Radioactive Seed Implants for Prostate Cancer information for patients and their families

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1 UROLOGICAL CANCER Radioactive Seed Implants for Prostate Cancer information for patients and their families The Alvin J. Siteman Cancer Center 660 South Euclid Avenue, Box 8100 St. Louis, MO Phone: Toll Free: Fax: The prostate brachytherapy program was developed with financial assistance from the Barnes-Jewish Hospital Auxiliary Parkview Chapter.

2 What is Brachytherapy? This booklet provides information on radioactive seed implants, an option that can be offered to many men with early stage prostate cancer. It describes the nature of the procedure, how to prepare for it and other information to help in understanding the treatment process. The booklet supplements a general guide on treatments for prostate cancer available from the Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine.

3 What is seed implantation? In this procedure, many tiny radioactive seeds are placed inside the prostate gland. The gland is located at the base of the penis, below the bladder and in front of the rectum. Radiation oncologists and urologists implant the seeds throughout the prostate gland. Depending on the gland s size, approximately 50 to 125 seeds containing either radioactive Iodine-125 or Palladium-103 are implanted. The seeds continuously give off radiation into the cancer of the prostate for up to one year. Relative size of the seed implants in comparison to the size of a dime. (Not actual size.) Why choose seed implantation? Seed implantation, also called brachytherapy, is one of three common treatment options for early stage prostate cancer. A man may choose the implants because they require a shorter treatment time than does treatment with an external radioactive source. With external beam radiation, it may take seven to eight weeks of daily treatments to complete therapy. By comparison, seed implantation generally requires three visits. The first is a half-hour visit to have non-invasive images taken before the seeds are implanted. The images are to measure the size and position of the prostate gland. Seed implantation requires a separate visit of about one to two hours in the hospital. You may go home the same day. About three weeks later, additional non-invasive imaging is done to verify the seeds positions in the prostate.

4 The seeds location within the prostate gland allows them to kill cancer cells while exposing less healthy tissue to radiation. The seeds give off two to three times more concentrated radiation than the radiation used for external beam treatment. The method appears to work as well at treating prostate cancer as external beam radiation and surgical removal of the prostate gland (prostatectomy). Seed implantation produces slightly less impotence and incontinence than the other two methods. However, the concentrated radiation of the seeds produces more damage to healthy tissue near the prostate during the first year of care. In particular, damage often occurs to the bladder and rectum (the final third of the large intestine). Side effects of seed implantation The prostate swells after seed implantation. The swelling frequently makes men feel the need to urinate frequently. A burning sensation in the bladder and urge to empty the bladder also may occur. Some men will experience more frequent urination at bedtime. In addition you may notice irritation of the rectum or bleeding from the anus. Although these symptoms tend not to be severe, ask your doctor for medication if needed. Rectal difficulties and bladder difficulties will lessen gradually as the seeds slowly lose their radioactivity, usually within three months to one year. About 25 percent to 35 percent of men who receive seed implants experience some level of impotence (inability to have an erection). This is about 10 percent less impotence than occurs with external beam radiation treatment or a nervesparing, radical prostatectomy. The impotence may respond to medication. Very few men experience incontinence (loss of bladder control) after seed implantation. Bladder Tumor in Prostate Gland PREPARING FOR THE PROCEDURE The first imaging study Several weeks before implantation, a volume study is done to measure the exact size and position of your prostate gland. The half-hour imaging session involves the use of harmless sound waves to create images. An ultrasound probe is placed inside your rectum, where it is close enough to the prostate gland to create good images. Several transrectal ultrasound images are taken to produce a 3-D picture. Your doctor and a physicist use the picture to determine the best number and placement of seeds for implantation. How should I prepare for the imaging study? You must undergo special steps to cleanse your bowels before the study. You will eat a special diet for four days, followed by a full-liquid diet the day before the study. In addition, you will take a laxative, Citrate of Magnesia, the night before. You will then receive a Fleet enema the morning of the study. How should I prepare for the implant procedure? After the volume study, the implant procedure is scheduled. Let your doctor know at this time if any of the following apply to you: Any allergies and what type of allergic reactions you have had Any previous surgery of the prostate, bladder, rectum or colon Any history/warning signs or past episodes of heart disease Any other medical conditions, including diabetes, kidney or bladder problems Current use of a blood-thinning therapy, such as taking Coumadin, Heparin, Aspirin, Ticlid or Ibuprofen. The doctor will explain the seed implant procedure to you in detail. You will be asked to agree to undergo the procedure by signing a form. It is important that you understand the procedure, including its benefits and risks, before signing the consent form. So please ask any questions or voice any concerns before signing.

5 Several days before the procedure, you will have routine blood tests, a urine culture, an electrocardiogram (EKG) and possibly a chest x-ray done. The doctor will let you know of any other tests needed. Transrectal ultrasound will be used to guide the seed implantation procedure. So you will need to cleanse your bowels again. You will eat a special diet and use enemas. Follow specific instructions on the type of enema to use and the times to use them. The night before the procedure, do not eat or drink anything after midnight. The day of surgery, do not eat breakfast or lunch. Take your usual medications, but using only a few sips of water. Do not take any sedatives or tranquilizers on this day because you will receive anesthesia. You will be admitted to the hospital as an outpatient. What should I bring and what should I leave at home? If family members accompany you, they are welcome to wait in the outpatient surgery waiting area until you return from the procedure. It will last about one to two hours. Do not bring large amounts of cash, credit cards or valuables with you. What happens the day of the implant procedure? You will have to come to the admitting/same day surgery department the morning of the scheduled procedure. From there, you will be taken to the pre-procedure area where you will change into a hospital gown. You should use the restroom to empty your bladder. An anesthesiologist will interview and examine you. Please provide all the information requested. A doctor or nurse will start an intravenous line (IV) in your forearm and prepare you for the procedure. You will receive extra blankets for warmth and comfort. What happens during the implant procedure? Seed implantation is done under general anesthesia or spinal anesthesia. This means you will either be asleep or you will feel nothing from your hips on down during the procedure. With spinal anesthesia, you also will receive medication so you feel relaxed and slightly drowsy.

6 You will lay on your back on a surgical table with your feet up in metal stirrups. The seeds will be injected into the prostate gland from the skin located between your scrotum and anus (the perineum). To access the area, your penis and scrotum will be wrapped and positioned out of the way. The doctor will place the seeds into the prostate with the help of live ultrasound pictures. An ultrasound probe will be inserted into your rectum for the imaging. A thin needle containing radioactive seeds will be inserted into your prostate and withdrawn, leaving the seeds behind. This implantation process will be repeated until the entire gland contains seeds. Blood loss during the procedure is minor, so that a transfusion won t be needed. You also will not have open incisions or stitches. The urologist will perform a cystoscopy to check that no seeds accidentally have entered your bladder or urethra. A telescope-like instrument will be inserted into your bladder to check this. What happens after the implant procedure? Depending on the type of anesthesia, you will wake up in the recovery room, where nurses will check your blood pressure and pulse frequently. An ice bag will be positioned at the procedure site. You also will be monitored for bleeding and will have the color of your urine checked. When little blood remains in your urine, the catheter placed inside your bladder will be removed. You may be discharged once you can urinate on your own. What if I am discharged the same day? To be discharged, someone must accompany you. That person should drive you home or assist in getting you to the nearby Hope Lodge Center. The Center provides free lodging for outpatient cancer care with a referral. Reservations at the Hope Lodge may be made by calling Someone also should stay with you overnight after the procedure. Wait until the next day to drive or make any legal decisions. For the next two to three days, you will tire easily. Avoid walking many stairs, heavy lifting and other strenuous activities. What should I do during the recovery period? Drink lots of fluid to help flush the bladder and prevent blood clots. But avoid carbonated, caffeinated, or alcoholic drinks. Take prescribed medications exactly as directed. For example, your doctor will give you a three-week supply of Ibuprofen. Even if you feel no pain, take all the pills to help reduce swelling of your prostate gland. A swollen prostate can cut off the flow of urine, requiring a catheter to be re-inserted into your bladder. To reduce swelling, you can place an ice pack on the procedure area when you are resting. Keep the area behind your scrotum clean and dry. That includes patting this area dry after showers. If you have a catheter left in, keep the collection bag below the level of your penis at all times. This prevents urine from flowing back into your bladder. After the catheter is removed, you might feel a slight burning sensation. It will gradually disappear. No major discomfort is expected, but your doctor will prescribe pain medication to help with swelling. Do not attempt to stand or walk without a nurse s help because your body might not have fully recovered from the anesthesia.

7 When should I call the doctor during recovery? Call the urologist or radiation oncologist if you experience: An increase in pain, drainage or swelling Pain or burning during urination that does not gradually get better Large blood clots coming out of the catheter A sense of fullness in your bladder, but no urine is coming out of the catheter A fever, even though you don t have a cold or flu A sense of fullness in your bladder, but you cannot urinate after several tries How will I know the seed implantation was successful? You will have a post-procedure checkup in one to two weeks. After two to four weeks, you will undergo computed tomography (CAT) imaging to verify the seeds locations in your prostate. You will be asked to urinate just before your scan so the doctor will know if you can empty your bladder. A physical examination of the gland and other tests also will be done during this and additional visits. For example, you will have blood drawn to check for a protein called PSA. The level of this protein helps indicate your cancer status. What do I need to know about the implant material? The seeds are covered by a titanium shell. Your body is unlikely to react to this metal. It also does not have magnetic properties. So the seeds will not activate airport X-ray scanners, and you can receive tests such as magnetic resonance imaging (MRI). Because the seed material is harmless, they are left in the prostate after treatment ends.

8 Will the radiation harm others? The radioactivity of the implanted seeds will not travel far beyond your prostate. So your clothes, urine and feces will not be radioactive. And you can go about most regular activities without harming others. However, on rare occasions, a seed may enter your urine or ejaculate. To be cautious, wear a condom during sexual activity for the first month. Any seed in your urine should be flushed down the toilet. Or, if you find a seed in bed, use forceps to handle it and flush it down the toilet. Then inform your doctor about the ejected seed during your next scheduled visit. Losing a single seed will not make your treatment less effective. Appointments Date Time Most of the seeds radioactivity will be spent in the first three to six months. Early on, use distance to protect partners and those who are most sensitive to radiation: children and pregnant women. For example, a child should not sit next to you, or on your lap, for very long. Other questions you may have: Use this space to write questions or to take notes about the seed implantation process:

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