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Prostate Seed Implants
Radioactive Seed Implants for Prostate Cancer 

Answers to questions for you and your family.
Today, there are several methods of treatment available for prostate cancer. The Radioactive Seed Implant is an option that can be offered to many men with early stage prostate cancer.

The Prostate Gland
The prostate gland is located at the base of the penis just below the bladder and in front of the rectum. It produces the fluid that transports semen during ejaculation. The size and shape of the prostate gland varies considerably between men, but it is usually about the size of a walnut in normal men.

Prostate Cancer
Prostate cancer, like other cancers, is a disease of the body’s cells. All cells reproduce themselves by dividing. Normal growth and repair of tissue takes place in an orderly manner with only enough new cells produced to replace those which die or are lost. Cancer occurs when cells grow and divide abnormally, invading and destroying nearby tissues and organs or spreading to other parts of the body.

Cancer may occur in any part of the prostate gland, but it is most commonly found in the outer portions.  The risk of prostate cancer increases as men get older, although the etiologies leading to prostate cancer is not clearly covered.


Treating Cancer with Implants
In order to destroy the cancer, your physician can place (or implant) radioactive "seeds" into your prostate gland. These radioactive seeds (either Iodine 125 or Palladium 103) emit low energy X-rays which travel just far enough to destroy the surrounding cancer in the prostate but do not affect the rest of the body.

Iodine 125 (also called I125) and Palladium 103 (also called Pd103) give up about 90 percent of their radioactivity within a short time, six months and two months, respectively. By one year, the radioactivity from either of these two sources has decayed so much that it can be considered gone. The radioactive seeds are about the size of a grain of rice. Typically, your physician places about 80 to 100 seeds into the prostate gland, depending on its size.

Even though the cancer may only be visible in a portion of the prostate gland, there may be tiny amounts of cancer throughout the gland. For this reason, the entire gland is treated.
                                   

Planning for the Implant
Before the implant procedure, your radiation oncologist will make a map of the prostate gland from a prostate ultrasound scan called a volume study.

A radiation physicist and the radiation oncologist, aided by sophisticated computers, use the volume study to determine both the numbers of seeds needed to treat the cancer and pinpoint exactly where the seeds should be placed.  Similarly, since each individual patients anatomy is different, you will need to undergo a CT Scan of the pelvis (also called a pubic arch study).  This scan will help your physician assess whether the prostate cancer has gone outside of the prostate gland.  Similarly, it will allow your physician to assess your bony anatomy and the potential for interference from your pubic bond in the pelvis, (hence the name "pubic arch study.")


How is the implant done?
The implant procedure does not require a surgical incision. Instead, thin needles are passed into the prostate gland through the skin between the scrotum and the rectum. As the needles penetrate through the prostate, they are seen on the screen of the ultrasound machine and can be accurately guided to their final position. While the needles are being inserted, an ultrasound probe will be in the rectum. The number of needles and seeds required varies from patient to patient depending on the size of the prostate gland. After each needle is in the correct position in the prostate, the needle is slowly withdrawn while individual seeds are injected into the prostate gland. Both the ultrasound probe and the needles are removed when the procedure is completed.


What will the procedure be like?
The radioactive seed implant procedure lasts about two to three hours. It is done in the operating room. Usually, general anesthesia is used so you will not be awake during the procedure. However, if necessary, the procedure can also be done under regional anesthesia.  You may also receive medication through an intravenous (I.V.) line, which will make you drowsy.

During the procedure a foley catheter will be placed temporarily in the bladder to drain urine.  Once the procedure is complete, you will be taken to the recovery room for about two hours, or until you are awake from the anesthesia.  While in the recovery room, the foley catheter will be removed and an ice bag may be placed between your legs to help reduce swelling of the implant area. When you are awake from the anesthesia and you have been able to urinate on your own, you will be discharged home.  In some circumstances, the catheter may need to be placed back into the bladder for 24 hours.

There is surprisingly little discomfort after the implant, although some mild soreness is expected between the legs for one to two days. If you do feel discomfort, pain medication is available.  You can not drive the night of the procedure and will therefore need a ride to return home.

What preparation is required before the procedure?
Before the implant, you will be given specific instructions to prepare for the procedure.

If you use aspirin or other anticoagulants for any reason, you must stop taking it altogether at least one to two weeks prior to the implant to prevent excessive bleeding. If you have any questions about the medications you are taking, you should discuss this further with your physician.

Approximately one week before the implant, you will get routine preoperative tests including blood work and possibly a chest X-ray or electrocardiogram (EKG).  Your doctor will determine which tests are necessary. The test results are used to inform the anesthesiologist of your ability to tolerate anesthesia.

Your doctor will provide instructions regarding some diet changes and use of enemas. The enemas help move fecal material out of the lower bowel and rectum so that during the procedure the ultrasound pictures of the prostate will be clear. Beginning at midnight on the night before the implant, you should not eat or drink anything until after the procedure. You will be asked to arrive at University Medical Center two hours prior to surgery.

What happens afterward?
Once you have regained full feeling in your legs, you may get up and walk. Initially, you should do this with some assistance. After you have recovered from anesthesia you may go home. You may feel a little weak. We recommend that you do not drive for at least 12 hours after the implant. You may resume eating and have visitors.

You may notice some blood in your urine; this is normal and will slowly decrease and disappear in approximately two to three days. If after, 24 hours, significant bleeding still persists, you have difficulty initiating urination or if you begin to pass blood clots, you should contact your physician immediately.

You should avoid heavy lifting or strenuous physical activity for the first two days once you are home. After that, you may return to your normal activity level.

Radiation Safety
Many of our patients are concerned about the potential dangers of radiation exposure to their family and friends from an implant. Both Iodine 125 and Palladium 103 emit very low energy radiation, which does not travel far. In fact, the vast majority of the radiation is stopped inside the prostate itself.  For patients who are sexually active, condoms should be used for the first two months after an implant, because a seed may come out during ejaculation.  However, very small amounts of radiation can reach other people from either a seed passed in the urine or by a tiny amount of radiation that escapes from the prostate and travels through the air. The amount that escapes is so small that it is not considered a risk for most people, and there are no restrictions on a patient’s travel or physical contact with other adults once they have been released to return home. However, small children and pregnant women may be more sensitive to the effects of radiation. For this reason, we recommend some additional precautions for these people when around the patient for the first two months following an Iodine 125 implant and for one month following a Palladium 103 implant.

If a child or pregnant woman is in the same room as the patient for more than five to 10 minutes, they should stay six feet or more away; at this distance the amount of radiation from the patient is negligible. Since the radiation is coming from the prostate, children should not sit on the patient’ lap during this initial one to two month period.

Although it is rare, an occasional seed may be lost during urination. If a seed is passed in this way, it almost always occurs within the first week following the implant procedure. Since each individual seed contains very little radiation, if a seed is passed it should be disposed of by thoroughly flushing down the toilet. If it is necessary to pick up the seed, this should be down with tweezers and placed in the toilet. Do not handle the seed with your hands.

On very rare occasions, a seed may be passed from the prostate more than one week after the implant. If you notice a seed, it should be disposed of in the same manner described above.

Although these precautions may seem elaborate, the amount of radiation exposure to the patient and those around him are really quite minimal and does not represent any significant risk. They are only meant to ensure that no one receives any unnecessary radiation exposure. Objects that a patient touches or items that are used do not become radioactive. Bodily wastes (urine and stool) are not radioactive unless there is a seed in them.

Are there any side effects from the procedure?
After the implant you may experience some slight bleeding, burning beneath the scrotum, or blood in the urine. The needles used to place the seeds cause these side effects. Usually, 20-25 needles are used. The seeds themselves and the catheter and other instruments used during the procedure also can contribute to these side effects. If you experience severe pain or severe bleeding you should call your physician.

A catheter is placed into the bladder during surgery and is removed several hours later. In some instances it is left in place overnight. It is normal to have some blood in the urine which drains from the catheter. This bleeding may continue for several days so do not be alarmed. If it becomes severe or associated with large blood clots, call your physician. Drinking plenty of water helps prevent blood clots and flushes the bladder.

After the catheter is removed, it is normal to experience some burning with urination. If you cannot pass your urine within six hours after removal of the catheter you will need to contact your physician or go to the emergency room for care. This is particularly true if you are feeling fullness and discomfort in the bladder area.

Side effects after the implant are generally due to radiation from the seeds in the prostate. It is very common to experience frequent urination, burning with urination, a sense of urgency or a decrease in the force of the urinary stream. These symptoms will gradually decrease as the seeds lose their strength, but may be present to some degree for six to 12 months after the implant. Drinking plenty of fluids and avoiding beverages containing caffeine may help relieve these symptoms. If they are bothersome, medication can be prescribed.

As with all medical procedures, there is a small chance that there will be long term, or even permanent side effects. Your physician will discuss these risks with you.

SUGGESTED FURTHER READING
"What You Need To Know About Prostate Cancer," National Cancer Institute, National Institutes of Health, NIH Publications No. 88-1576.

"Radiation Therapy and You," National Cancer Institute, National Institutes of Health, NIH Publication No. 94-2227.

"Taking Time: Support for People With Cancer and the People Who Care About Them," National Cancer Institute, National Institutes of Health, NIH Publication No. 92-2059.

The above pamphlets may be obtained from the Department of Radiation Oncology at 520-694-7236 or from the NCI Cancer Information Service at 1-800-4-CANCER.

If you would like to learn more about this procedure or would like to speak to a physician directly, please call the Radiation Oncology clinic at 520-694-7236.