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Side Effects of Radiation Therapy - Prostate Seed Implant

The following are the most common side effects, both acute and chronic, resulting from prostate seed implantation.  Unforeseen side effects may occur because of the unique and varied tolerance of individual persons.  Late effects of treatment may not always be predictable and may be influenced by concurrent and/or subsequent treatment for this and other diseases.  These common side effects include, but may not be limited to the following.

Before the implant procedure occurs, you will receive a prescription for Cipro which is an antibiotic.  This medicine is to be taken twice per day, starting one day before the implant.  Intravenous antibiotics are also given the day of the implant.  The remaining Cipro pills are to be taken after completion of the implant. You may also be given symptomatic medications to be taken as needed after the implant procedure for frequent, burning urination or pelvic pain.  We also usually prescribe a course of steroids to combat prostate swelling after the procedure.

The implant procedure is an outpatient procedure.  You should be able to return home 2-6 hours after the implant, although some patients will be advised to stay overnight depending upon their recovery from anesthesia.  The procedure is usually done under general anesthesia.   

Most patients have little difficulty for 1-2 weeks following the implant procedure.  There is usually a bruise with some pain and swelling in the patch of skin behind the scrotum, where the needles were inserted.  After that, the lower urinary tract becomes progressively more irritated over the following 1-2 months.  Resolution of side effects then typically follows gradually over the following several months.  A minority of patients will remain symptomatic for a year or more.

The urinary symptoms typically respond well to medical intervention.  We usually prescribe Flomax plus a non-steroidal anti-inflammatory drug (example: Aleve, Advil).    In more severe cases we may also prescribe steroids for 1 to 2 weeks.  The Flomax relaxes smooth muscle around the bladder neck and improves the urinary flow.  This medicine may also decrease blood pressure such that if you are already taking a blood pressure lowering medication, we may recommend decreasing the dose or even discontinuing it altogether.  We will discuss this with the physician who supervises your other blood pressure lowering medication(s) before making any changes.  The urinary symptoms may also be decreased by avoidance of caffeinated beverages as well as acidic or very spicy foods.  This particularly includes avoidance of citrus products. 

Occasionally, we also see a moderate degree of rectal irritation following the implant which may result in multiple stools per day, a sensation of incomplete emptying of the bowels and narrowing of the stools.  Less commonly, we see rectal bleeding, although usually not large in amount.  These symptoms are typically less bothersome than the urinary symptoms, but in rare patients will be prominent. 

Your radiation oncologist will work closely with you during your time of side effects to optimize the medications to treat them. 

Rarely, patients will expel seeds through the urinary tract weeks to months following the implant.  If this occurs, we advise you to recover the lost seed with a tweezer and place it within the supplied container.  If you have intercourse, you should wear a condom for the first month after the implant, to catch the rare stray seed that may be expelled.  The seeds should be returned to Radiation Medical Group for decay in our hot lab.  In some of the implant patients we have observed one (or rarely more than one) seed in the lung.  This is of no known biologically significant consequence.

While the vast majority of our patients have only mild to moderate side effects which respond to medication, a very few will develop severe lower urinary tract symptoms characterized by obstruction of the urinary outflow that may require prolonged placement of a Foley catheter or intermittent self-catheterization.  Other invasive maneuvers rarely become necessary, including a suprapubic cystostomy or a direct surgical intervention in the region of the prostatic urethra to improve the flow.  We typically advise that these urethral opening procedures be done only as a last resort, after all other measures have failed, due to an increased risk of urinary incontinence in patients who are treated with a combination of radioactive seeds and prostate surgery.

Rarely, other serious complications occur including damage to the rectum of potentially severe enough magnitude to require a colostomy.  The incidence of severe rectal injury is on the order of 1-3%, although even those patients usually do not require a colostomy. 

Potency is preserved in most patients who are under the age of 70 at the time of implantation and approximately half of the patients who are over the age of 70 at the time of implantation.  Sometimes there is a temporary disturbance in the potency occurring at the peak of a patient's urinary symptoms which gradually improves after the reaction subsides.  Unfortunately, it does not always improve. 

This statement is not a warranty, but it is simply meant to give information regarding typical prostate seed implantation side effects and their management.  Catastrophic or even fatal radiation complications may occur in rare cases.  Great care will be taken to minimize the side effects and reduce the risk of radiation damage to normal tissues.

News From Prostate Cancer Week of Nov. 3, 2002/ Vol. 2 No. 44
Study: Impotence Common Among Prostate Cancer Survivors

A large federally funded study of men has found that the "great majority" of men who survive prostate cancer do not achieve a return to functional sexual activity in the years after treatment.

The study of more than 1,200 men, who either had a prostatectomy or radiation therapy at the Cleveland Clinic between 1992 and 1999, found that 85 percent of the respondents had experienced erectile dysfunction within the previous six months an average of four years after their treatment.

"Only 13 percent of men were having reliable, firm erections spontaneously, and another 8 percent of men were having erections with the aid of a medical treatment," the researchers reported. "Men were as distressed about loss of desire and trouble having satisfying orgasms as they were about erectile dysfunction."

The researchers reported in the journal Cancer that men who underwent nerve-sparing prostatectomy or brachytherapy fared better sexually than those who opted for conventional external beam radiation or hormonal treatments.

Patients who underwent antiandrogen therapy fared poorest, possibly because the drugs suppress the male sex hormone testosterone.

The researchers found that younger men treated for prostate cancer were significantly more likely to have a better sexual outcome than older men, and said other factors that resulted in better outcomes included:

  • Having normal erections before treatment for prostate cancer;
  • Choosing a treatment based on the hope that it would preserve sexual function;
  • Having more sexual partners in the past year; and
  • Having a sexually functional partner.

"The priorities a man places on sexuality and on having a sexually functional partner are important factors in sexual satisfaction at follow-up, over and above the influence of age and medical factors," the researchers concluded

What are possible side effects of radiation therapy?

As radiation treatment progresses, it may cause patients to become tired. Resting is important, but doctors usually advise patients to try to stay as active as they can. Patients may have diarrhea and/or frequent and uncomfortable urination. In addition, when patients receive external radiation therapy, it is common for the skin in the treated area to become dry. Redness or tenderness is unusual. Radiation therapy can also cause hair loss in the pelvic area. The loss may be temporary or permanent, depending on the amount of radiation used.

Radiation therapy (either external radiation or "seed" implant) causes impotence in some men. The rate of impotence is similar to patients who undergo nerve-sparing prostatectomy. There is also a slight risk that bladder or rectal problems may occur with either type of radiation. If this occurs it usually presents itself one to three years after radiation

Quality-of-Life after Radiation -External Beam Radiation Therapy

External beam radiotherapy to the pelvis is well established as a definitive therapeutic option for early stage prostate cancer. In the last decade, 3-Dimensional (3-D) conformal radiotherapy has emerged as a significant advance in external radiotherapy technique with improved cancer-free survival and reduced side effects over conventional radiotherapy. Although using the 3-D conformal technique reduces side effects from external radiation, these patients can nevertheless experience bothersome urinary, bowel, or sexual symptoms8. Unlike surgical patients in whom the urinary symptom of concern is incontinence or leakage, however, the urinary symptoms among radiation patients are characterized by burning or pain with urination (‘dysuria’), urinary frequency, urgency, obstruction, and (less commonly) bleeding. These are called urinary ‘irritative’ and ‘obstructive’ symptoms or problems. Unfortunately, these symptoms have largely been ignored in prior patient-report QOL studies. One recent study showed that these urinary irritative and obstructive symptoms were worse after radiation compared to surgery, and were even more profound after brachytherapy (radioactive seed implants; see below).6
External radiation can also affect erections and sexuality. Mantz et al., noted initially high potency rates immediately after conformal external radiation, followed by a gradual decline thereafter over 5 years, at which point half of men reported impotence (ED)9. Viagra, MUSE, caverject, and vacuum pumps can be helpful for maintaining an active sex life despite problems with erections after external radiation.
In a small proportion of patients, external radiation can lead to problematic bowel symptoms such as painful, frequent, or bloody bowel movements or fecal soiling10-12. Such bowel symptoms can be problematic for 5-15% of patients long-term after external radiation administered by the 3-D conformal technique; these rectal problems are less frequent than was previously seen after conventional radiation (Figure 1)7,13.



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