Frequently Asked Questions

What were the historical events leading to today's Seed Implant (SI) technique?

How many implants have you done in total? How many do you do per year?

How many other doctors have you trained in the seed implant procedure?

I understand that after seeding I should not come into close prolonged contact with young children or pregnant women. To what extent and for how long should a patient limit his exposure to pregnant women and young children? What constitutes young? How long should I wait before I can again come into contact with them? Does it depend on the isotope implanted?

What were the historical events leading to today's Seed Implant (SI) technique?

1. In 1903, Alexander Graham Bell wrote " …there is no reason why a tiny fragment of radium sealed in a fine glass tube should not be inserted into the very heart of the cancer, thus acting directly upon the disease material. Would it not be worthwhile making experiments along this line?"

2. In 1910, Young used intraurethral radium for the treatment of prostate cancer, with encouraging results.

3. In 1930, Flocks first injected radioactive gold liquid into prostate for the treatment of prostate cancer.

4. In the early 1970's, Willet Whitmore, MD and Basil Hilaris, MD, Memorial Sloan Kettering Cancer Center, New York, NY, were the first physicians to perform prostate seed implants. An abdominal incision was used to implant the seeds directly into the exposed gland.

5. In 1983, Hans Holm, MD, University of Copenhagen, Denmark, was the first physician to perform the "closed" or "non surgical" implant method, which utilized transrectal ultrasound (TRUS).

6. In 1985, Haakon Ragde, MD, John Blasko, MD and Peter Grimm, DO further modified Holm's approach in Seattle, Washington. They began treatment in November 1985.

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How many implants have you done in total? How many do you do per year?

The Seattle Prostate Institute (SPI) implant team has performed more than 10,000 implants. Currently, Dr’s Sylvester, Grimm, Eulau and Takamiya are doing over 600 cases per year.

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How many other doctors have you trained in the seed implant procedure?

The Seattle Prostate Institute implant team now consists of 25 urologists and radiation oncologists trained here at the Institute in prostate seed implantation. The team meets monthly to discuss cases, improve the technique and improve our understanding of prostate cancer. While at the Northwest Tumor Institute, we (PG, JB, TM and JS) helped train over 800 physicians and physicists from outside the Seattle area to do the procedure. The Seattle Prostate Institute (SPI) began a state-of-the-art training program here at Swedish Medical Center in March 1997 and have since trained over an additional 750 physicians, physicists and nurses. We are currently training 30 to 60 physicians and physicists per month from around the world. In addition, SPI hosts an annual Advanced Prostate Brachytherapy Symposium for experienced brachytherapists.

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What parameters: PSA, Gleason score or other, should a man have in order to be a candidate for seed implantation?

Most men will be candidates for S.I. Seed implantation is performed either alone or in combination with external beam radiation. The challenge for physicians is deciding which patient needs external beam radiation. In general, patients with PSA less than 10 and Gleason score of six or less are good candidates for implant alone. We are using the Partin tables now more often to help us decide which patients need the combined external beam and implant approach. Patients with a high risk of disease outside the gland generally receive a short course of external beam radiation (5 weeks) prior to, or after seed implantation. Rarely, some men will have a large gland, unusual anatomy or TURP defect, which technically prevents a good implant.

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What is your in-office seed implant consulting/testing process?

We ask patients to send their information to us for evaluation prior to coming to Seattle Prostate Institute for a consultation. One of the physicians reviews this information and determines if a consult is appropriate and if additional testing is necessary. Patients are asked to send their pathology report, pathology slides and results of any testing done (PSA, bone scan, CT scan, etc.). Patients are notified and a consultation and appropriate pre-visit testing is arranged. At the time of consultation we generally perform a special study called a volume study, which is an ultrasound procedure in which we take images of the prostate. The volume study determines the size and shape of the prostate. If the patient is a candidate for seed implantation, appropriate dates are arranged. If external beam radiation is required this is usually arranged with the patient's hometown radiation oncologist.

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Either an ultrasound pubic arch study or a CT scan for pubic arch evaluation at the time of consultation is routinely performed. Why is this done?

One important determination in deciding whether seed implantation can be technically performed is to evaluate the position and shape of the pubic arch. The implant requires placing needles into the prostate. If the pubic bone, which is shaped like an upside down V or arch, is too narrow, it can be difficult or impossible to place the needles accurately. We have largely replaced the CT with an SPI developed ultrasound pubic arch study that evaluates the position of the pubic bone at the time of the volume study. Occasionally we will also order a CT, which can also do this evaluation. Determining whether the pubic arch will prevent a good implant is obviously valuable. For those patients who have large glands and arch interference, shrinking the gland with hormonal therapy can often make the patient an implant candidate.

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What factors do you take into consideration when picking Palladium 103 or Iodine 125 for the implant?

Gleason grade has been, in the past, the primary determinant for picking an isotope. Early open (laparotomy) implant experience with I-125 with moderate grades (2-6) was quite favorable but not so favorable with high-grade tumors (Gleason 8-10). We therefore initially elected to treat patients with low to moderate grades (2-6) with Iodine 125 and higher grades (7-10) with Palladium 103. To date, this has worked out well. For Gleason scores 5-7, either isotope is probably effective. It will require a controlled study and many patients to determine if one isotope is better than the other.

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Please describe the volume study and the mapping of the prostate.

The volume study is the first step of the mapping procedure. This is an ultrasound procedure in which images of the prostate are taken at 5-mm increments. These images are then reassembled on the computer to make a three dimensional model. Using this model, we can determine the exact placement of each seed. After a careful review by each member of the team (physician, physicist and dosimetrist and nurse), a map of the gland is created which describes the correct coordinates for needle and seed placement. This map is taken into the operating room and followed closely. Additional seeds are available in order to make adjustments at the time of surgery.

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Please describe the length of the procedure and the type of anesthesia.

Typically, the procedure takes about an hour and is done under spinal or light general anesthesia. Spinal anesthesia is preferred because patients seem to tolerate it quite well, are more alert immediately after the procedure and recover the feeling in their legs within thirty to sixty minutes. Since patients can be as alert as they wish to be during the procedure, they can watch the procedure on the monitor. General anesthesia is perfectly acceptable, however. Note too, that with a spinal anesthetic, the type and amount of anesthetic agent determines how long it takes for the anesthesia to wear off.

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What can the patient expect to feel like the remainder of the day after the procedure?

As with all procedures, patient response is varied. The procedure causes minimal trauma to the region beneath the scrotum, but there can be some tenderness and bruising. Most patients require only minimal pain medications such as Extra Strength Tylenol. After the procedure, most patients are somewhat tired and want to relax. Patients can do normal activities (walk around, dinner, etc.) if they feel up to it.

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Why will the patient have a CT scan and chest x-ray soon after the procedure?

The CT scan is done to confirm the placement of the seeds. The CT allows the implant team to do a dose determination called dosimetry. The post implant dosimetry acts as a permanent record of the implant. It also gives the implant team another means of evaluating the quality of the implant. On very rare occasions, additional therapy may be suggested.
Also on rare occasion, a "free" seed (a seed that is placed in the needle individually) will be inadvertently implanted in the middle of one of the large veins around the prostate. This seed can travel in the veins, eventually reaching the lungs. Seeds in the lung have not caused any harm to any patient and nor any adverse symptoms. The chest x ray is performed to determine if there is a seed in the lung.

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What medications do you prescribe before and after the procedure?

Typically, an alpha-blocker (Flomax, Cardura or Hytrin) is prescribed prior to the procedure. These are medications that relax the internal urethral sphincter muscle, allowing for improved urination. Because it can take a few days with Cardura or Hytrin to reach a proper dose, it may be started several days prior to the procedure. After the procedure, patients typically continue the alpha-blocker for four weeks, longer if necessary. In addition, patients are given an antibiotic and an anti-inflammatory drug such as Aleve. The Aleve helps to reduce the normal swelling, improving the urine flow.

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Please describe the Swedish Medical Center and their outpatient facilities.

The Swedish Medical Center is one of the best medical centers in the Northwest. It is located in downtown Seattle near excellent hotels and restaurants. It has superb facilities for both outpatient and inpatient care. In February of 1997 it opened a new state-of-the-art outpatient surgical center. The surgical center has a dedicated prostate implant anesthesia and nursing team. The Swedish Tumor Institute has been a leader in radiation oncology since the 1950's.

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How many years has this facility been doing permanent seed implantation?

Dr. Gottesman began doing permanent seed implantation through the open approach over twenty years ago. He and Dr. Mate have been performing temporary HDR implants since 1989. Drs Blasko and Grimm pioneered the development of transperineal seed implantation at Northwest Hospital with Dr. Ragde in 1986. Dr. Sylvester has been performing seed implantation since 1987. Drs Grimm, Mate and Sylvester along with the Seattle Prostate Institute urologic specialists formed SPI and the transperineal permanent seed implant program at Swedish Medical Center in March 1997. Dr. Blasko joined the SPI team in July 1998.

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Will you explain the differences between palladium and iodine seeds?

Iodine and palladium seeds are nearly identical in their appearance. Both are 0.45 cm long (about the size of a grain of rice) and are implanted in the same way. Both emit low energy radiation. The primary difference between these two isotopes is the rate at which they give off their energy. Palladium gives up 90% of its energy within two months, while it takes approximately six months for iodine to release 90% of its energy. There are advantages to using both isotopes, which is described below in a related question about seed selection. There is no proof that one seed is better or stronger than another. The doses and seed strengths, in fact, are prescribed to produce the same biologic effect.

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What dose of radiation will each kind of seed give during its lifetime?

It depends on whether the seed is used as implant alone or in conjunction with external beam.

Note that this new description for iodine doses (TG 43*) is being adopted by many centers. This is not a change in the energy given or seed strength used, but a means for physicists and physicians to describe more accurately what dose is given. For example, instead of the old prescription dose of 160 Gy, the new prescription will be 145 Gy. Patients should not be worried that they are getting less dose by this new method. It is the same dose used with the older system.

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Please explain seed "half life". How long will each kind of seed be radioactive after implantation?

Half-life describes the time in which an isotope loses half of its strength. For example, iodine, which has a half-life of 60 days, will be half of its strength at 60 days. 60 days later it will be half of this strength. It takes about six months for iodine to be at about 10% of its original strength and a year to lose effectively all of it.
Palladium has a half-life of 17 days. Within two months it has given up 90% of its energy and has lost almost all of it by six months. Again, there are advantages to both isotopes. Palladium gives up its energy quicker but this does not mean that it is necessarily better or stronger.

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How does radiation from seed implantation affect cancer cells? Are there forms of prostate cancer cells that will not be affected by seed implantation radiation? How will the radiation from seed implantation affect healthy cells in the patient's prostate?

Radiation kills cells primarily by affecting a critical target in the cell. This critical target is believed to be the DNA or RNA elements of the cancer cell, which are important for growth. Cancer cells don't die immediately after radiation. Instead, when the cell tries to divide into two cells, the effect of the radiation on the DNA/RNA prevents the cancer cell from dividing properly and the cell dies Since prostate cancer cells often divide slowly, the cancer cell may not die for months after the implant. This is why it sometimes takes a long time for the PSA to drop to low levels. Since the cancer cells are most sensitive to radiation at the time of division, we like to have some radiation present when this occurs. This is why, for slower growing cancers, Iodine 125 is used. For faster growing (higher-grade) cancers, the division is quicker and therefore it may make sense to give the energy quicker with Palladium 103.

All cells are sensitive to radiation. Normal prostate cells die as result of the implant radiation. Some normal cells remain however, which explains why PSA is still present years later. The result of the healthy cells dying is that the prostate function of producing prostatic fluid for ejaculation may be substantially reduced. The presence or absence of an ejaculate, however, does not reflect whether the cancer is cured or not.

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Will healthy cells regrow after the radiation is complete?

There is some regrowth of normal cells, but for the most part regrowth is probably very slow. This regrowth of normal prostate cells is believed to be responsible for PSA values to increase in some patents after treatment.

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If the patient had BPH (benign prostatic hypertrophy) previous to seeding, will it go away or return later?

No investigator has looked at this issue carefully. While the gland can shrink with the radiation, often patients have urinary function similar to that prior to the implant. In other words, at this point, seed implantation does not seem to be a good treatment for BPH.

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What are the chances the patient will be affected by prostatitis after seeding?

All patients have some inflammation of the prostate (prostatitis) after seeding, which typically resolves as the seeds lose their energy. The presence of prostatitis prior to seeding is always a concern because the prostatitis may be exacerbated by the radiation. Surprisingly, this has not occurred in the patients we have treated. This is not to say that prostatitis symptoms went away after implantation, but that the implant did seem not to have significantly worsened them. Caution is urged with these patients. This is an area that needs closer study.

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What effect would a TURP, either previous to or after seed implantation, have on treatment?

In some patients, the presence of a previous TURP prevents a technically good implant. In the past, patients with a prior TURP had an increased risk of urinary incontinence of approximately 25% at six years. The majority of this incontinence was minor, requiring a simple pad. In the past several years changes in the pattern of seed placement have been done in these TURP patients with the hope of decreasing this risk. Since it takes some time to learn the results, patients with a prior TURP are advised that their risk of incontinence is higher. There are, of course, often very good alternative treatments (radical prostatectomy or external beam radiation).
TURP after the implant also imparts a risk of incontinence. Therefore, a TURP in implant patients is not generally recommended. When a TURP is necessary after implant, someone who understands the problems associated with it should perform it.

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What follow up will there be after seed implantation?

The first visit is at 6-8 weeks and thereafter every three months for two years. After two years, visits are recommended every six months. After five years, a PSA is scheduled every six months and a physical exam at least once a year. Alternating these visits between the radiation oncologist and urologist insures complete care. If the patient has a good internist or family practitioner, we encourage his/her participation as well. Most important is to have a concerned, knowledgeable physician following the course.

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What are the effects of seed implantation on short and long term potency?

The effect of the implant on potency can be immediate or delayed. Our studies so far have indicated that overall, approximately 25% of men who are fully potent (able to achieve an erection) prior to implantation, will become impotent after. Another 25% will experience some decrease in their ability but still have intercourse. At present, there is no way of predicting who will be affected and when. Many men who are potent will notice a decrease in the durability or firmness.

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Can seed implantation cause long or short-term incontinence?

The risk of long term incontinence after either seed implant alone or in combination with external beam radiation in the typical, (non TURP) patient is extremely low, less than 1%. Short term, some patients experience significant urgency and may have difficulty reaching the restroom without some slight dribbling. This resolves as the seeds lose their energy.

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Please explain why nighttime is worse than the daytime for urine retention and difficulties in urination.

For many men, nighttime urination is a different experience than the daytime, with often a slower stream or difficulty initiating a stream. This phenomenon can be worsened after seed implantation or external beam radiation. The reason for this is unclear. It may be worse at night because there is slightly greater swelling of the prostate at night. Alpha blockers (Flomax, Cardura or Hytrin) are prescribed to help minimize this symptom. Often, walking around will alleviate this problem. Generally, this worsening of the urinary stream at night goes away as the seeds lose their energy.

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Do you recommend any strategies for alleviating nighttime urinary problems?

Alpha-blockers (Flomax, Cardura and Hytrin) can often help a lot. Finding the correct dose can be a challenge sometimes. Other techniques to improve flow are: walking around, getting into a warm shower or bathtub and urinating, taking Aleve or other anti-inflammatory drugs and avoiding acidic and bladder-irritating foods.

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Should a patient continue to drink fluids throughout the day and evening or should he reduce or stop fluid intake in the evening?

The advantage of taking fluids (particularly water) after seed implantation is that it dilutes and neutralizes the urine pH. Concentrated or acidic urine can be irritating. The disadvantage of taking larger amounts of fluid than normal is that it means more urination, possibly increased episodes of urgency and having to get up more times at night. In general, more fluid is not necessarily better. What fluid a patient takes may be more important. Fluids that cause the urine the to be acidic (fruit juices, coffee etc.) probably should be kept to a minimum. Everyone is different though, and often even these fluids do not cause any problems, so each patient needs to test them himself and adjust. In medical school there is a maxim, called the resident rule: "Ask the patient what he was doing before this symptom started….. Then tell him to stop doing that". Common sense.

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How much radiation will a patient normally receive from EBRT? Do you recommend either EBRT or conformal 3D radiation?

Typical dose for pre-implant EBRT is 4500 cGy. All radiation therapy performed today is 3 D (multiple fields). The initial fields for this treatment are purposely designed to treat the prostate, seminal vesicles and occasionally the lymph nodes. Standard EBRT is given daily, treating four fields, anterior, posterior, left and right laterals. Because we are often attempting to treat a region around the prostate, conformal therapy with more than four fields is often not indicated. Conformal 3 D (more than four fields) external beam radiation is used to treat just the prostate. With this technique, multiple fields and sophisticated blocking are done to avoid high doses to the rectum and bladder. It is used often after the 4500 cGy conventional radiation to deliver the boost dose to the prostate. Since patients receiving combined external beam and seed implantation receive their boost dose from the implant, initial conformal 3D therapy is usually not necessary.

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What side effects might be expected from either EBRT or conformal radiation?

The side effects are similar from either technique. Radiation to the prostate region can affect the bladder, urethra and rectum. Typical symptoms during treatment include increased urinary frequency, slower stream, irritation during urination, rectal tenderness, slight diarrhea and tiredness. These symptoms usually resolve shortly after the treatment is completed.

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I have noticed that some implant centers give external beam radiation (EBRT) after the seeding. Should the seeding be done before or after the external beam?

Some centers perform EBRT after the seeds in order to make corrections for occasional misplacement of seeds.  This is a reasonable approach IF you wait long enough after the seeds are placed in order to avoid significant “simultaneous” radiation to the anterior rectal wall.

The centers that do the implant just prior to external beam claim that it intensifies the radiation. Intensifying the radiation is unnecessary and adds to the expense of the treatment. In other studies, intensifying the radiation in this way has increased the complications or required that the total radiation dose to the prostate be significantly reduced. If one wishes to intensify the treatment one could simply increase the strength of the seeds!

EBRT is given to deliver a safe but effective dose of radiation to those areas that are at increased risk of harboring microscopic prostate cancer that is outside of the range of the radioactive seeds (the distal seminal vesicles and in some cases the lymph  nodes).  Generally speaking, the majority of expert brachytherapists feel that low risk and “favorable” intermediate risk patients should receive radioactive seeds alone, while “unfavorable” intermediate risk and high risk patients should receive combination therapy (EBRT and radioactive seeds).

In the past, our center always did the EBRT first, followed by seeds.  It was safe and effective, and our published results bolster these facts. Now however, there is new EBRT technology:  The Calypso™ system.

For the first time ever, we can track the prostate’s position continuously during the treatment, not just before the beam is turned on.  The prostate does move while the beam is in use, which is why the IMRT (Intensity Modulated Radiation Therapy) EBRT is much more accurate than any other EBRT technology available.

For instance, cyberknife checks porostate position frequently during each treatment fraction, but not continuously.  IGRT, tomotherapy, proton beam, ultrasound guided radiation and gold fiducials only check prostate position before the beam is turned on.  Before the advent of this new Calypso technology we felt that trying to customize the EBRT to correct for seed misplacement was too inaccurate to be of any real benefit.

In centers with the Calypso technology there are at least 2 potential advantages to doing the seeds first and EBRT second.  First, you can elect to have the Calypso beacons placed at the same O.R. setting that you have the radioactive seeds inserted (it only takes an additional 5 minutes), thus avoiding a separate visit to the O.R. for beacon placement.  Second, if it is determined that a few seeds were placed too close to the rectum, the EBRT fields can be customized to give that region a lower EBRT dose so that the final total dose is not too high.

So, currently we place the radioactive seeds and Calypso beacons first, followed by IMRT Calypso guided EBRT at facilities that have this technology in place.  At the other centers we do the gold seed fiducial marker guided IMRT EBRT first, and the radioactive seeds second.  We feel that either method is reasonable at the current time.

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Will radiation shrink the size of a prostate, and is this good or bad?

Both EBRT and implantation can cause the gland to be become considerably smaller. This is neither good nor bad. As mentioned earlier, the main concern is the effect on urinary function. Most men eventually return to their pre-implant function regardless of the size of the gland.

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Under what circumstances would you recommend combined hormonal blockade for seed implant candidates prior to the procedure?

The use of combined or sometimes called complete hormonal blockade (CHB) in treatment is increasing. The advantage for patients with large glands is that it can reduce the size of the prostate, allowing for a technically ideal implant. Several EBRT series have also demonstrated an advantage to using CHB prior to and during treatment. This fact, plus the relatively few side effects of CHB, has prompted the use of CHB in combination with the implant regimens. Many patients receiving seed implantation have high control rates with implant alone and will not likely benefit much from CHB. We have treated many patients in the past few years with CHB, so hopefully we will be able to report on its value for seed implant patients soon.

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What length of time do you believe is best for a course of CHB prior to seed implantation?

There is much opinion and little information to help decide the appropriate regimen of CHB prior to seed implantation. Our regimen has followed the EBRT and CHB trials that gave CHB for at least two months prior to seed implantation. Patients receiving combined EBRT and seeds receive CHB until the day of the implant. While our regimen stops the CHB the day of the implant, we see no harm in continuing the CHB after implant. Studies will be necessary to determine if one regimen is superior to the other.

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What effect does CHB have on the cancer and how does its inclusion support the SI procedure?

Complete hormonal blockade (CHB) results in significant cancer cell death. It also reduces the number of normal cells. It unfortunately does not kill all the cancer cells. Since radiation is more effective when there are fewer number of cells it needs to kill, CHB is attractive as additional treatment, especially in those situations in which there is a bulky cancer or a high chance of disease outside the gland. The morbidity of CHB is relatively low and short term compared to, for example, chemotherapy.

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What effect will SI have on PSA readings after the procedure and for how long might the procedure affect PSA readings?

PSA readings initially can actually be higher than original PSA if done shortly after the implant. This is probably due to the trauma of the procedure. Typically, PSA levels gradually fall over the first year. We have seen PSA levels continuing to fall over several years. Patients should be aware that often PSA levels could artificially increase and then subsequently decrease. We have seen this particularly at twelve to twenty four months from the implant. We are not sure why this "PSA "blip" occurs.

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What PSA level should be hoped for over the long term? What is a good level of PSA after seeding?

Most of the literature supports the observation that patients achieving a PSA level less than 1.0 have a better prognosis. We have, however, many patients who have stable PSA readings above 1.0. It has been speculated that the PSA rises to this level because of regrowth of normal prostate cells, similar to the way BPH can increase PSA. A stable PSA is probably more important.

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When should PSA be checked after SI and how often should it be repeated? If PSA rises, what would the options be at that point?

We generally recommend the PSA be done at each follow up visit. Usually the PSA is done at three-month intervals for the first two years after implant and then every six months thereafter. If the PSA should rise, we increase the interval of the PSA to monthly in order to establish a trend over three or four readings. Decisions or conclusions about the cancer should never be made on one PSA reading.
The most important thing to do if the PSA continues to rise is to establish if there is in fact cancer. See the above question about PSA levels. If there is a suspicion, the next step is to determine if it is in the prostate or not. Typically, bone scan and biopsies are the first steps.

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Should a patient have a biopsy after seed implantation?

The value of a biopsy after seed implantation is controversial. This is primarily because of the lack of skilled pathologists interpreting the biopsies and the discomfort associated with the procedure. There is also the suggestion that the biopsy may give no better information than the PSA in predicting success of the treatment.
Radiation can cause prostate cancer cells to appear quite abnormal. This has been particularly noted if the biopsy is done before two years. An unskilled pathologist may interpret a biopsy as cancer, while a skilled pathologist may interpret it as severely damaged and dying cancer cells. Obviously the cancer interpretation has serious ramifications. We fortunately have a very skilled pathologist who is an expert in this area and therefore feel that a biopsy can give us additional confirmation that the cancer is controlled. We have found that patients with a negative biopsy and normal PSA have an excellent chance of being disease free. If we do a biopsy, we usually do it at two years. Prior to two years, the pathology interpretation has little value.

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For what period of time is it possible to pass seeds through urination or sex?

If seeds are going to be passed, it will happen in the majority of circumstances at the first few urinations or climaxes. It is extremely rare for a seed to be lost in this way beyond this time.

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What is the likelihood of blood in the urine and passing blood clots after the procedure?

It is very likely that blood and/or clots will be noticed in the urine immediately after the procedure. This usually resolves within twenty-four hours. Occasionally it lasts longer or occurs spontaneously some time after the implant. It usually resolves relatively quickly. If it persists, then an evaluation is appropriate.

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Do you recommend Kegel exercises before or after SI?

Kegel exercises are exercises of the external urinary sphincter, the muscle which allows us to control the urine when we have the urge. This muscle can be impaired or weakened naturally, or as a result of the implantation. Kegel exercises can increase the strength of this muscle, allowing for more control of urgency often associated with the implant. It doesn't hurt to do them and they may help.

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If a patient is fully potent prior to CHB and/or seeding, what is the likelihood of regaining/retaining potency in the short and long term after SI?

In a patient questionnaire sent out several years ago, 20-25% of men fully potent prior to implantation became impotent (unable to achieve erection). Another 20-25% experienced a decreased in the firmness or durability but were still able to penetrate. Even with inability to achieve erection, men were often able to climax. We are currently taking more detailed histories of patients so that we can report more accurately for each individual the risks involved.

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What part does age play in loss of potency or incontinence after SI?

We have noticed that men over 70 have a slightly greater chance of impotency. This may be part of the natural aging process. We have not found that age is related to the risk of incontinence.

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What is the difference between the iodine and palladium seeds?

Radioactive palladium releases radiation more rapidly than iodine. Palladium seeds have been used for prostate cancer for about 8 years and iodine seeds have been used for prostate cancer for about 20 years. While the rates and doses of radiation are different for palladium and iodine, the biologic effect is considered to be the same. Palladium is typically chosen for higher-grade cancers and iodine for low to moderate grade cancers. So far, the cure rates with palladium and iodine appear to be about the same.

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What kind of physician typically performs the radioactive seed implantation procedure and in what kind of setting?

Radioactive seed implantation is usually performed in an outpatient hospital setting by a team of physicians consisting of a urologist, radiation oncologist and a radiation physicist. A spinal anesthetic is typically performed, but general anesthesia occasionally may be desirable. Some centers perform them in their hospital operating rooms. Both outpatient and inpatient settings are acceptable.

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Are there any other side effects from radioactive seed implantation? What ongoing pain/side effects might occur days after the procedure and for how long a period of time might there be a problem?

Complication rates with radioactive seed implants are less than those of radical prostatectomy or external beam radiation. After a radioactive seed implant, fewer than 1% percent of patients who have no had prior surgery ( i.e. TURP) will become incontinent. About 20-25% of the men will become impotent with another 25% partially impotent.
As a result of the implant procedure, some men experience mild discomfort in the groin area for two to three days, which is managed very effectively with mild analgesics. Some blood may be seen in the urine and sperm for a few days after the procedure. This is normal and stops after two to three days.
The effects of the radiation from the seeds usually begin one to two weeks after seed implantation. The main symptoms are urinary difficulties such as frequency, urgency or slight pain. These can last for 2-6 months. These can usually be controlled with simple medications. Occasionally, a temporary catheter is necessary.

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What are the advantages of non-surgical seed implantation as compared to other treatment options?

Seed implantation is associated with lower rates of impotence and incontinence compared to traditional treatments, such as radical prostatectomy and external beam radiation. For most patients, seed implantation is a one-time, non-surgical, low-impact procedure. Patients can return to normal activity, including work, within one to three days with little or no pain. Radical prostatectomy patients remain in the hospital for 4-10 days and require weeks of recovery at home. External beam radiation patients must visit a radiation treatment center almost daily over a seven to eight week period.

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What kind of patient is best suited for seed implant therapy?

This procedure is an alternative for men who have early-stage prostate cancer. Seed implant alone is used for patients who have a low risk of disease outside the gland. External beam radiation plus seed implantation is used in situations in which there is a greater risk of disease outside the prostate. Seed implantation is also an attractive option for men whose poor health precludes radical prostatectomy.

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Does the radiation from seed implants pose any danger to organs or tissue surrounding the prostate?

Because seeds are implanted with pinpoint accuracy, they pose little risk to surrounding organs or tissue, therefore having low complication rates. The radioactive isotopes used in this procedure (iodine and palladium) decay over a period of a few months.

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Does the radiation from seed implants pose any danger to the patient's sexual partner?

No, the seeds are of low energy and pose little risk to the partner. Patients may resume sexual activity very soon after the procedure. Occasionally, seeds are placed into the seminal vesicles and thus it is possible, but extremely unlikely, that the seeds might be mixed with the patient's ejaculate. For this reason, we recommend that patients initially masturbate. The initial climaxes may also be slightly painful or the semen may contain blood, both of which may be undesirable. The semen is not radioactive.

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Are patients radioactive after the seed implantation?

No. Although the seeds are radioactive, patients are not. Because the radioactivity is so low and the placement is so precise, virtually all the radioactivity is absorbed into the prostate. Patients are recommended to avoid prolonged close contact with small children and pregnant women in the first two months after treatment.

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How effective are seed implants compared to conventional therapies?

According to 7-year results of patients treated by Drs. Grimm, Sylvester, Blasko and Ragde and colleagues, patients treated with Iodine-125 and Palladium 103 seeds show an overall 92% 7-year cancer-free success rate for early stage cancer. 84% of these patients have PSA levels less than 1. Lower complication rates are noted with seed implantation as compared to patients undergoing radical prostatectomy and external beam radiation.

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What soreness, discomfort or pain should I anticipate having after the implant? How long will it last? What medications are available to deal with any discomfort or pain?

After the implant, there typically is some soreness underneath the scrotum. Occasionally patients describe feeling like they are "sitting on a golf ball". This is due to the slight swelling and bleeding associated with he surgery. It gradually resolves. Most patients require only mild analgesics like Tylenol Extra Strength. Narcotic pain medications are rarely required.

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Is there any chance of infection? If so, what should I do about it?

There have been no major infections in our patients. However, with all surgical procedures there is always a chance. Therefore, all of our patients take an antibiotic for about a week after the implant. Occasionally patients develop urinary tract infections or prostatitis months or years after the implant and require antibiotic therapy.

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How long will it take for the effects of Lupron and Casodex to wear off?

Patients of course respond differently to these hormonal agents. Typically, it takes from one to six months for the symptoms (hot flashes, tiredness, etc.) to wane.

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When should a patient expect to resume normal activities? How soon after SI should a patient be able to begin strenuous exercise? How long should I wait before going back to my exercise routine?

The insertion of the needles causes some trauma to the vessels surrounding the prostate. Therefore, immediately after the implant, any exercise or activity that puts pressure on the prostate should be avoided. We recommend that patients do not lift heavy objects or do vigorous exercise for at least three to four days after the implant. Very vigorous exercise after this period may cause some minor bleeding in the bladder. This is not harmful, but we ask the patients to limit their exercise until the bleeding stops. Activities such as bike riding, horseback riding, motorcycle riding in which there is pressure on the prostate should be avoided for at least six months. The repetitious jarring of the prostate with these activities can cause some swelling and impair urination.

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How long should I wait before trying to engage in sexual intercourse?

In the past we recommended that patients wait at least two weeks before intercourse. We also recommended a condom with the initial few encounters. This recommendation was based on our concern that a seed might fall out in the semen. This concern was unfounded, as we have only documented one case in which a seed came out in the ejaculate. At present, we feel that patients can engage in sexual activity any time after the implant. Because there is occasionally blood in the semen or there may be some slight pain at climax with the first ejaculates, we recommend that patients initially masturbate. While sexual intercourse is not harmful with these first ejaculates, we think that these symptoms may be undesirable for a partner. It is OK to engage in intercourse any time thereafter. Of note is that the semen is not radioactive. If there is some blood in the semen this represents no danger to the partner. In the unlikely chance that a seed would be deposited in the vagina, it would fall out very quickly and present no danger.

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Are there any nutritional changes that I can make in my diet to improve the health of my prostate?

Many patients tell us of nutritional supplements that either improve their function or reduce their PSA levels. Unfortunately, there have been no good studies that we are aware of that support one regimen or another. Most of them do no harm however and therefore we have no objection to their use.

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I understand that after seeding I should not come into close prolonged contact with young children or pregnant women. To what extent and for how long should a patient limit his exposure to pregnant women and young children? What constitutes young? How long should I wait before I can again come into contact with them? Does it depend on the isotope implanted?

There is a small amount of radiation from the isotopes palladium and iodine. While there has never been a report of harm to someone near an implant patient, we feel it is prudent to observe some precautions and avoid exposure to young children and pregnant women. The seeds lose their energy quite quickly. Waiting two months before close, prolonged contact is prudent. Patients can have normal contact time such as brief hugging, sitting at the dinner table, sitting on airplanes, etc. before the two months. Simply keep a modest distance such as 4- 6 feet if the contact is going to be prolonged (more than several hours).

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