Placement of the seeds is performed under ultrasound guidance, and under local or general anesthesia. Up to 80 short-wave radioactive sources, so-called seeds, containing the isotopes, are inserted directly into the prostate. Needles preloaded with radioactive seeds, are inserted directly into the tumor, precisely at previously calculated areas. The needle devise is then removed, and the seeds remain permanently in order to develop their radiation effect to the prostate cancer. With the seeds in place, the tumor tissue is destroyed from the inside by highly dosed, targeted radiation.
- procedure is performed during a short-term hospital stay
- patient can leave the clinic no later than one day after the therapy
- procedure will last between 60 and 90 minutes
- correct positions of the seeds are checked four weeks after implantation
- PSA level will be determined quarterly.
For early stages of prostate cancer, the seed implantation is in its results equally successful to radical surgery, whereby it is minimally invasive. Within three years of the treatment, incontinence is almost never noted; erectile dysfunction generally affects between 10 and 30 percent of brachytherapy patients. This is significantly less than after a surgery. Erectile dysfunction is noted to not occur directly after treatment as is the case with surgical removal of the prostate, but rather develops gradually.
According to recent data from the Seattle Prostate Institute, the 10-year survival rate after seed implantation in patients with low risk is at 94 to 98 percent, in patients with moderate risk it is 89 to 97 percent. As the results of a long-term study of the West German Prostate Center* demonstrate, the biochemical recurrence-free rate after a follow-up of 71 months for patients with a low and medium risk profile is 97 and 94 percent. The results confirm long-term studies of major European and U.S. institutions. A similar result was obtained by Potters and his colleagues (Potters et al 2004.): Of 733 patients 84 percent showed after seven-year treatment a PSA of
*Neubauer S, Derakhshani P., Weise C., Spira G.: Interstitial low-dose-rate mono-brachytherapy with I125-relapse-free survival and dosimetric outcome for localised prostate cancer in a single European institution
Under the current guidelines of professional societies for urology and radiation therapy the seed implantation is suitable especially for low-risk patients with a PSA According to the current guidelines of the Urology and Radiation Therapy specialists, the seed implantation is recommended for low-risk patients with a PSA <10, a Gleason score <7b and a tumor stage of T1c or T2a as well as a prostate volume of <50ml. Patients who have had transurethral resection of the prostate during the last six months are not suitable.
After the urologist and radiotherapist, have obtained an indication for a seed implantation, the "pre-planning" is performed six to eight days prior to the procedure via a transrectal ultrasound. The resulting images are transmitted to a planning computer. Based on the size, shape and location of the prostate, the radiation therapist determines the number and position of the seeds. Blood-thinning medications such as aspirin, aspirin or Plavix® should be discontinued one week before the surgery. On the second day before the procedure the patient is administered antibiotics and an alpha-blocker following the prescription of the treating physician. The day prior to the procedure difficult to digest foods should be avoided. Six hours before the procedure the patient may neither eat nor drink anything. On the evening before the procedure an appropriate laxative is given to empty the rectum.
In a "seed implantation" procedure, under full or partial anesthesia and continuous ultrasound guidance, Up to 80 short-wave radioactive sources, so-called seeds of iodine are inserted directly into the prostate. Very thin sharp hollow needles are placed on a coordinate system to accurately target pre-calculated positions in the prostate. The seeds are stored at the desired position in the prostate, where they remain in order to develop their radiation effect on prostate carcinoma. Thus, the tumor tissue is destroyed by high doses of targeted radiation from inside. Until a few years ago, pre-planning for a seed implantation was performed leading to a radiation plan calculated a few days or even weeks before the actual planting of the seeds. This method was replaced by the much more accurate on-line planning. The planning is now only necessary to order the number and activity of the seeds for the actual day of the procedure. The actual planning is done "online", i.e. that only during the anesthesia of the patient; the ultrasound images are created providing the basis for the inpidualized treatment plan of each patient. The desired positions of the seeds are constantly compared with the actual location in the ultrasound image. Shifts of the radiation plan can therefore be corrected more accurately. The precision in brachytherapy increases leading to an optimization of the treatment.
The procedures lasts about 60 to 90 minutes. Since this is a minimal invasive procedure, the method is not strenuous on the organism of the patient.
About four weeks after the procedure, a so-called post-operative procedure using computer tomography takes place to verify that the seeds are still in their originally scheduled locations. At this time, a correction is still possible without any problems, if necessary.
All other urological follow-up tests, such as the evaluation of the PSA, an ultrasound examination and the evaluation of erectile function and urination takes place after the first quarter using standardized questionnaires. Please be advised that an inflammatory reaction of the prostate, a temporary increase in PSA can occur. The so-called PSA bounce is not necessarily a progression of the cancer, but can be triggered by the radiation to the prostate tissue. The increase in PSA occurs in about 44 percent of men (Critz et al, 2003).
Usually, patients can resume their professional activities within a few days after the surgery. During the first period, the patients should take care of themselves physically and be aware that bathing, swimming saunas, sexual activity, and heavy lifting are prohibited during the first two weeks after the procedure. Compressive loading of the prostate and perineum, e.g., cycling, horse riding or sitting on hard surfaces should be avoided for about eight to twelve weeks.
The side effects of seed implantation are very low. Acute side effects mostly occur as late as 2 to 4 weeks after the procedure. They are characterized by transient irritation of the bladder and bowel. There may be an increased stool frequency and discomfort during urination. Some patients also report blood, in the urine, or when ejaculating. However, significant bleeding is only very rarely observed. Long-term, 20 to 30% of the patients experience erectile dysfunction, which in most cases necessitates a drug therapy.
In the US, the seed implantation has been practiced for more than 20 years. With about 80,000 patients per year, it is used more frequently than the surgical removal of the prostate. Due to the good cure rates at minor side effects, the method has become well established in Germany and is a widely recognized method of treating prostate cancer. For the early stages of prostate cancer, the seed implantation is considered an equivalent effective method to radical surgery; it is however less invasive and less straining on the patient. According to current guidelines (2009) of the German Society of Urology (DGU), patients suffer significantly less from erectile dysfunction after seed implantation*. The urinary incontinence, which by the radical removal of the prostate gland occurs in up to 50 percent* of the patients, is negligible with 0.3 to 3 percent after seed implantation and actually occurs only after previously performed transurethral prostate removal (TURP). In the choice of therapy in addition to the healing rate, increasingly more experts are calling to more strongly consider the side effects of a treatment as the most important criterion.
Consultation version of the S3 guideline for prostate cancer in 2009, German Society of Urology (DGU).
Thompson I, Thrasher JB, Aus G, Burnett AL, Canby-Hagino ED, Cookson MS, D'Amico AV, Dmochowski RR, Eton DT, Forman JD, Goldenberg SL, Hernandez J, Higano CS, Kraus SR, Moul JW, Tangen CM, AUA Prostate Cancer Clinical Guideline update panel. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol 2007; 177 (6): 2106-31.
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