1.My consultant tells me that Brachytherapy is an obsolete method which has been neglected for many years due to its disappointing results. Is this true? And if so, why is it being proposed again?

It is true that Brachytherapy was very widely used in the treatment of prostate cancer at the beginning of the Seventies but was then abandoned due to its high failure rates. At that time, prostate cancer was diagnosed at a late stage, it was not possible to measure PSA levels in the blood, to use diagnostic techniques such as ultrasound, CT, RMI or to make ultrasound-guided prostate biopsies. Furthermore as these techniques were not available, seeds were implanted via a surgical incision in the abdomen and were placed very inaccurately free-hand. Inside the prostate there were still "cold" areas which did not receive a sufficient dose of radiation to destroy the cancer. It was also impossible to make an adequate evaluation of the quality of the implant due to the technological drawbacks and to the lack of adequate software systems.

Today, about 70/80% of prostate tumors are diagnosed when the disease is still organ-confined compared to only 20/30% in the times before PSA and pre-ultrasound. Thanks to transrectal ultrasound, the implant no longer requires a surgical incision and all its associated complications. The implant is performed by introducing thin needles in the perineum (region between the scrotum and the anus). It is possible to control at the same time the quality of the implant to avoid leaving "cold" areas. The availability of CT, RMI and dedicated software systems permits accurate dosimetric evaluations after the implant to confirm that all the prostate gland has been treated with adequate radiation doses.

Several important Northern American Centers have been performing implants in a codified and standardized manner for over 10 years. Long-term therapeutic results are published in literature. Brachytherapy can cure patients with organ-confined prostate cancer with success rates comparable to those obtained with surgery.
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The decision of whether to treat or not a patient suffering from prostate carcinoma is still a dilemma. On the one hand some slow-growth neoplasms might not interfere with the life expectancy of the patients and therefore not require any therapy. On the other hand, prostate cancer is the second most frequent cause of death for tumor in men.

By evaluating a set of parameters, a Specialist in prostate cancer can reasonably identify cases worthy of treatment and suggest the most suitable treatment for patients. Since it cannot be ruled out that a neoplasm changes its degree of aggressiveness and becomes a factor impacting on the life expectancy of patients, most doctors recommend treatment also for tumors in the less aggressive and earliest forms.

Permanent Brachytherapy (implantation of radioactive sources in the prostate) is a valid treatment, which should not be ignored in the treatment for clinically localised prostate tumors; especially in view of its excellent long term results and low level of complications and side effects compared with other treatment options.
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Brachytherapy is indicated for clinically-localized prostate neoplasms. In locally-advanced neoplasms, it is used in association with external beam radiotherapy (EBRT).

Patients eligible for Brachytherapy must also undergo uroflowmetry and fill in an IPSS questionnaire (International Prostate Symptoms Score). An obstructed urinary flow puts the patient at greater risk of side-effects. Eligible patients therefore have:

It is also necessary to assess the gland size by transrectal ultrasound as it is technically possible to carry out the implant only in prostates sized between 20cc and 60cc. Should the gland volume exceed 60cc, the patient can be treated with androgen bloc for a period of at least 3 months before the implant. This therapy can induce a volumetric reduction of the gland by up to 40% therefore allowing the implant.

A rare exclusion factor is the inability of the patient to adopt a gynecologic position (coxarthrosis, hip prothesis).

If the patient and the disease meet the above requirements, decisions regarding treatment can be made by evaluating together with the Specialist the pros and cons of the various methods (permanent brachytherapy, radical prostatectomy, other methods).
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Patients suffering from clinically-localized prostatic neoplasm and eligible for Brachytherapy must undergo a transrectal prostate ultrasound, an uroflowmetry with evaluation of the post-voiding residue and complete an IPSS International Prostate Symptom Score and a FACT-P questionnaire for patients with prostatic carcinoma.
Ultrasound shows the form and size of the prostate thus allowing the assessment of the number and position of radioactive sources to be implanted into the gland. The assessment of the size of the prostate is necessary because there could be technical problems in the treatment of patients with prostate sizes over 60 cc or below 20 cc. The uroflowmetry and questionnaire are necessary to detect conditions of urinary obstruction which could be aggravated by radiotherapy.
At a pre-operative stage an andrologic examination can be done to assess the erectile function of the patient (history, objective examination, penile dynamic echocolordoppler, night penile rigidometry, completation of the IIEF International Index of Erectile Function questionnaire).
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The week before the implant a diet free fromt fibers and fizzy drinks is recommended to allow a proper bowel preparation, this process will be completed with the administration of enemas the day before the implantation.

Patients with urinary obstruction symptoms a treatment cycle with alpha-blockers to improve bladder voiding without side-effects might be suggested. If the gland volume exceeds 60 cc, a hormone treatment (androgen bloc) might be suggested to reduce the gland volume by up to 40%. The treatment is administered for 3 months before the implant and for the following months (3 months after the implant with Palladium and 6 months after the implant with Iodine).
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The procedure is completed in 60-90 minutes. It is performed in the operating theatre under local or general anaesthesia according to the patients' clinical characteristics. In the operating theatre an Urologist, a Radiation Oncologist, a Physicist, an Anaesthetist and nurses will be present.

At the end of the procedure, a vesical catheter is sometimes inserted and removed the evening of the implant or the following morning.

Patients are discharged the day after the implant and do not require house visits. A few days after discharge, patients can resume their daily activities and should only avoid physical activities for 2/3 weeks.
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Given the limited penetration (limited field of action) of the radiation produced by Iodine 125 and Palladium 103, patients are not significantly radioactive (the level of radioactivity reaches environmental level at a 1 meter distance from the pelvis of the patients). In particular, urine and sperm are not radioactive as they do not contain seeds. It is obvious that particular care has to be taken in case of contact with pregnant women or children.

Upon discharge, patients will receive a copy of the behavior rules to be followed in the post-operative period in order to reduce exposure to relatives and other people.
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16.What kind of disorders can I expect and how long for?

Are there any therapies to control them?

After the implant irritative disorders of the genito-urinary and intestinal tract can appear. These disorders, if present, can vary in intensity from patient to patient. In general they are more marked in the first 4/6 weeks after implant and resolve gradually.

The following symptoms can appear: increase in frequency both day and night, urethral burning, urgency, haematuria, vesical and rectal spasms, voiding disorders. In particular a reduction in the urinary flow and an increase in the post-voiding residue can appear up to urinary retention (recorded in a minority of patients). The severity and duration of the disorders are extremely variable from patient to patient and also depend on the kind of radioactive source which is used, the size of the prostate and the number of seeds implanted as well as on the quality of the implant.

The quality of treatment is strictly related to the experience of the team performing the intervention. Patients should therefore refere to a specialized center with very-experienced doctors. To safeguard the quality of treatment, all centers for brachytherapy in the early stages of activity do implants under the supervision of qualified experts.

Upon discharge, doctors might prescribe an antibiotic treatment to prevent possible infections of the genito-urinary tract and drugs against irritative symptoms (alpha-blockers to improve micturition, antiphlogistics and steroids at very low doses to reduce the edema (swelling) of the prostate, pain-killers and spasmolitycs for major discomfort).
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18.When can I resume sexual activity?

It is possible that I lose the radioactive sources with the sperm?

Patients can resume normal sexual activity soon after the implant given that they observe radioprotective measures to protect the health of their partner (limit her exposure at a distance of less than 1 meter to under 20 hours a week in the first months after the implant).

Only rarely, during first sexual intercourses seeds can be found in sperm. For this reason a condom should be used in the first months after the implant. Two months after the implant with Palladium and four months after the implant with Iodine, any seeds which might be ejaculated are no longer significantly radioactive to radioprotective purposes.

Should an initial erectile deficit appear, a temporary rehabilitation cycle with Sildenafil (Viagra) or prostaglandins may be prescribed.
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In the first 2 years following the implant, ups and downs in PSA levels do not have any pathologic meaning.

The following results can be considered as possible indicators of treatment failure:

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Urinary incontinence and urinary fistulas affect less than 1% of treated patients but can require corrective surgery.

The risk of urinary incontinence is higher in patients who have previously undergone deobstructive interventions of the prostate (TURP, transvesical adenomectomy).

Erectile dysfunction is reported by a number of patients varying according to the age 10%(patients below 60), 20% (60/70) up to 50% (patients above 70). Patients might benefit from a rehabilitation cycle with oral drugs (Viagra) or with endocavernous injections (prostaglandins).
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