Men who have undergone a procedure known as a TURP (a scraping of the prostate for difficulty urinating) will have a higher risk of urinary complications after seed implantation. For this reason, we counsel patients who have significant urinary symptoms that seed implantation is probably not the best treatment option for their prostate cancer.

With accurate placement of the seeds, injury to the rectum after implantation is rare. Rectal complications occur in less than two per cent of cases. The majority of these complications will be radiation proctitis ( inflammation and irritation of the prostate and bowel tissue), which can be controlled with medication. A fistula (connection) between the rectum and the urethra which may require surgery to repair occurs in well below one per cent of cases.

The risk of impotency (inability to have an erection) appears to be less with seed implantation than with any other treatment for clinically localized prostate cancer. Patients who undergo seed implantation have a 50-90% chance of retaining their potency.

Does private insurance or Medicare cover seed implantation?

Both private insurance and Medicare will pay for this procedure.

Who do I contact for further information?

Patients who would like further information regarding seed implantation should call (617) 754-5800 and asked for a list of the New England Baptist Urologists. Let the receptionist know you are interested in seed implantation.

Brachytherapy

Patient Discharge Instructions

Diet:

Resume your usual diet upon discharge. It may help to drink juices such as, prune, apple and cranberry that are at room temperature to begin with. You may take whatever stool softener you find that will work for you or the urologist may prescribe one for you.

Daily Activities:

v No driving or heavy lifting for the first two days after discharge

v Full activity (including driving) can be resumed on the third day after discharge

v No bike riding, horseback riding or riding lawn mowers for the first month after the procedure

v Any other physical activity should be approved by your doctor before you resume it

Family Relations:

You may resume sexual intercourse two weeks after the procedure. A condom should be used for the first two weeks after sex is resumed. Your semen may be discolored dark brown or black. This is normal and is a result of bleeding that may have occurred during implant.

Postoperative swelling:

Expect swelling of scrotum, as well as bruising of scrotum and perineum. This will resolve spontaneously in one to two weeks.

Postoperative Urination:

Some men may experience burning on urination and/or urinary frequency. If this becomes bothersome, contact your doctor as medicine can be prescribed to relieve these problems.

Special Instructions related to the seeds:

It is possible to lose a Iodine 125 seed in your urine, so you will be asked to strain your urine for two weeks. You will receive a urine strainer at discharge. If a seed is found ( seeds are silver in color and look like a grain of rice) in the strainer pick it up with a spoon and place it in a glass jar. The seed should not be handled with your fingers. The jar should be placed in an inaccessible area of your home until it can be brought with you to the follow-up appointment with your urologist.

Hormonal therapy:

If you have been on hormonal therapy prior to the seed implantation, the injections will be continued for six months after the procedure.

Contact your doctor for:

temperature greater than 101° F

increasing pain

inability to urinate

The first follow-up visit should be scheduled for three weeks after the procedure.

Radiation Precautions After Seed Implantation

Radiation safety is a concern of many of our patients. I-125 is a low energy radioactive material and loses its activity very quickly at short distances from the seeds. The low energy of the seeds means that their radiation is contained within the prostate gland, for the most part. Objects that the patient touches or items the patients use are not radioactive. Bodily wastes (urine and stool) are not radioactive.

The Nuclear Regulatory Commission (NRC) has determined that no radiation precautions need to be taken for patients who undergo prostate seed implantation with 1-125 seeds. The NRC states that these patients do not represent any risk to the people around them, including young children and pregnant women. However, in keeping with general principle that radiation exposure should be kept as low as reasonably possible we suggest of our patients and their families a few common sense guidelines be followed.

They are:

1. Children should not sit on the patient's lap for the first two months after the procedure
2. Pregnant (or possibly pregnant) women should avoid prolonged close contact with the patient for the first two months after the procedure
3. She can greet the patient briefly and then move to a distance of six feet or more away
4. At a six foot distance, there is no limit to the length of time she can be in the same room with the patient