BERKELEY, CA (UroToday.com) - The study in men with prostate volumes ≥ 100cc who underwent prostate brachytherapy sets a new standard by increasing the opportunity for men with large glands to be offered this treatment option. While the article addresses the outcomes of men with very large glands, its important impact is more closely tied to the two-phased technique that is described in the article. While pubic arch interference is often associated with very large glands, that is not always the case. A narrow arch and a small prostate can create havoc for the brachytherapist who encounters difficulty in placing the lateral anterior needles and seeds. In such cases, if proper measures are not taken in the OR, the needles and seeds end up more central, driving up urethral doses and compromising the anterolateral prescription dose cloud. The two-phase technique allows the brachytherapist to circumvent this problem and assures that the patient receives an adequate implant.
Another important feature worth highlighting is the advantage of using intraoperative treatment planning software. All seed implants are works in progress; in other words the implant and resulting doses evolve as seeds are placed during the case. Ideally the finished product (from a dose perspective) will closely match the 30-day CT dosimetry study. When relying on the two-phase technique, the intraoperative computer allows the brachytherapist to document, in real-time, the ending point of phase one and to finish the periphery of phase two with a high degree of accuracy. Patients with prostate cancer and coincidental BPH may not be offered brachytherapy because of “technical” concerns. Intensity-modulated radiation therapy (IMRT) or robot-assisted laparoscopic prostatectomy (RALP) are more often mentioned as the preferred treatment options. These alternatives have their own complications. With IMRT a much greater volume of the rectum receives irradiation and with RALP, the technique is more difficult and more likely to be associated with incontinence and erectile dysfunction. In addition, patients who present with high-grade disease (Gleason score ≥ 8) may be offered IMRT where the total dose of radiation delivered is far less than what can be delivered by a combination of seed implant, plus external beam radiation therapy (EBRT).
Finally, while retention rates were higher in men with very large prostates, the need for subsequent TURP was no greater than in men with smaller glands. Temporary retention is easily managed with catheter drainage or CIC and completely resolved in all patients.
Written by:
Nelson Neal Stone, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Professor of Urology and Radiation Oncology, Mount Sinai School of Medicine, New York, NY USA
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