Urinary morbidity following ultrasound-guided transperineal prostate seed implantation

Purpose: To assess the urinary morbidity experienced by patients undergoing ultrasound-guided, permanent transperineal seed implantation for adenocarc inoma of the prostate, Methods and Materials: Between September 1992 and September 1997, 693 conse cutive patients presented with a diagnosis of clinically localized adenocar cinoma of the prostate, and were treated with ultrasound-guided transperine al interstitial permanent brachytherapy (TPIPB), Ninety-three patients are excluded from this review, having received neoadjuvant antiandrogen therapy . TPIPB was performed with I-125 in 165 patients and with Pd-103 in 435 pat ients, Patients treated with implant alone received 160 Gy with I-125 (pre TG43) or 120 Gy with Pd-103, One hundred two patients received preimplant, pelvic external beam radiation (XRT) to a dose of either 41.4 or 45 Gy beca use of high-risk features including PSA greater than or equal to 10 and/or Gleason score greater than or equal to 7, Combined modality patients receiv ed 120 Gy and 90 Gy, respectively for I-125 or Pd-103. Atl patients underwe nt postimplant cystoscopy and placement of an indwelling Foley catheter for 24-48 h, Follow-up was at 5 weeks after implant, every 3 months for the fi rst 2 Sears, and then every 6 months for subsequent years, Patients complet ed AUA urinary symptom scoring questionnaires at initial consultation and a t each follow-up visit. Urinary toxicity was classified by the RTOG toxicit y scale with the following adaptations; grade 1 urinary toxicity was sympto matic nocturia or frequency requiring none or minimal medical intervention such as phenazopyridine; grade 2 urinary toxicity was early obstructive sym ptomatology requiring alpha-blocker therapy; and grade 3 toxicity was consi dered that requiring indwelling catheters or posttreatment transurethral re section of the prostate for symptom relief. Log-rank analysis and Chi-squar e testing was performed to assess AUA score, prostate size, isotope selecti on, and the addition of XRT as possible prognosticators of postimplant urin ary toxicity, The prostate volume receiving 150% of the prescribed dose (V1 50) was studied in patients to assess its correlation with urinary toxicity , Results: Median follow-up was 37 months (range 6-68), Within the first 60 d ays, 37.3% of the patients reported grade 1 urinary toxicity, 41% had grade 2, and 2.2% had grade 3 urinary toxicity. By 6 months, 21.4% still reporte d grade 1 urinary toxicity, whereas 12.8% and 3% complained of grade 2 and 3 urinary difficulties, respectively. Patients with a preimplant AUA score less than or equal to 7 had significantly less grade II toxicity at 60 days compared to those with an AUA score of >7 (32% vs, 59.2%, respectively, p = 0.001). Similarly, prostatic volumes less than or equal to 35 cc had a si gnificantly lower incidence of grade LI urinary toxicity (p = 0.001), There was no difference in toxicity regarding the isotope used (p = 0.138 at 60 days, p = 0.45 at 6 months) or the addition of preimplant XRT (p = 0.069 at 60 days, p = 0.84 at 6 months), Twenty-eight patients (4.7%) underwent TUR F after 3 isotope half-lives for protracted obstructive symptoms. Five of t hese men (17%) developed stress incontinence following TURF, but all patien ts experienced relief of their obstructive symptoms without morbidity at la st follow-up. The percent of the prostate receiving 150% of the prescribed dose (V150) did not predict urinary toxicity, Conclusions: TPIPB is well tolerated but associated with mild to moderate u rinary morbidity, Pretreatment prostatic volume and AUA scoring were shown to significantly predict for grade 2 toxicity while the use of preimplant, pelvic XRT and isotope selection did not. Patients undergoing TURF for prot racted symptoms following TPIPB did well with a 17% risk of developing stre ss incontinence. V150 did not help identify patients at risk for urinary mo rbidity, As transperineal prostate implantation is used more frequently the associated toxicities and the definition of possible pretreatment prognost ic factors is necessary to properly inform patients of their treatment opti ons. This prospective report documents the results from a large cohort of p atients treated with modern techniques and should help guide future practic e. (C) 1999 Elsevier Science Inc.