Curietherapy

     This procedure consists of inserting radioactive sources (grains, threads or micro sources) within the prostate. These radioactive sources destroy cancer cells. Thanks to the radioactive elements (iodide, iridium) properties, it allows localized irradiation to the prostate, sparing surrounding healthy tissues.

     The bladder as well as the rectum is therefore protected from the rays. Some treatments by implants are temporary (iridium), other are permanents (iodide grains), meaning that they stay in the patient’s body but loose their radioactive potential after a few weeks or a few month.

     It is important to discuss the treatment choice with one’s own doctor. The procedure should be done by a trained and specialized team. The treatment should be adapted to each person and to each situation.

When does the doctor suggest this type of treatment?

Curietherapy is limited to the prostate. That is why it is suggested to patient with a tumor limited to the inside of the prostate. The doctor should take into consideration the clinical exam (Digital Rectal Exam) PSA rate and biopsies results. (Gleason score). Contra indications to Curietherapy :

Hip movement problems
Prostate bigger than 50-60g
Past medical or surgical problems that could contra indicate curietherapy (surgery for prostate adenoma for example)
Difficulty in urination before the treatment.

The patient tells the patient is te procedure is possible. He explains the technique used, the duration of it, as well as the duration of the hospital stay, the results expected and the possible side effects as well as specific precautions. Curietherapy with permanent iodide 125 implants is the most common nowdays. It is usually used alone, but can be preceded by hormonal therapy, and rarely can be combined with external radiotherapy.

It is used in the USA since 1987 and in France since 1998. C….with temporary implants (iridium source) is more rarely used. It is usually associated with external radiotherapy and sometimes hormonal therapy.

How does the procedure takes place?

Curietherapy with permanent implants

     Before the intervention the patient meets the anaesthesiologist during a pre anaesthesia consultation where it is decided whether the operation will be done under general or epidural anaesthesia. A rectal ultrasound is done few days before the intervention, or right before the procedure. It allows determination of the number of radioactive grains to be implanted, and visual guidance for the physician to be able to treat the prostate while protecting the healthy tissues. This exam of dose repartition before the implantation is called provisional dosemetry.

     The patient is generally hospitalized the day before the curietherapy, sometimes the same day. The sources are introduced through the perineal skin during an ultrasound. A urinary probe is inserted at the beginning of the intervention and left for 24 to 48 hours. With permanent implants, around 50 to 100 radioactive grains are placed in the prostate through fine needles introduced in the perineal skin, under rectal ultrasound guidance.

     Once the grains are implanted, the needles are removed. The patient wakes up in the curietherapieOperating room. He is followed up for a few hours in the recovery room. Generally the patient is quickly transferred to the reanimation department. The hospitalization usually lasts 2 days. A CT scan and sometimes an MRI are done to visualize the iodide grains in the prostate and verify the quality of the treatment. A chest X-ray can also be done to look for grains in that area. It has no bad consequences for the patient.

With temporary implants

     It is done by introducing temporary implants through fine empty needle containing iridium threads. The procedure is ultrasound guided as well, and lasts around 20 to 30 minutes. The patient wakes up in the Operating room. He is followed up for a few hours in the recovery room. Generally the patient is not transferred to the reanimation department.

     Once the patient is awake either the needle containing iridium threads are left in place for 1 to 3 days, or the needles are plugged to a machine that makes iridium micro sources circulate. When this technique is done in the specialized department the treatment consists of 2 to 3 cycles of few minutes per day, for 1 to 2 days. We talk about high rate technique (it’s an option) When the machine is installed in the patient’s room, the cycles last few minutes every hour for 1 to 2 days

     We talk about low rate technique (it’s also an option). The hospital stay is on average 3 to 6 days. The technique with temporary implants is associated with external radiotherapy. A consultation with radiotherapy is fixed after the intervention, to evaluate and treat the eventual side effects.

What are the immediate side effects?

      After the intervention, a hematoma can appear in the perineal area. This hematoma is not painful and usually disappears without specific treatment. There is also the possibility of blood in urine (hematuria). These are temporary side effects due to the needle insertion.

      A foley catheter is left in place the day after the procedure for 24 to 48 hours. The hematuria should disappear in the next 24 hours.

      Acute urinary retention, meaning painful difficulty in urinating, is rare. If it happens a foley is placed for a few days to a few weeks to evacuate urine. If it is not possible to insert a foley, a suprapubic cathether is placed.

     The foley catheter can lead to a temporary discomfort, with a persistent urge to urinate. When it is removed the discomfort felt can be accompanied by urination difficulty. This discomfort disappears rapidly.

What are the most common side effects of curietherapy ?

Transient urination difficulties are common after the procedure. They appear 1 to 2 weeks postop, are maximal for 6 weeks, and finally disappear after a few weeks to month. It is due to the fact that a part of the urethra within the prostate is not completely protected from the implants. A painful burning or irritative sensation during urination, frequent urge to go to the bathroom, urinary discomfort, a weak flow or an urge to urinate are the most common side effects after this procedure.

These discomforts are more or less intense in each patient. Urinary difficulties may persist for more than a year after the procedure. A urethra dilatation or even the resection of the natural track can be proposed to the patient. This resection should not be done within the first 6 month of the procedure because it has a risk of leading to incontinence. If a prostatic resection or other intervention on the prostate or bladder is suggested to the patient within the 3 years following the procedure, the department which did it should be informed.

Particular precautions that should be taken

     If the patient is admitted in a protected area of the department, that is reserved for the c…., the visits are forbidden during the hospital stay to prevent a possible exposure ton the rays. In case of procedure with temporary implants (iridium threads), there are no particular precautions to be taken when living the hospital. Whereas in the case of permanent implants (iodide 125), the radioactivity of implanted sources decrease progressively. Children and pregnant women should be careful for the first 2 month following the intervention. Practically, the patient should not be taking any children on his lap for the first 2 month following the procedure. The implanted sources could leave the prostate go through the urine. That is why the doctor can ask the patient to filter his urine through a net (i.e. tea net), for around 2 weeks after the treatment. If a grain is eliminated, it is asked of the patient to put it in a specific small container given in advance by the department.

     The first sexual intercourses should be protected by using a condom. Whatever the technique used, it is advised to drink a lot of water and to urinate frequently to decrease the risk of urinary infection. In order to decrease urinary side effects, a medical treatment tends to be prescribed. In addition, the rules concerning radioactivity states that in case of death within 3 years of the procedure, no incineration can be done. The patient should not hesitate to discuss with his doctor and the medical team any questions he might have. This dialogue helps the patient familiarize with the treatment and adapt to it. Digestive problems are rare. They are due to the inflammation of the rectum (rectitis) and can appear transiently (frequent feeling of bowel movements, burning sensation). A rectal inflammation is rare when this procedure is done with permanent implants.

     Una ignición del recto es rara después de la curietherapia por implantes permanentes. La presencia de sangre en las silletas es posible de los años después de la curietherapia en razón de un debilitamiento de la mucosa del recto. La presencia de sangre en el esperma es posible durante algunas semanas. Problemas sexuales, cuya impotencia, pueden aparecer. Esta impotencia puede instalarse en algunos meses, o incluso en algunos años.

     Blood in sperm can also occur after a few weeks of the intervention. Sexual problems, such as impotence, can appear. This impotence can sick in within a few month, to years. It depends on the sexual activity of the patient before the intervention and on the age of the patients as well. Even if the majority of patients keep good quality erections, some mention less good erections after the intervention. The quantity of sperm also decreases after the procedure.

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