Prostate high dose rate (HDR) brachytherapy

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law, we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to having the procedure and understand what it involves.

Staff will explain all the risks, benefits, and possible alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please do not hesitate to speak to speak to the team looking after you.

During your time with us we aim to provide the highest standards of care and support you in your decisions regarding your treatment. We will respect your dignity, individuality, and personal preferences.

Your care will be managed and given by therapeutic radiographers, doctors, and nurses. You will meet both male and female healthcare professionals during your treatment. If you have any concerns about this, please talk to the radiographers about it. We try to be sensitive to your needs, so please do not hesitate to discuss things with the team caring for you.

Prostate HDR brachytherapy is a specialised form of internal radiotherapy. Internal radiotherapy is where a radioactive material (material that gives off radiation) is placed in your body to destroy the cancer cells. It is placed within or near to your cancer, as the radiation does not travel very far. A computer-controlled machine called a Flexitron pushes a single radioactive iridium pellet into small flexible tubes, also called treatment catheters, placed into the prostate gland. The doctors can give a high dose of radiation direct to the prostate, while limiting the dose to surrounding healthy tissue.

Brachytherapy is an established procedure for prostate cancer that has not spread outside of your prostate gland. We usually give HDR brachytherapy in combination with a four to five week course of external beam radiotherapy, which starts approximately two to three weeks after your HDR treatment. The external beam radiotherapy expands the treatment area beyond the prostate to include other regions where there may be microscopic deposits of undetected cancer. Your doctor will discuss with you the treatment options that are appropriate for you.

You will have several appointments before your HDR treatment. You will meet with your Clinical Oncologist to discuss the treatment and sign a consent form.

You will be called by a member of the pre-admission clinic. They will do some routine medical checks which are required before having an anaesthetic, including taking a full medical history. If required, you will be sent for routine tests such as blood tests, and an ECG or electrocardiogram (a recording of the electrical activity of your heart).

Two weeks before your HDR treatment, you meet with the brachytherapy team in the radiotherapy department to discuss your treatment, and to answer any questions you might have. They will ask you to provide a urine sample to check that you do not have a urinary infection.

The brachytherapy team will also ask you to go to the pharmacy at UCH to collect medication to help with preparation for your treatment:

• Micro-enemas, which is a medication to empty your bowels.
• A medication, called Tamulosin, which helps reduce bladder symptoms such as urinary frequency. It will also help to reduce the risk of urinary retention.
• An antibiotic called ciprofloxacin.

Make sure that you have collected these medications before you leave the hospital. You must bring this medication into hospital with you on your admission day. You will be told when to start taking each of the medications.

If you are taking antiplatelet medicines such as aspirin, clopidogrel or dipyridamole or medicines that thin the blood, for example warfarin or rivaroxaban, the pre- assessment team will tell you when to stop taking them before your HDR treatment. Also tell your doctor or specialist nurse if you have diabetes as you may need to alter the dose of your diabetes medicines, as you will need to fast before the procedure. We will give you more advice about this.

Do not make any changes to your usual medicines and continue to take them unless you are told otherwise. Please remember to bring them with you on the day of your admission. Please let us know if you are taking any regular medicines, including anything you buy yourself over the counter or any herbal or homeopathic medicines, and if you have any allergies to any medicines.

You will be admitted to University College Hospital the day before, or the morning of, your HDR treatment. Please do not eat or drink anything, except non-fizzy water, for six hours before your HDR treatment. You can drink water up to two hours before treatment. This will be explained to you in the pre-admission clinic. If you do not follow these instructions, your procedure may have to be cancelled.

On the morning of the procedure, you will have a rectal enema as it is important your bowels are empty. You will also be given elastic stockings to wear. This is to prevent any blood clots caused by lying still. At around 8:00am, you will be brought down to the brachytherapy suite in the radiotherapy department. You will meet the anaesthetic and brachytherapy teams before having a spinal anaesthetic or, occasionally, a general anaesthetic.

Brachytherapy treatment to the prostate is delivered through thin, flexible tubes that are inserted into your prostate gland. The prostate gland is visualised by an ultrasound probe which is placed in to your rectum. The tubes are inserted through the skin in your perineum (the area between your scrotum and anus). The tubes are held in place by a plastic template that is stitched onto the skin.

Three gold markers, also called fiducial markers, will also be inserted into your prostate at the same time. The fiducial markers will help with the accuracy of both brachytherapy and external beam radiotherapy, which you will have at a later date. A urinary catheter will also be inserted into your bladder to drain urine.

Once the tubes are in position, you will be taken for a CT scan. This scan is necessary to plan your brachytherapy treatment. Your clinical oncologist and the radiotherapy physicists will plan your treatment. Once your treatment is planned and approved, the data is transferred to the Flexitron unit. We will then deliver the brachytherapy treatment.

Treatment takes approximately 15 minutes. You will not feel anything during treatment. After the treatment has finished, the plastic template and the tubes are removed. There is no radioactive material left in your body.

Once the treatment and removal of the tubes and template is complete, you will go back to the ward. The urinary catheter will be left in place for one to two days to ensure there are no problems with emptying your bladder. It is common to see blood in your urine after treatment, and this will subside with time. Once the catheter has been removed, we will ensure you are passing urine properly. We will scan your bladder on the ward to make sure you can empty your bladder. If you have no blood in your urine and can empty your bladder, you will be discharged home.

You are not radioactive at any time while in hospital, or when you are at home. There is never any radiation exposure to your family or to hospital staff. You are safe to be around children and pregnant individuals.
 
Your external beam radiotherapy treatment will be scheduled to start approximately two to three weeks after the HDR treatment. The dates for radiotherapy planning and treatment will be given to you before you are discharged home.

If you have any questions or worries about your treatment or treatment side effects when you are at home, please call the brachytherapy team (9am-5pm) on 020 3447 3782.

For out of hours advice please call the out of hours oncology advice number (available 24 hours) on 07947 959020.

Your consultant will advise you of any side effects that you may experience following the HDR brachytherapy treatment.

Early side effects can be related to swelling of the prostate gland or effects on the surrounding tissues. Side effects may begin shortly after HDR brachytherapy or in the following weeks after treatment, and can include:

• A weaker flow when urinating. If you have to wait before urine starts to flow, having a warm bath or placing your penis into a bowl of warm water can help.
• An urgent need to empty your bladder.
• Frequency to urinate during the night. Try reducing your fluid intake a few hours before going to bed. Have sips of water if required during the night.
• Pain and a burning sensation when passing urine. Drinking plenty of fluid can help. Reducing drinks that may irritate the bladder such as fizzy drinks, alcohol, and drinks containing caffeine (tea, coffee and cola) may also help.
• Blood in your urine. You will probably have blood in your urine immediately after the tubes are removed. This usually settles down over the next few hours, but you may still see a slight trace of blood in your urine for a few days afterwards. This is quite normal, so don’t be alarmed. Drinking plenty of water during the day helps to flush out the bladder.
• If you are producing semen, you may notice some blood, it may be painful to ejaculate, or the ejaculate may stop after treatment.
• Some men have less feeling along their penis immediately after HDR brachytherapy. This may slowly improve but it can occasionally be permanent.
• Changes in your bowel motions or blood or mucus in your stools. Sometimes inflammation of the rectum causes constipation, loose bowel motions or diarrhoea for a few weeks. This is more common during external beam radiotherapy.
• Pain, temporary swelling and bruising in the area where the needles were inserted. If you need pain relief, we recommend an anti-inflammatory medicine such as ibuprofen, or alternatively paracetamol. You should check with your doctor or pharmacist to ensure these medicines are suitable for you and do not interact with other medicines you’re taking.
• 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. Being on hormonal therapy, as well as the external beam radiotherapy which follows radiotherapy may add to the tiredness. If you get up a lot during the night to urinate, this can also make you feel tired during the day.
• All these symptoms are to be expected and should heal with time. Before you are discharged home, we will give you a course of medication to reduce these symptoms. A repeat prescription should be obtained from your GP.

If you notice an increase in blood in your urine, seek medical attention immediately.

In the unlikely event that you are unable to pass urine, also called urinary retention, you should seek urgent medical attention. You should attend your local emergency department. You may require a urinary catheter to be fitted.

If a catheter is fitted it usually needs to stay in until the end of your external beam radiotherapy. It may need to stay in for two to three months or longer, to allow things to settle, but this is rare. Occasionally patients need surgery to the prostate to allow them to pass urine normally.

There may be late side effects of HDR brachytherapy. Late side effects can occur months or years after radiotherapy has finished. Many men may have experienced similar symptoms already due to their cancer. Your consultant will have an in-depth consultation with you to explain these potential late side effects.

Narrowing (stricture) of the urethra (the tube that carries urine). About one in twenty men can develop a narrowing or stricture of the urethra, which may slow your urinary stream. This may require a small operation under anaesthetic to widen the narrowing.

Urinary Incontinence (the leakage of urine) can occur in one in ten men in the first few weeks, but after three years less than one in twenty men experience leakage.

Urinary frequency and urgency. About one in five men experience some urgency usually for up to three to six months after brachytherapy. These symptoms are mild in four out of five patients and moderately severe in one out of five patients. The symptoms usually peak at the end of external beam radiotherapy and improve after this. They can be controlled by making sure you drink plenty of clear fluids and avoiding caffeine and alcohol. We can also give you medication if needed, to improve your urine flow and reduce irritation to your urethra.

Urinary retention (the inability to pass urine). This is unusual (two in 100 patients) but can occur particularly if your prostate is large and swells further after treatment. If we think you are at risk, we will discuss the options for managing this with you before your treatment.

Erectile dysfunction (the inability to achieve satisfactory erections) occurs in approximately 30% to 75% of men and may be permanent. Impotence occurs more often in older men and men already having some difficulty. Treatment such as Viagra or Cialis is available for men who develop impotence, but treatment is not always successful. Your GP can prescribe some treatment free of charge on the NHS. Most men will lose their ejaculate following treatment, because the prostate produces fluid that is part of semen. You may have a ‘dry orgasm’ where you have the sensation of an orgasm, but don’t produce any semen.

Bowel side effects. This includes changes in your bowel motions or blood or mucus in your stools. If you are to undergo any investigation of your bowel in the future, please ask your bowel specialist to contact your brachytherapy consultant before you have any biopsies of your bowel. If you receive anal sex, then bowel problems may be a particular issue. If you do have bowel problems, wait until these have improved before trying anal play or sex. Talk to your doctor or nurse for more information.

Very rare side effects include bladder or bowel damage, injury to the muscle that opens and closes the anus, or an opening (fistula) between the bowel and urethra.

There are many people you can talk to about these symptoms and ways to manage them, so please ask. We are here to help.

Brachytherapy radiographers

Telephone: 020 3447 3782
Email: uclh.RadiotherapyBrachy@nhs.net

Uro-oncology CNS team
Email: uclh.uro-oncology.cns@nhs.net

Radiotherapy reception Telephone: 020 3447 3700/3701

Out of hours oncology advice number (available 24 hours) Mobile: 07947 959020

If you have any concerns that you would like to discuss in confidence, please contact our PALS (Patient Advice and Liaison Service) for information and advice.

Email: PALS@uclh.nhs.uk
Telephone: 020 3447 3042
Website: www.uclh.nhs.uk

Prostate Cancer UK Telephone: 0800 074 8383
Website: www.prostatecanceruk.org

Tackle Prostate Cancer Website: www.tackleprostate.org/

Orchid: Fighting Male Cancer Telephone: 0808 802 0010
Website: www.orchid-cancer.org.uk

Errol McKellar Foundation (Black Afro-Caribbean men with prostate cancer) Website: www.theerrolmckellarfoundation.com/

Metro Walnut (peer support group for LGBTQ people with prostate cancer) Website: www.metrocharity.org.uk/community/metro-walnut

Live Though This (LGBTIQ+ Cancer Support) Website: www.livethroughthis.co.uk

Continence Foundation
Email: info@continence-foundation.org.uk
Website: www.continence-foundation.org.uk

Macmillan Cancer Support Telephone: 0808 808 0000 (Freephone)
Email: cancerline@macmillan.org.uk
Website: www.macmillan.org.uk

Cancer Research UK Telephone: 0808 800 4040
Website: www.cancerresearchuk.org

Maggies
Website: www.maggies.org

Carers UK
Telephone: 0808 808 7777
Email: adviceline@carersuk.org
Website: www.carersuk.org

Carers Trust
Website: www.carers.org/

NHS Choices Website: www.nhs.uk

UCLH cannot accept responsibility for information provided by other organisations.