Brachy Treatment

What does this procedure involve?

Insertion of radioactive seeds into your prostate gland using needles passed through the skin behind your scrotum. It may also involve telescopic examination of your bladder.

What are the alternatives?

• Active surveillance – this may be an option when your tumour is low volume and the risk of progression is felt to be low
• External beam radiotherapy – using X-ray beams directed at your prostate gland from outside the body
• Radical prostatectomy – by open or robotic-assisted laparoscopic (keyhole) surgery

What happens on the day of the procedure?

Your urologist and/or oncologist (or a member of their team) will briefly review your history and medications, and will discuss the surgery again with you to confirm your consent.

An anaesthetist will see you to discuss the options of a general anaesthetic or spinal anaesthetic. The anaesthetist will also discuss pain relief after the procedure with you.

We may provide you with a pair of TED stockings to wear, and we may give you a heparin injection to thin your blood. These help to prevent blood clots from developing and passing into your lungs. Your medical team will decide whether you need to continue these after you go home.

Details of the procedure

• we normally use a full general anaesthetic and you will be asleep throughout the procedure
• you will usually be given an injection of antibiotics before the procedure, after you have been checked for any allergies.
• we pass a catheter into your bladder through your urethra (waterpipe)
• we put an ultrasound probe into your rectum and direct 15 to 30 needles into your prostate, through the skin behind your scrotum
• we then put 60 to 90 radioactive seeds through the needles into your prostate gland (pictured in the X-ray below)
• we place a compression dressing between your legs to reduce any bleeding or swelling
• we usually remove your bladder catheter immediately, although it may be left until the next day
• most men go home on the same day as their treatment
• the procedure takes between 1 to 2 hours

Are there any after-effects?

The possible after-effects and your risk of getting them are shown below. Some are self-limiting or reversible, but others are not. We have not listed very rare after-effects (occurring in less than 1 in 250 patients) individually. The impact of these after-effects can vary a lot from patient to patient; you should ask your surgeon’s advice about the risks and their impact on you as an individual:

After-effect	Risk
Bruising & discolouration of the perineal skin (behind your scrotum)	Almost all patients
Inability to pass urine (retention of urine) requiring insertion of a catheter or the need for intermittent self-catheterisation	Between 1 in 7 & 1 in 10 patients (10 to 15%)
Erectile dysfunction (impotence) due to unavoidable nerve damage	Between 1 in 2 & 1 in 5 patients (20 to 40%)
Rectal discomfort with passage of blood or mucus (slime) from your bowel	Between 1 in 10 & 1 in 50 patients
Temporary incontinence of urine	Between 1 in 10 & 1 in 50 patients
Infection of the bladder requiring antibiotics	Between 1 in 10 & 1 in 50 patients
The need for surgery to the prostate if you have persistent difficulty passing urine	Between 1 in 10 & 1 in 50 patients
Other treatment (e.g. surgery or hormones) if the tumour does not respond completely	Between 1 in 10 & 1 in 50 patients
Permanent urinary incontinence	Between 1 in 50 & 1 in 250 patients
Damage to the rectum requiring a temporary colostomy	Between 1 in 50 & 1 in 250 patients
Anaesthetic or cardiovascular problems possibly requiring intensive care (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death)	Between 1 in 50 & 1 in 250 patients (your anaesthetist can estimate your individual risk)
A new radiation-induced cancer in the years after treatment (approx. 1% risk for every 10 years after treatment)	Between 1 in 50 & 1 in 250 patients

What is my risk of a hospital-acquired infection?

Your risk of getting an infection in hospital is between 4 & 6%; this includes getting MRSA or a Clostridium difficile bowel infection. The risk is lower for day-case surgery but higher if you are in a group of patients who have had:

• long-term drainage tubes (e.g. catheters);
• long hospital stays; or
• multiple hospital admissions.

What can I expect when I get home?

• if your catheter was not taken out immediately after the procedure, we will remove it before you go home
• you will be given advice about your recovery at home
• you will be given a copy of your discharge summary and a copy will also be sent to your GP
• you will be prescribed antibiotics, painkillers and tablets to help you pass urine, dispensed by the hospital pharmacy
• if you develop a fever, severe pain on passing urine, inability to pass urine or worsening bleeding, you should contact your local urology department (using contact details provided by them) or your GP.

Can radioactivity from the seeds harm other people?

Yes, it can. You should take note of these points:

• Children, and women who are (or may be) pregnant should not sit close to you, or on your lap, for three months after seed implantation
• You should use condoms during sex for the first five ejaculations after implantation, regardless of the time delay between treatment and your first ejaculation
• You should put used condoms in a dustbin, double-wrapped
• Some men pass seeds in their urine; if you do, they can safely be flushed down the toilet
• If a seed is discharged at any other time, pick it up with long-handled tweezers or a spoon and flush it down the toilet
• If a man, for any reason, dies within 20 months of having seed implantation, he should not be cremated without discussing it with the implanting centre first

If you need specific advice about any aspect of seed implantation, please contact your urologist, oncologist, specialist nurse or brachytherapy co-ordinator.

General information about surgical procedures

Before your procedure

Please tell a member of the medical team if you have:

• An implanted foreign body (stent, joint replacement, pacemaker, heart valve, blood vessel graft)
• A regular prescription for a blood thinning agent (e.g. warfarin, aspirin, clopidogrel, rivaroxaban, dabigatran)
• A present or previous MRSA infection
• A high risk of variant-CJD (e.g. if you have had a corneal transplant, a neurosurgical dural transplant or human growth hormone treatment)

Questions you may wish to ask

If you wish to learn more about what will happen, you can find a list of suggested questions called “Having An Operation” on the website of the Royal College of Surgeons of England. You may also wish to ask your surgeon for his/her personal results and experience with this procedure.

Before you go home

We will tell you how the procedure went and you should:

• Make sure you understand what has been done
• Ask the surgeon if everything went as planned
• Let the staff know if you have any discomfort
• Ask what you can (and cannot) do at home
• Make sure you know what happens next
• Ask when you can return to normal activities

We will give you advice about what to look out for when you get home. Your surgeon or nurse will also give you details of who to contact, and how to contact them, in the event of problems.

Smoking and surgery

Ideally, we would prefer you to stop smoking before any procedure. Smoking can worsen some urological conditions and makes complications more likely after surgery. For advice on stopping, you can:

• Contact your GP
• Access your local NHS Smoking Help Online
• Ring the free NHS Smoking Helpline on 0300 123 1044

Driving after surgery

It is your responsibility to make sure you are fit to drive after any surgical procedure. You only need to contact the DVLA if your ability to drive is likely to be affected for more than three months. If it is, you should check with your insurance company before driving again.