EARLY AND LATE COMPLICATIONS OF PROSTATE LOW DOSE BRACHYTHERAPY DZNELADZE, MD, PhD G. BOTCHORISHVILI, MD, PROF. A. BOCHORISHVILI, MD

Prostate Brachytherapy accounts more than one century Prostate Brachytherapy accounts more than one century. First attempt to treat prostate cancer with radiation was done in 1901 in Paris, France.

Different techniques and different radioactive materials had been used to treat prostate cancer

Results were controversial until 80th, when ultrasound developed and industry offered transrectal approach and commercially available I125 and P103 seeds.

One of the first patients treated by modern Prostate Brachytherapy – Low Dose Radiation

LDR - the method we use to treat patients with prostate cancer since 2010

Awareness among patients and even among urologists was and is still poor

Clinical Stage Gleason Score PSA (ng/ml) Low T1-T2a 2-6 <10 National Comprehensive Cancer Network Risk Group Definitions for Clinically Staged Patients Clinical Stage Gleason Score PSA (ng/ml) Low T1-T2a 2-6 <10 Intermediate T2b-T2c 7 10-20 High T3a-T3b 8-10 >20 Very High T4 Node Positive

Different kinds of techniques are proposed to plan and insert radioactive materials into the prostate Pre-treatment planning with previously loaded needles. Real-Time planning with sophisticated software to plan and insert seeds. Peripheral planning & inserting the seeds using Mick Applicator.

Peripheral planning & inserting the seeds using Mick Applicator

Very High T4 Node Positive National Comprehensive Cancer Network Risk Group Definitions for Clinically Staged Patients Clinical Stage Gleason Score PSA (ng/ml) Low T1-T2a 2-6 <10 Intermediate T2b-T2c 7 10-20 High T3a-T3b 8-10 >20 Very High T4 Node Positive

We insert transrectal transducer (ultrasound scanner B&K) to visualize prostate, make Real Time planimetry and control seed placement

We calculate number of seeds, which is necessary to give to the prostate mPD 144Gy

Transperinealy we insert peripheral needles and than implant seeds (using Mick Applicator. Number of seeds implanted peripherally is 75% of that totally prescribed. 25% of seeds we implant internally

Seed implantation is checked by X-ray immediately after the procedure

From 2010-2017 years 51 Patients

Hematuria after LDR. TUC. (e) N Patient # age Initial stage Initial PSA Initial PV Initial GS Vmax After5 years   PV Complication Death 1 68 y T1c 12,1 35cc 3+3 12ml/s 0,21 22cc 11ml/s no 2 62 y T2a 15,1 50cc 3+4 10ml/s 0,32 40cc 3 65 y 12,0 49cc 13ml/s 0,5 38cc 16ml/s 4 54 y 14,9 42cc 0,23 15ml/s 5 78 y 9,5 80cc+adt =50cc 0,65 55cc 6 T2b 19,0 4+3 17ml/s + 10,5 30cc 14ml/s Hematuria after LDR. TUC. (e) 7 74 y 18,1 45cc ++ 0.01 25cc ADT 8 10,0 48cc 0,16 9 71 y 16,5 44cc 0,2 32cc 10 12,5 0,6 36cc 11 70 y 9,6 13,0ml/s 26cc 12 72 y 15,6 9ml/s 0,1 13 76 y 16,0 0,8 Dysuria (e+l) 14 16,1 +++ 9,1 Hormonal Mono Scheduled salvage RP 15 9,8 16 5,6 0,3 17 6,8 Dysuria (e) 18 8,1 39cc 19 66 y 1,0 20 67 y 0.1 21 59 y 5,0 0,01 20cc 22 7,1 34cc 23 8,0 24 17,8 ++++ TURP 25 69 y 10,6 0,9 Proctitis (l) 26 7,6 33cc 27 16,7 +++++ - Cancer related 28 7,2 29 11,0 37cc

29 Patients Average age – 68 Highest PSA - 18.1ng/ml

Histological 18 patients Gs6 3+3 (Grade 1)

Prostate volume 30-50cc Urodynamics Vmax lowest 9,1ml/s

During 5 years PSA control every 3 month TRUS every 6 month

Cancer status for 5 years

4 patients cancer recurancy 3 patient – ADT 1 Patient died due to cancer progression 1 patient is waiting for salvage prostatectomy

Early Complications Two cases of Urine Retention: 1 case retention 1 case with hematuria

Early Complications

Late complications

Conclusion Prostate Low Dose Radiation is well accepted method of treatment of prostate cancer in Low and sometime Intermediate Risk patients. This method is recommended by guidelines of Urology and Radiation Oncology associations. We know, that modern approach to manage low risk patients is also active survilance. Though, many patients diagnosed with prostate cancer are anxious and demand to be treated. Prostate Low Dose Brachytherapy is good option to offer to those patients. This is effective method of treatment with comparably less complications. Number of early and late complications, we observed are limited to urine retention, bleeding and inflammation associated with radiation. Any inflammation lasts until radiation expires. Urine retention and bleeding must be treated surgically. Although surgeon must aware, that intervention after radiation should be minimal. We had no case if urine incontinence after implantation. We know, that this is rare complication and in most of the cases it happens after TURP.

Thank you for your attention.