Radioactive Seed Implant
Potential Complications of Prostate Brachytherapy
The prostate brachytherapy procedure is usually well tolerated with temporary urinary tract side effects that resolve. Unfortunately, this is not always the case. Rarely, severe urologic or rectal complications have occurred following the brachytherapy procedure. A more detailed list of potential complications follows. When one reviews this list, he needs to keep in mind that similar magnitude complications may be seen following any potentially curative therapy for prostate cancer.
Potential brachytherapy complications:
Mild:
- Some patients may have a permanent change in quality and/or frequency of urination, usually responsive to Flomax or similar medication, and not severe enough to affect the patient’s lifestyle.
- Dysuria (pain with urination) – Rarely this will be a significant and long lasting condition after prostate brachytherapy, though with eventual resolution in the vast majority of patients who have it. Very rarely it will take several years to fully resolve.
- Blood in the urine – This may occasionally be seen long after the brachytherapy procedure. If it occurs greater than 6 months after the brachytherapy procedure, it should be fully evaluated by a urologist to exclude other causes such as a bladder tumor. If the bleeding is secondary to the brachytherapy procedure, it has normally not caused any serious health problems and eventually resolved.
- Rectal bleeding – This is seen in a minority of patients after brachytherapy, due to injury of small blood vessels in the rectum by radiation from the seeds. If seen, this condition usually responds to conservative treatment or resolves spontaneously. Rarely it will persist or require more intensive management, such as argon-plasma laser photocoagulation of bleeding points along the anterior rectal wall, over the prostate. We advise that no treatment of rectal bleeding occur without discussing it with one of our radiation oncologists first. If managed incorrectly, rectal bleeding may progress to a rectal ulcer or fistula – a more severe complication (see below).
- Seed migration to the lung – Some patients have had one or more seeds travel through the blood stream to the lung(s). There are have been no described adverse health consequences when this has occurred.
- Erectile dysfunction – The incidence of this complication depends on the age and health of the patient prior to treatment. Younger patients with good pre-existing erectile function tend to have a better chance of potency preservation, while older patients, diabetic patients, smokers or those with pre-existing erectile dysfunction have a higher chance of losing their potency function after the treatment. Some patients experience a temporary disturbance in their potency function after brachytherapy, which recovers over time. Patients that develop significant erectile dysfunction after brachytherapy often respond well to sildenafil (Viagra).
Severe or Potentially Severe:
- Incontinence of urination - Some patients have had temporary urgency incontinence after the brachytherapy procedure (meaning if they get the call they must void immediately or they will wet themselves). This condition normally improves to complete resolution over time. Rare patients will have permanent incontinence – most likely to occur if a trans-urethral resection of prostate (known as a “TURP”) occurs after the brachytherapy procedure. In our experience, patients who have had a TURP procedure prior to the brachytherapy procedure have normally done well from a urologic viewpoint, as long as a peripheral loaded brachytherapy technique was done.
- The incidence of permanent severe incontinence after prostate brachytherapy is approximately 1%. If a patient develops severe permanent incontinence, he may be a candidate for urologic surgery such as an artificial sphincter placement, to attempt to improve the condition. This surgical procedure is often successful.
- Urethral stricture – This means scarring and narrowing of the urethral tube after the brachytherapy procedure. This may or may not become a severe complication, but if it occurs it may increase the chance of severe voiding problems or incontinence. Some patients will become permanently obstructed to urinary flow if this complication develops, mandating surgical correction. Surgery on a prostate after it has received brachytherapy may increase the risk of surgical complications, potentially culminating in permanent urinary incontinence. Urethral strictures are not a common occurrence after brachytherapy.
- Rectal Ulcer – This means a chronic, potentially painful bleeding area in the anterior rectal wall over the prostate, which may cause a major disruption in the patient’s quality of life. This is a serious complication of brachytherapy whose incidence is on the order of 1%. Surgical measures or hyperbaric oxygen treatments may be required to treat it.
- Bladder injury – Rarely a patient will develop severe urinary bleeding or scarring as a result of radiation injury to the bladder. Surgical measures or hyperbaric oxygen treatments may be required to treat it. This is rare.
Catastrophic:
- Urethral to rectal fistula – This means a hole formed between the rectum and the urethra and requires major surgery, potentially including urinary and rectal diversion, with ileostomy and/or colostomy.
- Colostomy (diverts the stool) – May be the end result of a fistula or rectal ulcer
- Ileostomy (diverts the urine) – May be the result of a fistula or a very severe urinary tract injury.
- Fortunately, the incidence of a major surgical complication is very rare, on the order of 1/500 patients in our experience.
- Seed migration to the heart – There has been one case described in the literature (not ours) where a patient had two seeds embolize to the heart, lodging in or near the heart’s natural pacemaker, identified as the potential cause of cardiac death in that patient. The incidence of this complication appears to be on the order of 1/100,000 patients
