Seed Implantation for Early Prostate Cancer
Seed Implantation for Early Prostate Cancer
A 76-year-old man underwent retropubic prostatectomy for obstructive symptoms 10 years ago. He now presents with newly diagnosed prostate carcinoma, Gleason score 4 (2+2), PSA 8.2, stage T1c, prostate size approximately 40 g. Is seed implantation contraindicated? What is the risk of complications?
This patient would be an excellent candidate for expectant management -- he has low-risk features and could very well succumb to cardiovascular or cerebrovascular events before he will be symptomatic from his prostate cancer. If a decision were made to treat because of increased PSA velocity or as a result of patient or physician preference, his options would include radical prostatectomy, external beam radiation, brachytherapy, or cryotherapy.
Most of the data on the risk of complications of seed implantation following previous urologic surgery come from patients who have had a prior transurethral prostatectomy (TURP); there is a paucity of data regarding prior retropubic or suprapubic prostatectomy. In 1991, Blasko and colleagues reported a 20% rate of urinary incontinence in patients with a preimplant TURP. However, improvements in implant technique with peripheral loading patterns have reduced urethral doses dramatically, so that current incontinence rates reported are less than 10%. Thus, previous TURP is considered only a relative -- and not an absolute -- contraindication to seed implant.
Note that TURP involves direct trauma to the urethra since the obstructing prostatic tissue is resected through the urethra, whereas the suprapubic or retropubic approach enucleates the hypertrophic adenoma through the bladder and/or the prostatic capsule without direct damage to the urethra. Thus, prior retropubic prostatectomy is not a contraindication to seed implantation. It is, however, imperative to confirm the absence of urethral scarring or stricture by cystoscopy prior to seed implantation.
In the absence of data from the literature and based on anecdotal experience, I would guess that in the hands of an experienced practitioner, the risk of urinary tract morbidity for this patient would be less than 10%.
A 76-year-old man underwent retropubic prostatectomy for obstructive symptoms 10 years ago. He now presents with newly diagnosed prostate carcinoma, Gleason score 4 (2+2), PSA 8.2, stage T1c, prostate size approximately 40 g. Is seed implantation contraindicated? What is the risk of complications?
This patient would be an excellent candidate for expectant management -- he has low-risk features and could very well succumb to cardiovascular or cerebrovascular events before he will be symptomatic from his prostate cancer. If a decision were made to treat because of increased PSA velocity or as a result of patient or physician preference, his options would include radical prostatectomy, external beam radiation, brachytherapy, or cryotherapy.
Most of the data on the risk of complications of seed implantation following previous urologic surgery come from patients who have had a prior transurethral prostatectomy (TURP); there is a paucity of data regarding prior retropubic or suprapubic prostatectomy. In 1991, Blasko and colleagues reported a 20% rate of urinary incontinence in patients with a preimplant TURP. However, improvements in implant technique with peripheral loading patterns have reduced urethral doses dramatically, so that current incontinence rates reported are less than 10%. Thus, previous TURP is considered only a relative -- and not an absolute -- contraindication to seed implant.
Note that TURP involves direct trauma to the urethra since the obstructing prostatic tissue is resected through the urethra, whereas the suprapubic or retropubic approach enucleates the hypertrophic adenoma through the bladder and/or the prostatic capsule without direct damage to the urethra. Thus, prior retropubic prostatectomy is not a contraindication to seed implantation. It is, however, imperative to confirm the absence of urethral scarring or stricture by cystoscopy prior to seed implantation.
In the absence of data from the literature and based on anecdotal experience, I would guess that in the hands of an experienced practitioner, the risk of urinary tract morbidity for this patient would be less than 10%.
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