Initial Visit | Volume Study | Seed Implant | Follow Up | Clinical Research | Testimonials

The Implant Procedure

How will I need to prepare for the procedure?
Preparation for the treatment is relatively simple. Prior to the procedure, we will ask for several tests and studies to insure a safe surgical procedure. This will include an EKG and some blood tests. Our nurses will describe these tests to you. In addition, you will have instructions to help clear the bowel of stool which will include dietary restrictions after midnight, a laxative and an enema.

 What happens on the day of the procedure?
You can expect to spend three to four hours at the surgical center from beginning to end. When you first check in, a pre-operative nurse will give you a thorough reassessment including asking about allergies, any current medications and answer any of your questions.

 Will I be anesthetized for the implantation?
After signing an informed consent, you’ll be taken to the operating room for anesthesia. There are two types of anesthesia: spinal or general. Spinal anesthesia involves inserting a needle in the back and injecting an anesthetic into the epidural region of the spinal cord. With this approach, all sensation below the waist is blocked for about 1- 1½ hours. The feeling in the legs recovers typically within 30-45 minutes after the procedure. You have the option to remain fully awake and alert during the implant or receive a mild sedative to sleep through the procedure.

With a general anesthetic a soft tube is placed in the mouth and a mask placed over the face and an anesthetic gas provides the anesthesia. Patients also recover quickly from this type of anesthesia.

 Who is in the operating room, and what are their roles?
In our center, Dr. Grimm  or Dr Hsi along with an experienced urologist perform the implant together. Each physician contributes specific skills to the procedure. Others include the operating room nurses and anesthesiologist.

 How are the seeds implanted?
The setup for performing the implant is identical to the volume study. After the anesthesia is started, you will be carefully positioned on the OR table identical to the volume study. The area beneath the scrotum (perineum) is carefully cleaned with an antimicrobial agent. Shaving is usually not necessary. A catheter is placed into the urethra a short distance and a dye (tiny air bubbles in surgical gel) is injected so that the team can easily identify the urethra during the implant.

The ultrasound probe is supported by a stabilization system attached to the table. The ultrasound is introduced into the rectum and then attached to the stabilization device. A template is attached to the stabilizer which allows the needles to be guided accurately into the prostate.

 Who places the seeds in the needles?
The seeds are loaded into needles at the manufacturer site (or at a company that specifically performs this task) and are then sent to the surgical center several days prior to the procedure. The seeds used for implantation are preloaded into needles before the procedure according to the plan developed by the PCCS planning team. We currently use the latest technology with connected seeds including the ThinStrand, Rapid Strand and Source Link technologies. These connected seed technologies keep the seeds in place, preventing seed migration and allowing seeds to be placed just outside the prostate, thus better treating microscopic extra-prostatic disease.

 What is real time dosimetry?
Dr Hsi performs dosimetry in the operating room. This caalled real tiem or more appropriately  intraoperative dosimetry, mapping or planning. It simply refers to their preference to plan the implant just prior to the procedure in the operating room. It is a reasonable way to plan an implant however it requires more anesthesia time . The quality of the implant is similar to preoperative dosimetry tecniques. “Real time” dosimetry is simply intraoperative planning just prior to and during the procedure.   All “real-time dosimetry” centers still perform post-implant CT dosimetry to really evaluate how well they did. We rare comfortable with both techniques to accurately place the seeds.

 How are the seeds placed into the prostate?
Dr Grimm uses a preloaded needle technique in which needles with seeds inside are inserted through the template, through the skin of the perineum and directly into the prostate gland according to preplanned map. The needle position is verified by both physicians on the ultrasound screen and then double checked by measurement. A stylet in the needle allows the seeds to be gently placed in to the planned position. It usually takes approximately 45 minutes to one hour from anesthesia to completion. Most procedures require 16 to 28 needles and 60 to 130 seeds.

 How is the implant quality assessed during the procedure?
As the seeds are deposited, they can be seen on the ultrasound. See the image below. The team evaluates the seed placement after each needle is placed and again at the completion of the implant using both ultrasound and fluoroscopy simultaneously. If a cold spot is noted, additional seeds are available to fill in this region.

A hot spot is just the opposite. Seeds that are too close together can create a region in which the dose is too high; “a hot spot”. A small hot spot is unlikely to cause any side effects. But, if the hot spot is quite large, it is possible to injure the urethra, the urinary sphincter or the rectum. Fortunately, this is rare with modern planning, connected seeds and techniques when performed by very experienced physicians.

Are the seeds permanent?
The seeds are actually titanium tubes into which is placed the radioactive material. While the radiation eventually dissipates completely, the titanium tube remains in the prostate permanently. Titanium is the same material used for artificial limbs and is not rejected by the body. There is no danger from these inert seeds remaining in the body. Titanium is not magnetic and thus will not prevent you from undergoing an MRI in the future, if needed for any reason. The amount of metal is so small that it is not picked up in airport security screening.

Can I see what’s going on during the procedure? Can I ask questions during the procedure?
If you received spinal or epidural anesthesia and are awake, you’ll be able to hear what’s occurring in the operating room. It’s unlikely, however, that you will actually be able to see the actual implant. We encourage our patients who are awake, to refrain from coughing, laughing or boisterous conversation since these activities can be distracting to the team or create unwanted movement of the prostate.

Are the lymph nodes evaluated/treated during the procedure?
No, the lymph nodes are not evaluated or treated during the implant procedure. If the lymph nodes are to be treated, this is done with external beam radiation. Low risk and most intermediate risk patients have a very low risk of lymph node involvement and therefore do not require that their lymph nodes be treated. If a patient has high risk disease, we often combine a shortened course of external beam radiation therapy (5-6 weeks instead of 8.5 weeks) with a somewhat lower dose implant. In these situations, we frequently treat the lymph nodes with the EBRT portion of the therapy.

 What is a cystoscopy and why is it done after the procedure? Does it have side-effects?
Cystoscopy is the process of looking into the bladder with a fiber optic scope. This is performed after the procedure to insure that no seeds have strayed inside the bladder, there are no large blood clots and to check for bladder tumors. This is an optional step but it does not significantly increase the short term urinary discomfort many patients experience for the first few urinations after the procedure. Most of the burning associated with the first  urinations is related to the catheter.

 What medications are prescribed before the implant?
We typically will have you start with Flomax or similar medication a few days prior to the procedure which will continue after the implant for a number of months. This is designed to improve your urinary flow. Following the procedure, we will also ask you to start Aleve and an antibiotic the day of the procedure. The Aleve is prescribed after the procedure to minimize the swelling and urethral spasm that typically is experienced the first few weeks after implantation. Some patients may take Tylenol extra strength to minimize their discomfort for a few days. Celebrex may also be used if Aleve is not allowed due to other medications or poor tolerance. We routinely prescribe an antibiotic for the first 8 days after the procedure. This is standard for patients undergoing any kind of procedure in any operating room. Your nurse  can describe these medications to you.

Immediately Afterwards

Will I experience pain?
After the anesthesia has worn off you may have some modest pain in the area where the needles were inserted (the perineal area) which is usually a feeling of fullness or achiness. This pain is usually mild to moderate and easily managed by Aleve or Celebrex. Extra Strength Tylenol may be added to these for more relief. The primary pain patients feel is discomfort urinating on the first urinations. This pain, although brief, can be quite intense. It typically diminishes dramatically after the first few urinations. We seldom recommend codeine or stronger medications , as they can have their own side effects.

 Will I need to take medication afterward?
You will receive a few prescriptions, including one for an antibiotic and one for an alpha-blocker. Alpha-blockers, such as Flomax, relax the bladder neck so it’s easier to urinate. Alpha-blockers are prescribed for a few months after implantation for the majority of patients. Some patients, however, require maintenance alpha blocker for periods greater than one year.

You’ll also be asked to take an over-the-counter anti-inflammatory such as Aleve or Motrin for a short time.

 Will long distance travel be a concern after brachytherapy, due to possible prostate swelling and the long hours in the air?
Long distance air travel should not present any additional problems for you. You will be asked to stay in town for at least a day after the procedure. If you are doing well the first 24-48 hours after the implant, it is unlikely you will need a catheter due to urinary retention during the next 72 hours.

If you do travel, however, take the usual precautions against blood clots in the legs by exercising the lower leg muscles and walking about the cabin every few hours. For convenience, it is wise to have an aisle seat, in case you need to get up to urinate, and avoid alcohol and caffeine on the plane flight.

When can I get up and start walking around? I’ve heard it’s within 24 hours. Is this really true?
Yes. You can be up when the anesthesia wears off and are fully awake. You can, in fact, walk out of the hospital or clinic a few hours after the implant. Many patients go out to dinner the night of the implant.

Take it easy for a week or two. That means no vigorous exercise. It is ok to do some walking, light yard work, golfing and tennis, but, again, be advised to take it easy for the first week or two. It’s good to get up and walk around but nothing strenuous for the first couple of weeks.

 When can I resume my regular physical activities—strength training, running, bicycle riding, horseback riding?

You can return to your normal activities almost immediately. But if something hurts, stop doing it.

A word of caution if you engage in activities that require straddling or bouncing—riding bicycles, horses, motorcycles, farm tractors, snowmobiles and the like. The bouncing motion jars and traumatizes the prostate, this can cause some swelling and possibly the need for a catheter. We advise patients to refrain from these activities for at least three to five months and when resuming, to start slowly and use common sense.

 How long does pain with urination occur after brachytherapy?
A substantial burning sensation can occur when you pass urine the first few times. You could also see a small amount of blood or small blood clots. This is normal. After the first 10 days or so, any burning should be minimal and is due to the radiation. If you have this burning sensation, the best thing you can do to minimize it is to drink more water and take your medications. Water dilutes the urine and creates more comfort as it passes through the urethra. Another trick, if you experience burning that lasts more than a couple of days, is to avoid food and drinks that are known to be bladder irritants. A list will be given to you on the day of the procedure .

 Will I feel the effects of radiation on the urethra?
It is likely that you will feel the effects of the radiation for several months. These effects are frequency and urgency. This be most noticeable for the first few months. An occasional patient will have some slight discomfort or burning on urination after the first few days. These effects gradually decrease as the radiation wears off. In the long run, it’s possible, but very unlikely, that you will have chronic discomfort or difficulty urinating. We plan the implants carefully to avoid high doses to the urethra. Do not be surprised if the symptoms wax and wane, particularly during the first year.

 Is there any chance of infection after seed implantation? If so, what can I do about it?
The risk of infection is extremely low. We have not had any in over 10,000 patients. Antibiotics are generally given before and during the implant procedure intravenously and oral antibiotics for a few days afterwards. If an infection develops afterward, additional antibiotics should knock-out the problem.

Is there any immediate follow-up there after the implant?
We typically ask our patients to return 24 hours later for focused CT scan of just the prostate (no contrast is needed). This CT scan will be used to perform dosimetry calculations to insure that the prostate will receive the proper amount of radiation. If there is a significant cold spot, we will contact you about your options, including the possibility of going back for additional seeds (there has only been 1 such patient over the last 15 years).

We will discuss long term follow-up in a later section.

 How can a seed migrate from the prostate to the lung, and is it dangerous?
The seeds we use for every patient are connected together with either absorbable suture or links, which, in our and several other studies, has reduced seed migration beyond the prostate region from 20% with unconnected seeds to almost zero with the Rapid Strand and ThinStrand seeds. In the rare instance that migration did occur in the past, there was no evidence that this affected the patients in any way.

 Am I “radioactive” after the procedure? What precautions, if any, should I take around my wife and other family members?
No, you are not radioactive and the seeds are only temporarily radioactive. The radioactive material is only inside the seeds. Very little radiation reaches the surface of your body. You don’t need to take special precautions with your spouse; sleeping in the same bed is fine.

A study was done by Dr. Michalski at Washington U that showed, on average, a spouse receives only 10-11 mrem’s of radiation exposure during the lifetime of the seeds radioactivity. To put this in perspective, 10-11 mrem’s is what one is typically exposed to during one flight from New York to Tokyo or 3-4 months of living in Denver (due to radiation exposue at higher altitudes). None of the bodily fluids (blood, urine or semen) are radioactive, only the seeds themselves.

 When can I resume sexual activity?
Resuming sexual intercourse is fine as soon as you feel comfortable. We sometimes recommend that you wait 2 weeks to let the seeds better lock in place before the prostate contracts during sexual activity. It is probably a good idea to masturbate first as the semen may have blood in it and the first few ejaculations can be a bit uncomfortable. This is normal and results from bleeding that occurred just after the implant or which may occur during the first few ejaculations. The new ThinStrand might reduce this bleeding some. This is part of one of the research protocols we are currently doing. The likelihood that a seed will come out during intercourse is extremely unlikely. If you wish, you can wear a condom for the first three to five ejaculations because of the small chance of passing a seed.

 Should I avoid contact with young children because of the radiation?
The dose from the implant to the surface of your body is very low, so the amount of radiation of anyone on your lap would be extremely small.  However, we don’t want any association with a child’s routine sicknesses’ or a problem with a pregnancy be associated with you. We, therefore, recommend a few extra measures to insure their safety and to avoid any association with the radiation. It’s fine to be in the same room with children and pregnant women and even sit next to them on the sofa while watching television or playing video games. Don’t avoid giving those hugs and kisses. But for the first two months after the implant, do avoid having youngsters or pregnant women sit on your lap.

 If I pass a seed, what should I do with it?
Retrieve it with tweezers, wrap it up in aluminum foil and return it to us. If you mistakenly flush the seed down the toilet, don’t worry. You won’t irradiate your town’s waste water system.