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Date of last update: 8/13/2017.

Forum Name: Urology Topics

Question: Brachytherapy or Prostate Removal

 jjacobs57 - Fri Dec 18, 2009 5:29 pm

I have recently been diagnosed with prostate cancer. I had a biospy and 1 out of 12 samples was positive. I am 52 years old and very active athletically (biking, running, swimming). My urologist gave me two options. Removal of my prostate via robotic surgery or brachytherapy (radioactive seed implantation). Based on my age and activities, is one procedure preferable over the other?
Thanks for you considering my question.
 Dr.M.Aroon kamath - Tue Dec 22, 2009 1:55 am

User avatar Hi,
Generally 3-6 core biopsies may be obtained from each side of the prostate gland.In your case, one of them had turned out to be positive for prostate cancer.
What is perhaps most important from management point of view is whether the cancer is "Organ confined" or has spread beyond the prostate's confines.
Which option is best depends on the stage of the disease, the Gleason score, and the PSA level.

"Organ confined" tumors may be offered
- radical prostatectomy
('open' or robotic assisted laparoscopic) or
- prostatic brachytherapy.

The two main methods of prostate brachytherapy are
- permanent seed implantation and
- high dose rate (HDR) temporary brachytherapy.

Permanent seed implants involve injecting approximately 100 radioactive seeds into the prostate gland under image guidance.They irradiate at a low dose rate over several weeks or months, and then the seeds remain in-situ permanently. Modern technology has ensured, less adverse effects on neighbouring structures such as the urethra,seminal vesicles, urinary blader etc).

HDR temporary brachytherapy involves placement of very tiny plastic catheters into the prostate gland, and then a computer-guided machine pushes a single highly radioactive iridium seed into each catheter in sequence. Because the computer is pre-programed to control how long these seeds remain in their respective catheters, one can control the radiation dose in different regions of the prostate, thus concentrating the radiation dose to the tumor. HDR may be combined with external beam radiotherapy.

It is typical to have symptoms of urethral, bladder, and rectal irritation for a few months following the HDR and external beam therapy. Serious long term rectal injury is not common.

The chance of incapacitating urinary incontinence needing urinary pads is approximately 2.5% (5% or more for standard prostatectomy ). The risk of impotency is approximately 35 - 40% for those patients treated with HDR + external beam. This is similar to other forms of radiation or brachytherapy, but better than the risk associated with prostatectomy.

Prostatectomy may cause erectile dysfunction in two ways.
- damage to the neurovascular bundles(unilateral or bilateral)
- by compromising the blood flow to the penis.

Of late more evidence is emerging which casts a suspicion that the incidence of erectile dysfunction is perhaps much higher than previously thought.

One study found that 60% were impotent 18 months after the surgery, 8% experienced total urinary incontinence, and 40% had occasional genitourinary problems (JAMA 2000;283:354-60).

Orgasms post- prostatectomy are likely to be dry orgasms, which is the absence of ejaculatory fluid. As the prostatectomy removes the seminal vesicles and prostate gland which are responsible for producing much of the ejaculate.

Open nerve-sparing radical prostatectomy has continued its evolution into the highly refined techniques that we see today. Limitations in visualization and dissection of the neuro- vascular bundle have continued to pose a challenge to even the most experienced prostatic surgeon. The introduction of robotically assisted techniques to modern laparoscopic surgery has provided many an advantage, the two most significant being wristed instrumentation & improved three-dimensional (magnified) vision.These are expected to result in more neuro-vascular bundles being spared.
Best wishes!

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