CLINICAL INVESTIGATION
Temporal resolution of urinary morbidity following prostate brachytherapy

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Abstract

Purpose: To report the short-term urinary morbidity for prostate brachytherapy patients without a preimplant history of a transurethral resection of the prostate gland and who received prophylactic and prolonged α-blockers. α-blockers may decrease radiation-induced urethritis and increase urinary flow. Multiple clinical and treatment parameters were evaluated to identify factors associated with increased acute urinary morbidity.

Materials and Methods: One hundred seventy consecutive patients without a prior history of a transurethral resection of the prostate gland underwent transperineal ultrasound guided prostate brachytherapy for clinical T1c-T3a carcinoma of the prostate gland. For all patients, an α-blocker was initiated prior to implantation and continued at least until the international prostate symptom score (IPSS) returned to baseline levels. Clinical parameters evaluated for short-term urinary morbidity included patient age, clinical T stage, preimplant IPSS (obtained within 3 weeks of implantation), and prostate ultrasound volume. Treatment parameters included the utilization of neoadjuvant hormonal manipulation, the utilization of moderate dose external beam radiation therapy before implantation, the choice of isotope, the urethral dose, the total implant activity in millicuries, and a variety of dosimetric quality indicators (D90 and V100/V150/V200). Catheter dependency and the duration of α-blocker dependency was also evaluated. On average, 11.2 IPSS surveys were obtained for each patient.

Results: One hundred fifty of the 170 patients (88.2%) had the urinary catheter permanently removed on day 0. Only one patient required an urinary catheter for > 5 days. Two patients (1.2%) required a subsequent transurethral resection of the prostate gland because of prolonged obstructive/irritative symptoms. To date, no patient has developed an urinary stricture or urinary incontinence. The IPS score on average peaked at 2 weeks following implantation. This score returned to within 1 point of the antecedent value at a median of 6 weeks and a mean of 13.3 weeks. At 26 and 50 weeks, 85% and 56% of the patients, respectively, continued with α-blockers. Of the clinical and treatment parameters evaluated for short-term urinary morbidity, only variants of the IPSS such as the maximum, maximum increase, and preimplant IPSS values correlated with time to return to the referent zone with p < 0.05.

Conclusion: The return of the IPS score to baseline occurred more rapidly in our series than what has previously been reported. The 1.2% incidence of transurethral resections also compares favorably with the published literature. We believe these results may be due to maintaining the average urethral dose to approximately 115% of the prescribed dose and the prophylactic and long-term use of α-blockers.

Introduction

Over the past decade, transperineal ultrasound guided prostate brachytherapy has been increasingly utilized as definitive management for early stage carcinoma of the prostate gland. The results of prostate brachytherapy have been reported to be as favorable as the most positive radical prostatectomy series with a decreased incidence of urinary incontinence and sexual dysfunction 1, 2, 3, 4, 5. In addition, significant rectal injury is rare (6). A paucity of data, however, has been published regarding the short-term urinary morbidity following prostate brachytherapy. Almost all patients experience some degree of urinary irritative/obstructive symptomatology including urinary frequency, dysuria, urgency, interruption of the stream, incomplete voiding, straining, and nocturia; 3%–22% of patients develop acute urinary retention following prostate brachytherapy 4, 7, 8, 9, 10, 11. Terk et al. (7) were able to correlate the risk of urinary retention with the preimplant international prostate symptom score (IPSS). A recent controlled study concluded that peri-operative dexamethasone does not significantly alter short-term urinary morbidity (12).

The IPSS was developed by the American Urological Association (AUA) in 1992 as a measure of symptomatic relief following prostatectomy for benign prostatic hypertrophy. The generated score resulted in excellent test-retest reliability and was sensitive to change (13). Recently, the reproducibility of the IPSS index was revalidated (14). Barry et al. (13) reported “the AUA symptom index as clinically sensible, reliable, valid and responsive. It is practical for use in practice and for inclusion in research protocols.” The IPSS index has also been proven a useful tool for evaluating urinary symptomatology following prostate brachytherapy (7).

Herein, we report the short-term urinary morbidity for 170 consecutive prostate brachytherapy patients without a preimplant history of a transurethral resection of the prostate gland. α-blockers may decrease radiation-induced urethritis by relaxing urinary smooth muscle tone with a subsequent reduction in urinary flow resistance. In all patients, prophylactic α-blockers were initiated 2–3 weeks prior to implantation and continued until the IPSS declined at least as low as its preimplant value. Multiple clinical and treatment parameters were evaluated to identify factors associated with increased acute urinary morbidity.

Section snippets

Materials and methods

One hundred seventy consecutive patients without a prior history of a transurethral resection of the prostate gland underwent transperineal ultrasound guided prostate brachytherapy from December 1997 through early April 1999 using either 125I or 103Pd for clinical T1c–T3a carcinoma of the prostate gland. The choice of isotope was dependent upon Gleason score. Because of well-documented inaccuracies in Gleason grading, all cases originating from outside institutions were reviewed prior to the

Results

Table 2 details the clinical and treatment parameters of the evaluated patient population. The urinary catheter was removed on the day of implantation in 150 of the 170 implanted patients (88.2%). The pie chart in Fig. 1 illustrates that 10 of the 170 patients (6%) required a urinary catheter for > 2 days, and 5 of these patients (3%) required a catheter beyond 3 days. One patient was catheter-dependent for > 5 days (5 months). This patient, and one other, subsequently underwent a

Discussion

Over the past decade, prostate brachytherapy has been increasingly utilized as definitive management for early stage carcinoma of the prostate gland. The results of prostate brachytherapy have been reported to be as favorable as the most positive radical prostatectomy series with a decreased incidence of urinary incontinence and sexual dysfunction 1, 2, 3, 4, 5. A paucity of data, however, has been published regarding the short-term urinary morbidity following prostate brachytherapy. Almost all

Conclusions

One hundred fifty (88.2%) of the 170 patients in our series had the urinary catheter permanently removed on day 0, and 169 (99.4%) by day 5 following implantation. The mean patient IPSS values peaked at 2 weeks and returned to antecedent values on average at 13 weeks, with a median of 6 weeks. This return is significantly more rapid than what has previously been reported. The 1.2% incidence of transurethral resections also compares favorably with the published literature. Multivariate analysis

References (26)

  • L. Kleinberg et al.

    Treatment-related symptoms during the first year following transperineal 125-I prostate implantation

    Int J Radiat Oncol Biol Phys

    (1994)
  • H. Ragde et al.

    Interstitial iodine-125 radiation without adjuvant therapy in the treatment of clinically localized prostate cancer

    Cancer

    (1997)
  • H. Ragde et al.

    Brachytherapy for clinically localized prostate cancerresults at 7 and 8 year follow-up

    Semin Surg Oncol

    (1997)
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