High dose-rate (HDR) brachytherapy
What is HDR brachytherapy?
Brachytherapy is a form of highly targeted radiotherapy which can be used to treat prostate cancer with the intention of curing it. High dose of radiation is delivered over minutes to prostate gland, while minimising dose to surrounding normal tissue. A tiny radioactive source (iridium pellet) travels through needles placed directly into the prostate while the patient is under anaesthetic.
Who can have HDR brachytherapy?
HDR brachytherapy can be used to treat patients with:
Low risk prostate cancer
This means a PSA < 10, Gleason score of 6, and T stage equal to less than T2a.
In this situation you are offered two brachytherapy treatments, one week apart Hormones and additional external beam radiotherapy are usually not required, although hormones may occasionally be helpful for around three months to shrink the prostate.
Medium risk prostate cancer
T2, Gleason 7, PSA 10 – 20.
You will be offered a single brachytherapy treatment followed around 2-3 weeks later with three weeks of external beam radiotherapy. Before you undergo brachytherapy, you will require 3-4 months of hormone injections to increase the effectiveness of the treatment.
High risk prostate cancer
T3 or T4, Gleason 8 or more, PSA greater than 20.
You will be offered a single brachytherapy treatment followed around 2-3 weeks later by up to 4 ½ weeks of external beam radiotherapy. Before you undergo brachytherapy, you will require up to six months of hormone treatment and this is likely to continue for up to 3 years after completion of radiotherapy to increase the effectiveness of the treatment.
Some other things may affect your suitability for brachytherapy:
If you have a very large prostate it may not be possible to successfully insert the needles past the pelvic bones.
If you are not able to have an anaesthetic.
If you are at increased risk of bleeding (eg on warfarin or blood thinners)
If you have pre-existing severe urinary symptoms (for example a weak flow, or problems emptying the bladder properly) because this may increase the likelihood of needing a catheter after the procedure.
If you have severe hip mobility problems
What are the advantages and disadvantages?
Advantages:
Brachytherapy allows the prostate and cancer to be treated with higher doses of radiation than external beam radiotherapy alone which may improve chance of the treatment being successful.
The dose of radiation to the healthy surrounding area (bladder and bowel) is lower and this may reduce the risk of side effects.
Recovery is often quick and you can usually return to your normal activities within a week.
You are only likely to need to be in hospital for a day and occasionally overnight.
No radioactive material is left in the prostate, so it’s safe for you to be around other people, including children and pregnant women.
Disadvantages:
It can cause urinary, bowel and erection problems.
It requires an anaesthetic.
It may take longer before you know if your treatment has been successful.
If your cancer comes back after brachytherapy it is usually not possible to have surgery, in this situation hormones may be used to treat the cancer.
You will have an assessment appointment with your oncologist to discuss the treatment, and also the anaesthetic team to ensure you are fit for an anaesthetic.
You will be given some Octenisan antiseptic wash. Please use this to wash the perineum (the area between the penis and anus) for two days prior to the procedure.
A bed will be reserved for you on the ward. On the morning of the procedure, you will be asked to use an enema to ensure that your rectum is empty. This helps us to get clear pictures of your prostate using the ultrasound scanner.
You will be given a course of preventative antibiotics to reduce risk of infection after the procedure. For most patients this will mean taking two antibiotics (ciprofloxacin and metronidazole) 2 hours before the procedure, 6 hours after the procedure and then again, the following morning. Let your team know if you are allergic to any antibiotics.
You will also be given a prescription for tamsulosin which helps to relax the prostate and improve urine flow. The first dose is taken 3 days before brachytherapy treatment, and you will also be given a four week course to take home when you leave.
The anaesthetist will give you an anaesthetic so you will be asleep throughout the procedure, this will usually last between 3 to 4 hours
Once in theatre you will have a catheter inserted through the penis and into the bladder to drain the urine.
An ultrasound probe will be inserted into the back passage (anus) and the ultrasound scan will be used to carefully insert up to 20 needles into the prostate. The needles are inserted into the skin between the base of the penis and the anus (perineum).
Once this has been done your oncologist and the physics team will use the scan to plan the brachytherapy treatment.
Treatment
Once the treatment plan is finalised you will be moved while still under anaesthetic to the brachytherapy treatment room and the treatment will be delivered by Specialist Radiographers.
During the treatment a transfer tube is attached to each of the needles that have been inserted into the prostate. A radioactive source attached to the end of a wire is passed into each of the needles and removed in turn automatically, by a machine called a Flexitron.
You will be moved to the recovery room and the Anaesthetist will wake you up.
Once you have recovered sufficiently you will be transferred to the ward with the catheter still in place.
You may need to stay in overnight after the procedure, but most patients go home the same day. It is common to pass blood in the urine after the procedure. The catheter is used to slowly wash out the bladder with fluid from a bag to prevent clots forming.
Once the bleeding has improved enough the team will remove the catheter and if you are able to pass urine you will be allowed to go home.
You shouldn’t drive for 24 to 48 hours after the anaesthetic. Ask a family member or friend to take you home, or discuss with your medical team for hospital transport to be arranged
You will be given paracetamol and ibuprofen to help with any pain, and a four-week course of tamsulosin to help improve the urine flow. We advise you to get a repeat prescription of the Tamsulosin for 2 months from your GP.
You may notice some blood in your urine for a few days after your treatment. You may also have some discomfort and bruising in the area where the needles were placed. Your bowel movements may also feel a little uncomfortable. This should settle down after a few days.
If you need to have external beam radiotherapy after your brachytherapy this will usually start around 2-3 weeks after the brachytherapy.
If you have any questions of concerns, please contact the team using one of the numbers below.
Urology Clinical Nurse Specialist
029 2061 5888 extension 4639/4681 – 9 am to 5 pm. Please leave a message if no-one is available to take your call. Someone will call you back.
Treatment help line
029 2061 5888 ask for the treatment helpline. Available 24 hours.
If you have any of the symptoms below contact your team or go to the nearest A&E:
You can normally resume normal activities a few days after your procedure. Speak to your team for more specific advice about your individual situation or occupation.
You will have an appointment with your doctor or nurse a few weeks after your treatment. They will monitor how well you are recovering from the treatment and ask about any side effects.
Your PSA level should gradually drop to its lowest level (nadir) after 18 months to two years. How quickly this happens, and how low your PSA level falls, varies between men. If you have hormone treatment as well as HDR brachytherapy, your PSA may fall more quickly. Some PSA will still show up in tests because healthy prostate cells may still produce small amounts of PSA.
A sign that your cancer may have come back is if your PSA level has risen by 2ng/ml or more above its lowest level, or if it has risen for three or four PSA tests in a row.
If your PSA level does start to rise, talk to your doctor or nurse about what treatment might be suitable for you.
Like all treatments, HDR brachytherapy can cause side effects. These will affect each individual differently, and you may not get all the possible side effects. Before you start treatment, talk to your doctor, nurse or radiographer about the side effects. Knowing what to expect can help you deal with them.
You may have more side effects if you have HDR brachytherapy and external bean radiotherapy together – although this doesn’t always happen. These side effects may occur months or even years after treatment.
You might also get more side effects if you had problems before treatment. For example, if you already had urinary, erection or bowel problems, you may find these are worse after HDR brachytherapy.
You may feel tired for the first few days after treatment as you recover from the anaesthetic. The effect of radiation on the body may make you feel tired for longer, especially if you are on hormone therapy as well. If you are getting up a lot during the night to urinate, this can also make you feel tired in the day.
Fatigue is extreme tiredness that can affect your everyday life. It can affect your energy levels, your motivation and your emotions. Fatigue can continue after the treatment has finished and may last several months.
Immediately after the procedure blood loss in the urine is common. This usually settles within a few days after the procedure. Very rarely it may be necessary to be transferred to the urology team to help settle the bleeding.
HDR brachytherapy can cause urinary problems, including:
Rarely some patients may need to have a catheter for a period of months after brachytherapy at which point it can usually be removed.
HDR brachytherapy and external beam radiotherapy may cause problems getting and keeping an erection (erectile dysfunction). This may gradually get worse over several years, especially if you have both treatments together with hormones.
You may be more likely to have problems getting an erection if you had any erection problems before treatment.
Some patients may experience loss of sensation along the penis and also may experience reduced semen during ejaculation.
For some patients there are treatments which may help them to regain an erection (speak to your doctor or nurse if you would like to discuss this) although this is not always successful.
Brachytherapy may make you infertile, which means you won’t be able to have children naturally. But there is still a chance that you could make someone pregnant after brachytherapy. It’s possible that the radiation could affect your sperm, and this can be harmful to any children conceived, although the risk of this is very low. If this is relevant to you, use contraception to avoid having a child for a while after treatment.
The risk of bowel problems is low in people who have HDR brachytherapy. But you are more likely to have problems if you are also having external beam radiotherapy
Bowel problems can include:
Bleeding from the back passage is a rare side effect of HDR brachytherapy. It can also be a sign of other bowel conditions such as piles, but it is important to rule out bowel cancer, so tell your nurse or GP about any bleeding. They may do some tests to find out what is causing it. They will also be able to tell you about treatments that can help.
This information is also available in Welsh.
This leaflet was written by health professionals. The information contained in this leaflet is evidence based. It has been approved by doctors, nurses and patients. It is reviewed and updated every 2 years.