The Implant Procedure Step by Step
All pre-op work is done well in advance, so ask your nurse for details. Some patients need to have a relatively recent EKG done, others will not. The date of the procedure is also scheduled well in advance, as the radioactive seeds of the correct strength and activity need be ordered.
If you usually take blood thinners such as aspirin, Coumadin, Warfarin, etc., these will need to be stopped ~ 1 week prior to the procedure. Please discuss these medications with the nurses regarding timing and starting them after the procedure. Other pre-op instructions regarding diet, etc. will be discussed with you by our nurses as well. An instruction packet explaining the pre-op steps will be mailed to you.
The day of the procedure you will check into the outpatient Ambulatory Surgical Center (ASC) 1-1 ½ hours prior to the procedure. The staff will do some confirmatory paperwork and take you to the Pre-Op area. In the Pre-Op area, a nurse will ask a few more questions, start an I.V. and introduce you to the anesthesiologist. The anesthesiologist will describe the anesthesia procedure prior to entering the operating room.
You will initially lie on the O.R. table and undergo either a light general anesthesia or spinal anesthesia depending on your choice and the anesthesiologist's recommendation. Most of our patients undergo a light general anesthesia.
In the O.R., the nurses will position you in the same position that you were in during the ultrasound volume study. They will clean the perineum with anti-septic solutions and instill 150-200cc’s sterile water into your bladder. Then they will insert a lubricated catheter into the urethra and inject a solution of air, lubricant and water through the urethra. This solution allows us to see the urethra during the procedure and avoid traumatizing it.
The nurses and Dr. Grimm or Sylvester will position you on the table, insert the ultrasound probe and begin visualizing the prostate. Once the prostate is positioned correctly, the entire system of probe and stepper/stabilizer/template needle guidance device will be locked into place and the needle insertion begun.
Following this step, Dr. Grimm or Sylvester and the urologist will insert each needle containing the radioactive seeds into the correct coordinate designed for your implant.
The needles are inserted in the region between the scrotum and anus through the perineal skin and into the prostate. Each individual needle is advanced into the coordinates according to the plan designed for you. After several needles are inserted, Dr. Grimm or Sylvester will again verify the exact 3-dimensional position for each individual needle.
When a needle is verified by both the urologist and Dr. Grimm/Sylvester, the stylet inside the needle will be advanced until the first seed reaches the tip of the needle. The needle will be slowly withdrawn by the urologist while Dr. Grimm or Sylvester hold the stylet which deposits the seeds. Since the seeds are connected, this will result in seeds deposited in a uniform manner along the length of that needle within the prostate. This process is repeated with each needle, starting from the most anterior row and progressing down to the most posterior row.
Quality Assurance Seed position is checked after each row of seeds are deposited and compared to the pre-plan.
After all of the planned seeds are inserted, we again evaluate the quality of the prostate coverage by ultrasound and X-ray.
If we feel additional seeds would be of potential benefit, we insert them under ultrasound guidance at that time. A CT scan the next day is performed to triple check the position of the seeds.
After the procedure, it is probable that we will perform a cystoscopy in a which a fiber optic rod is inserted into the penis and bladder. This is performed to remove any clots, check the general condition of the bladder and remove any seeds that may be seen .
After the procedure, you will be transferred to the recovery room with a catheter in your bladder. After you wake up and the anesthesia is sufficiently worn off, the nurses will remove the catheter and discharge you from the ASC. You will have printed instructions regarding your follow-up CT scan (usually the very next day) and appointments. The CT scan allows us to document the quality of the implant. We recently published
our dosimetry outcomes.
In order to reduce some of the swelling in the area below the scrotum, you can place an ice pack or bag of frozen peas on the perineum for 20 minutes, then off for 20 minutes and back on for 20 minutes, etc. that afternoon and evening. With the new treatments, it is often not necessary. A non-steroidal anti-inflammatory medication (Aleve or Celebrex) for 3-4 weeks is given to you to help reduce swelling , improve urination and decrease any initial pain. An alpha-blocker (Flomax, Uroxatrol, etc.) 1-2 per day will be necessary typically for 4-12 months. An antibiotic (Cipro or Sulfa) for 1 week is also prescribed. You can do normal exercises but avoid any activity that would put constant pressure on the prostate such as horseback riding, bicycle riding, etc. for the first three to four months. You can do most normal activities within a day or so. If you have a question about a physical activity, ask your nurse.