Prostate Seed Implants ( Brachytherapy ) From the Patient’s Point of View.    [This is a continuation of E.W.'s experience of having a prostate biopsy in which cancer cells were found.]   Executive Summary   232,000 new cases of prostate cancer were diagnosed in 2005, and 30,350 men died from the disease. Although the lifetime risk of a man of 50 is 42%, his risk of dying from it is 3%. [www.advanceweb.com] Untreated, prostate cancer can be a death sentence spread out over many years. It’s earliest symptoms are: Frequent  urination.  (But this can also be caused by benign prostatic hyperplasia(enlargement) or BPH, which also interferes with urination but is not deadly). Or, as in my case, of sub-clinical diabetes. "Sub-clinical" meaning you've got a mild case, but the medical establishment has set their diabetes threshold far too high. Abnormalities in the shape (lumpy) or consistency (durometer) of the prostate gland when palpated (felt) by a urologist. A rising score in the last 3 PSA blood tests (Or a sudden dramatic raise--from 2 to say, 7.)  When any of the above occur, you must get a prostate biopsy—a series of simple, now painless core samples taken of the prostate tissue in a 15-minute out-patient procedure. It's a procedure only a little more complicated than giving blood. Anyone who exhibits any of the above symptoms and does not have a prostate biopsy is a fool. (Sound harsh? This is the Big C.  Whom are we kidding?)   If cancer is detected, the next step depends on the severity of slow-growing prostate cancer. IF NOTHING IS DONE, older men—say 70+ years with Gleason scores of 6 or less will most likely die of something else.  Younger men or those with higher Gleason scores ( e.g., 7 or greater) will die of prostatic cancer in some number of year—say 10 years. It’s a lousy death that can be easily prevented.   There are a number of procedures to remove the cancerous tissue. Surgery to remove the prostate has been the most common.  This is an effective and major operation with a 3-5 day hospital stay followed by weeks of recuperation. There is a very real risk of incontinence and impotence. If the cancer is contained within the prostate gland, radioactive seed implants (“brachytherapy”) is a very patient-friendly alternative.  This article describes a patient’s brachytherapy experience.  There are a number of other, relatively new treatments for prostate cancer, and anyone interested in the subject should take the time to Google them. But, when doing so, remember three important things:   The newest, most novel techniques (e.g. “HiFu”) generally do not yet have a 10-year follow-up record, the only real measure of success. When you read about any results, be sure to check the date of the history.  Many old examples are given (e.g., brachytherapy) with so-so success rates that have been superseded by rapid improvements in technique, and they have by now acquired sufficient 10-year studies. Brachytherapy is most successful when performed by a highly experienced team that specializes in the procedure and has performed many, many of them. The correct mapping of the prostate and accurate implanting of the radioactive seeds makes a big difference in the success rate of the procedure. __________________________________________________________________________________   E.W.'s Experience I actually had two prostate biopsies.  I had it done it because my PSA which was always around 1.7 to 2.0, suddenly went up to 5. The first one of only six core samples showed no cancer, but enough anomalies to suggest a second biopsy.  The second biopsy took 12 samples.  In 25% of one of the 12, cancerous cells were found with a Gleason score of seven. (That is a high score, i.e., a fairly virulent cancer.)  However, my prostate was not enlarged, nor were there any bumps or excrescences—an indication that the cancer cells were probably all still inside the gland.     This cancer was discovered in March of 2005. We discussed the various options: radical prostectomy--a surgical removal of the prostate.  This is the most certain, but it is major surgery with a long recovery time, possible incontinence and impotence, etc. Proton beam radiation, every day for five weeks. Even HiFu--the experimental use of focused ultrasound to burn the prostate away without surgery. (The ultrasound passes harmlessly through the skin and only burns the cells at its focal point inside the gland. Technically, this sounds really cool--except it seemed to me to be a solution looking for a problem.) And finally, the least invasive--radioactive seed implants.  This is also not considered surgery because the radioactive metal seeds are injected by needle, so there is technically no incision--although it is carried out in an operating room with a surgeon.  It is a one-time, 20-40 minute outpatient procedure. For various reasons, it an only be used on patients whose prostate cancer has not spread beyond the gland, i.e., you must qualify for this procedure.  But if it is available to you, it is the least invasive and by far the easiest one to undergo.     Here is an excerpt of an interesting description of Brachytherapy: Approximately 220,000 men will be diagnosed with prostate cancer in 2003. Early diagnosis, primarily due to more widespread PSA screening, has resulted in more patients being diagnosed with early stage disease.1,2 For disease that is likely confined to the prostate and the immediate surrounding area, surgery, external beam radiation (EBRT) and seed implantation are the primary treatment options. In recent years, seed implantation has become more popular as a treatment option. It has been estimated that up to 50% of patients with early stage prostate cancer are now receiving ultrasound-guided seed implantation.13 This rise in popularity is most likely due to (1) the fact that five- and ten-year disease control rates of brachytherapy equal those of the top surgical and radiation series, (2) the toxicity and side-effects are perceived to be lower, and (3) the brachytherapy involves just a single outpatient treatment.7-11,14   Ultrasound-guided transperineal interstitial permanent prostate brachytherapy with I-125 or Pd 103 radioactive seeds is a form of radiation therapy in which radioactive sources, or “seeds”, are permanently inserted into the prostate. The principal advantage of this technique is that the seeds can deliver a substantially higher radiation dose to the prostate and surrounding tissue compared with external beam irradiation. Because of the low energy of I-125 (Iodine 125) and Pd 103 (Palladium 103) isotopes, the dose falls off quickly with distance and, therefore, the seeds deliver low doses to the adjacent rectum and bladder.  [Another interesting book on radiation therapies is Surving Prostate Cancer Without Surgery by Don Kaltenbach.] While most recent descriptions of brachytherapy laud the procedure as the most efficacious over the short and long run, not all urologists are convinced of the >6-year outcomes of "quality of life." (Exculpatory evidence)   Important Note: When you Google "prostate brachytherapy," be careful to note the dates of the articles.  A lot has happened in the past few years, which has caused this process to become more favored, when it can be used.   Because I had no medical insurance, I asked the doctor if I could wait until November 2005 when I turned 65 and Medicaid would help cover the fee (which was probably around $25,000). Because my cancer appeared to be highly localized, even though I had a Gleason score of seven, he agreed.    A few weeks before the procedure, I went to the hospital to have the radiologist map my prostate.  This is done with you recumbent on a table, lying with your legs in stirrups, just like a women when she gives birth.  The shove a thick ultrasound probe up your rectum--it is uncomfortable but it doesn't hurt--and fiddle around for 15-minutes mapping the shape of your prostate, where the urethra is, etc.  The idea is to calculate where and how many radioactive seeds to implant. They don't want them too near the urinary sphincter, the rectum and the nerve bundle that controls erections.  But, of course, they are going to be near those three vulnerable areas to some degree--which will be the source of undesirable side effects.   Day Zero:   My PSA is 1.9 (!).  I was given general anesthesia for a process that takes these guys about 20 minutes (they do a lot of them!).  Awoke with the usual post anesthesia nausea. The nurse put phenergan into the IV.  I fell asleep and awoke 30 minutes later completely refreshed and nausea-free.  What a boon! …despite decades of advances in surgical technique and improved anesthetic agents, one out of three patients will still experience nausea and vomiting after surgery. These events not only influence patient satisfaction with their procedure, but can also prolong recovery, lengthen hospital stays and negatively impact the surgery itself, the researchers said. "There are more than thirty-five million surgical procedures performed each year in the U.S., so postoperative nausea and vomiting is an extremely important health care issue," said Tong Joo (TJ) Gan, M.D., Duke anesthesiologist. "Vomiting is also an issue that most physicians do not take seriously enough -- they see it as a short-term nuisance that will soon pass," Gan said. "However, studies have shown that nausea and vomiting after surgery is the major factor influencing whether or not patients are satisfied with their surgery. When I talk to patients before their surgeries, most are more afraid of the vomiting afterwards than they are of the pain."    Day 0: Took my first pee 30 minutes after waking up. OW! It burned as if some one had stuck a hot ember up my penis.  A pain of 9 on a scale of 10.  Urine is dark pink .Otherwise, felt great. My wife picked me up (it is mandatory to be picked up by some one) and we took the subway home. Felt pretty good with only very minor soreness of my t’ain’t.[1]  Drank a lot of water.   Took FloMax and Lavaquin (antibiotic—14 day course) at breakfast.  Take one 200mg ibuprofen with each meal.  This reduces swelling.  Peeing that night was still quite painful and quantities were just a slight dribble. FloMax relaxes the swollen muscles around the prostate and makes peeing much easier. Instead of a stinging dribble, you get more of rush of urine with less pain. FloMax takes a few days to reach full effectiveness.   Day 1:   Felt 100% again.  Peeing still unpleasant but the fact that it was becoming less painful, was reassuring. Pee starts off with a small spurt of pink, turning right away to normal pale yellow. This is much less blood than I lost from my prostate biopsy.  But quantity and pressure is feeble. An ugly clot of blood particles was expelled in one urination.      Day 2: Except for the pee-burning, felt as if nothing had been done to me.  Dr. Z called to ask how I was doing. He said the worst period is weeks 2 & 3.  108 seeds had been implanted.   Day 3:   Woke up at 4AM needing to pee.  Sat on the pot for a while with only the faintest dribble issuing, yet the never got the feeling I was completely empty.  Drank 8 oz of water.  Tried again at 5 and 6AM.  After taking a shower, had a normal pee which made me feel emptied out, so the continuation of the “need-to-pee” sensation was probably due to my inability to completely empty my bladder.  Taking a warm shower definitely tends to induce the need (and ability) to pee. (Urologists, take note!)  Made a rule always to drink 8 oz of water after every time I peed—no matter how little. This at least gave my poor bladder a chance to pee out something, instead of the dry heaves.   Walking around and doing things took my mind of the faint urge-to-pee.  Drinking plenty of water and peeing standing-up helped me void more completely, reduced the urge and lengthened the peeing interval. Having the urge means you haven’t completely voided. Not being able to completely void is due to swollen parts that you don’t have enough back pressure to force open when the quantity of urine drops below a certain level.  Thus, being able to void completely is a big advantage.   Day 6.   Peeing loosened up so that I actually had a stream (rather than a thin dribble) and occasionally there would actually be some pressure to arc the stream (rather than pouring straight down. If it still stings when you can't pee any more--you've still got some urine left in your bladder--and will need to go again pretty soon. When that happens, run tap water (so you can hear it) and--believe it or not--you'll often be able to pee some more a minute or so later.   Day 11.   Feel normal in all regards except:   Peeing is not normal yet, but much improved.  Best during the day, slowest in the early AM (5 AM—6 AM). Faint blood no longer apparent on initiating urination. Feel a slight tenderness in the taint when I sit on a hard seat.  Otherwise, nothing. Occasionally, feel the faintest bit bilious, which could very well be psychosomatic or due to something else (a cold, predilection to motion sickness, etc.).     The issue is how completely you empty your bladder.  When the internal parts are swollen, i.e., the urinary sphincter (the on-off valve that controls urination), the back pressure of a half-full bladder is enough to force it open it and permit urination.  But, since it is still swollen, it will close off when the contents of you bladder drop to, say, 1/4 full.  Then it doesn't take long for your bladder to get back to half-full, and you feel the need to go again. You can usually sense that you haven't voided completely because there is still that faint tingle of having to go more--but you can't.  If this happens to you (it does with me) it helps a lot to continue to take your FloMax--ideally an hour or so after your evening meal--and one ibuprofin with every meal.   End of 3rd Week:  Met with the Doctor.  I asked whether it might not have been a good idea to put some lidocane (anesthetic) in the tip of the urethra to dull the intense pain of the first urination.  He said that the pain is actually in the bladder at the urinary sphincter and is “referred” to the head of the penis.  In other words, tough luck.   He said better urination whether standing or sitting varies with the patient, most being better off in one position or the other. He agrees that the shower idea is a good one--both the sound of running water and the sensation of warm water induces an urge to pee. When you pee into a toilet bowl standing up, pee into the water-portion of the bowl to generate the sound of running water.   I asked if there was still a chance I would need a catheter.  He said the worst time is weeks 2-3, and if I didn’t need one then (one in four patients do), I would not need one in the future. This shut-off is caused by swelling, which is why it so important to take the ibuprofen and the Flowmax.  Decadron (dexamethasone), a powerful anti-inflammatory, can be used if ibuprofen is not effective.   They took a CT scan—mostly to make sure the seeds had not wandered out of place.  Each series of nine seeds is connected by a strand of material that dissolves in 90 days, by which time the work of the gamma radiation has done its job of killing most of the cells—healthy and cancerous--in the prostate gland. But the cancerous cells are affected more because they reproduce more rapidly. More generations of cancer cells are irradiated, and this leads to their demise.   I will meet the doctor again in six months.  This is really a waiting period to see if the treatment really did kill all the cancer cells, or if some survived and escaped to show up elsewhere—outside the prostate gland (which will now be a shrunken, useless sack). In that case, if all the cancer hasn't been killed, although there are still lots of treatments, one has entered the beginning of a long, slow slide downward with treatments that now can greatly prolong life—10 to 20 years--but if you don't die of something else, the prostate cancer will eventually catch up with you.   [Remember, dying of prostate cancer is an ugly way to go. So you should do everything possible to catch it in time. Have annual PSA tests and prostate palpations.  Once it escapes the prostate gland, the cancer migrates into the lymph glands and/or the bones where it is difficult to treat adequately.  Eventually (many years later) the pain becomes difficult to ameliorate (especially in today’s climate of anti-drug hysteria). ]   End of 4th Week: I’m finally experiencing some of the side effects I was warned about: “Frequency & Urgency.” Sudden urge to pee, and when I do, only a thin dribble comes out.  This occurs perhaps once every hour of so, but can vary from 20 minutes to two hours.  If I ignore it, if often goes away, but sometimes it comes back with a vengeance.   It surely is at least partially psychological, but Erectile Dysfunction (ED) has definitely set in.  It’s not that it doesn’t work, but rather that it’s more work to make it work. One Doctor said to relax—the nerve bundle that controls the process is inflamed from the radiation, and that the situation should return to near normal after the radiation dies down—generally after 3-4 months. However, the brachytherapy literature also notes that about one in three to four men over the age of 65 will experience a gradual loss of their powers in about a year after the procedure. Those are really pretty lousy odds!  (But consider the alternatives--longer "functioning" and an earlier death.)  Ejaculate is tan now rather than the dark red of the first week and dark brown in the second. (Also, as a mild late-onset diabetic and with moderately high blood pressure, I am a prime candidate for ED, so whether it is the brachytherapy that has accelerated it, is an open question.) According to The Clinical Advisor, April 2006, Cialis is the most effective treatment of ED for post prosatectotomy, with Levitra second and Viagra third.  (But see below.) Of 90,000 men who have biopsies, 20,000 will be diagnosed with cancer. If 10,000 were to undergo surgery , 10 would die from the surgery (i.e., not brachytherapy), 300 would develop sever urinary incontinence, "and even in the best of hands, 4000 would become impotent." 6th Week: Had the first mid-day pees in two days that were both entirely normal: Normal pressure (for the first time) and no stinging a few hours after taking FloMax.  An encouraging sign. (But still some minor stinging the rest of the time.)   8th Week: Well, is my peeing getting better? I'm noticing more bouts of "urgency'"--the sudden need to pee and when I do, not much comes out. But this issue comes and goes.  Drinking coffee seems to exacerbate the problem. When heading for the john, the anticipation of being able to pee in a few seconds creates a stinging backpressure that can just be held back! One trick I've discovered is, having finished peeing, waiting about 30-60 seconds to find I am often able to pee out a bit more--some times a significant bit more. Then I'm really empty, and may go several hours before needing to go again. But I still need to go more frequently--at night--usually every two hours.  (But that was true before the procedure too, so it is not a cause).   I also notice more often a faint sensation to want to move my bowels, nothing that would necessarily send me to the john.  But If I do go, there's nothing there.  So what is probably happening is that my bodily parts are getting tired of the cumulative radiation, even as the radiation declines in strength every week. More discouraging is that ejaculation is no longer an explosive event. Rather it is an increasing good feeling that gradually peaks and then subsides--sometimes with little or no emission. Hopefully a transitory side effect.   9th-12th week:   Definitely notice a bruised lump in the prostate region when I sit down.  It's not bothersome because it doesn't really hurt, but it is a new ache. Urination is unchanged--often still stinging, but not painfully so. However, I have now stopped taking 3 ibuprofens a day and this is causing some increase in the frequency of the need to pee. My hypothesis is that because the urinary sphincter is still swollen from the radiation, it will still not open completely without some urinary backpressure. The more swollen it is, the more backpressure is required--i.e., at least a half-full bladder.  However, once a small portion of the urine escapes, the pressure drops and the sphincter shuts off.  So you have peed but not emptied. It doesn't take long before the bladder refills that small amount and you have to go again. (I would continue with the ibuprofen, except that 3 a day required me to take a Prilosec a day to manage the acid reflux.)   FloMax works really well in relaxing the urinary sphincter.  I find it best to take this pill about an hour after my evening meal so it can go into effect for the night, and not have its effectiveness blunted by the meal.  Presumably, now that I have passed the 3-month period, the radiation will have declined significantly (half-life?), and the internal swelling will resolve.    3rd Month:   Oh boy, just when things seemed to be getting better, I had a relapse. Woke up at 3AM to pee and had to go every half-hour thereafter.  Instead of this frequency decreasing during the day, it continued.  If I tried to hold back, I got the usual burning urgency and a few times just made it to the toilet.  My God, I thought, is this it? Am I on the way to incontinence? The next night I went to bed sitting on a heating pad.   Hmmm, that felt good from the get-go. [For those readers yet to undergo brachytherapy, I can imagine them thinking--"Oh my gosh, this guy is 3 months into his "procedure" and he's still not functioning right." But not to worry.  Except for the night-time frequency of peeing, my normal day is pretty normal. Even flying on an airplane for 6 hours is not a big deal (go twice to the loo.) Others may experience more frequency or more bouts of urgency during the day or less. I was already going every 2-3 hours at night before the procedure (but every 4 hours during the day--and no sudden urgency or stinging--which I now still have.) But the real question is, what are your alternatives?  In another couple of months I can expect to be pretty much symptom- free-- and cancer free . Avoid treatment for a year, and in the same trouble-free time span you will be 10% on your way to an early grave.] 3.5 months:  Starting to notice the prostate area more often.  It feels like a small lump that gets irritated if I sit on a hard seat or hard cushion. No change in peeing.  I still need FloMax, now taken (after much experimentation) an hour before bedtime.  If I have a bad day (lots of short interval peeing episodes, I take another FloMax in the morning to give me some daytime relief.   4 months: Finally peeing is getting easier--but I still take FloMax in the evening. And I rarely experience the sudden onset of "urgency"--the need to get to the john immediately--or else. I stopped taking ibuprofen several weeks ago, with no deleterious effect--and I could therefore also stop taking Prilosec as an antidote for heartburn. Emission pretty much back to normal.    PSA test came in at 1.1 last week, down from 1.9 prior to the procedure. (But still 1.1 is not zero--which it would be if the prostate were totally dead.) Emission reduced in quantity but otherwise satisactory. This is also supposed to more or less disappear--the ejaculation, not the orgasm.   Peeing frequency is not going down, and may even be going up during the day--when I used to be pretty normal, i.e., once every four hours or so.  Now it's around every 2 hours, sometimes less than that. And I'm lucky if I can stretch it to 2 hours during the night.  Don't know if that is all prostate related or partially diabetes related, which I have got a mild case of.   Hooray--finally...after 4-1/2 months , some noticeable improvement.  I now have almost normal sensation of impending need to pee., i.e., I get reminders that are gentle and become stronger as the bladder fills up.  No more sudden onslaught of need-to-pee in 30 seconds or lose it. (But this is while still on FloMax.)   And, as encouraging, I am just beginning to get back some sense of control of the urinary sphincter. Previously, I voided (peed) until the sphincter spontaneously closed-up.  This was often not when the bladder was empty (and you could tell because there was still the sting of an unfinished urination). There was nothing I could do in terms of willing my sphincter to pee some more.  Now, I am able, sometimes, to urge it to open up some more and let the rest out.   A first for me and a great sign that things are actually getting better.   Observations: When peeing stops, I can now give it another squirt --and get a little streamlette more output.  This was never possible before, so must be a sign that I am getting more control over the sphincter--and less interference from swelling. Another encouraging sign. I've just stopped taking FloMax (because taking fewer pills is better than taking more pills). Now my peeing is not as effortless as before, but still manageable. However, I am peeing a lesser volume of urine each time--and therefore more frequently.

5 months:   Well, went back on FloMax because peeing stang (past participle of  "to sting"?).  But now that I am taking it again, peeing seems absolutely normal: good strong stream, complete emptying as marked by the ability to give a few final additional squirts after the flow has stopped for the first time, and longer intervals being needing to go.  Also, no onset of "urgency" which has started up again without the pill.   Newly Discovered Factoids: 1.  At a dinner party some marijuana was passed around.  I took two tokes.  That night my need-to-pee frequency was cut literally in half--from (typically) every 1-1/2 hours to 2-hours to 3 and 4 hours. (Urologists take note.) (However, I have since discovered that my nocturnal pee-frequency is a symptom of diabetes onset, not brachytherapy.) 2.  Some of the prostate literature recommends patients do "Kegel execises" to strengthen the muscles that control the act of peeing. Explanations of what these are and how to do them vary greatly in incomprehensibility.  Here is a clear-cut description:   Sit on a hard surface.  This will let you feel what you're doing. Flex (contract) your anus as if you were trying to keep in a pressing bowel movement.  Hold the flex strongly for 5 seconds.  Repeat 5 times at least twice a day.  In a few weeks, you will feel (by doing this exercise on a hard surface) the muscles in that area have grown bigger and stronger.  This should help control urination--and possibly slightly improve ED. 3.  In informal discussions at the Lodge, a small group of prostate sufferers who were experiencing some Erectile Dysfunction (ED) came to these conclusions about the three major drugs: A. Viagra and Lavitra begins to work in as early as 20 minutes to those who need it least, to 30-40 minutes to those who need it most. Both are most potent after about 45-minutes to 1-1/2 hours after ingestion, declining gradually to no longer effective for the neediest at about 3 hours, but still providing vestiges of effect 12 hours later to those who need it least . Most users reported mild side effects, mostly stuffy nose and facial flushing. Levitra works fabulously on a completely empty stomach (i.e., upon waking up in the morning), and is less effective if taken after a fatty meal. B.  Cialis --the so-called 36-hour Spanish fly--was hardly effective at all for the neediest, but useful for the others. Some younger users said ED drugs were not necessary for them--they could perform fine without--but their use did nicely stiffen their resolve to both their own and their partner's delight.   12 months: Feel completely normal in all regards. However, I am taking FloMax daily, which my urologist said would probably be necessary for the rest of my life. (Boy, there's a business to be in--selling drugs that don;t cure anything, but have to be taken daily for a life time!). Once in a blue moon, peeing stings mildly for a few seconds or starting up takes a few seconds longer than normal, but at my age (66) that could be completely normal without brachytherapy. Thank God for modern medicine!   44 months: Well, well, well, finally, after many attempts to stop taking FloMax, only to have urinary annoyances return after a couple of days, I have now gone TWO WEEKS without taking any--and feel just fine. MAYBE I'll be one of the lucky ones whose urinary sphincter heals completely. Now, if the foreshadowing of ED would just follow suite!   Yep--Four months without taking FloMax. Looks like I'm back to normal--(except I still have to pee every 1-1/2 to 2 hours at night).   It's now been six months since I've taken any FloMax. And everything feels normal. But ED--which started before the prostate issue--has set in to the point where the maximum dose of Levitra--20 mg--just barely gets the job done. Boo-hoo.   Click here for an interest FAQ on brachytherapy _______________________________________________________________________________  1. "Taint:" Black English ("Ebonics") for the perineum, the area between the anus and the scrotum.  "T'ain't pussy, t'ain't asshole."  *****************************************************************************************************************