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As of January 1, 2000 the Urology Wellness Center joined with the Fairfax Urology Ltd., in Association with Wm. In recent years insertion of radioactive seeds into the prostate has become a routine treatment for prostate cancer.
Before the advent of seed implant, a man’s choices for addressing clinically localized prostate cancer included radical prostatectomy or external beam radiotherapy. To be eligible for seed implant alone, a man should have Stage T1-T2 disease, Gleason score 6 or less, PSA less than 10, and a prostate size less than 50 cc. When external beam radiotherapy is used in combination with seed implant, the patient typically receives a 4-5 week course of external beam radiation therapy. In some men hormone therapy, also known as androgen deprivation therapy, is given in the form of Lupron prior to starting treatment with radiotherapy. Once the patient decides to proceed with seeds, the next step includes evaluation by our radiation oncology colleagues. The seeds are implanted using needles which are placed through the perineum (this is the area in back of the scrotum and in front of the anus).
An ultrasound probe is present in the rectum to guide proper needle placement and seed distribution.
After the procedure, patients are allowed to resume their normal activity within the first week. Long-term complications associated with the procedure include erectile dysfunction, urinary frequency and urgency, and bowel irritability. Localized prostate cancer is cancer that is confined within the prostate and has not spread to other sites, which is to be distinguished from prostate cancer that has spread beyond the prostate to other parts of the body. As men grow older, they experience the normal age-related, noncancerous enlargement of the prostate (also known as benign prostatic hyperplasia, or BPH). Prostate cancer, when it first begins and is in its early stages, may not cause any symptoms.
Current patterns of practice include two tests to screen for prostate cancer, the digital rectal exam and PSA. The PSA is a blood test done to measure the level of PSA, prostate specific antigen, which is a protein made by the prostate. If there is a concern that prostate cancer may be present, for example if there is an abnormal digital rectal exam or an elevated PSA, then further evaluation is carried out with transrectal ultrasound (TRUS) and prostate biopsy.
Grade is a term used to describe the microscopic appearance of the prostate cancer, and can help predict the potential aggressiveness of prostate cancer. From a practical point of view, clinical experience shows that most patients with prostate cancer have Gleason scores between 6 and 10. Furthermore, those cancers confined to the prostate can be more successfully treated than those that have spread beyond the prostate. Life expectancy, rather than patient age, is important to keep in mind when choosing a treatment.
An assessment of a patient’s health status includes review of their current medical problems, including consideration of the seriousness of any coexisting diseases, and evaluation of the family history of medical problems. The three most common treatments for localized prostate cancer are expectant management, which includes active surveillance and watchful waiting, radiation therapy and surgery. Active surveillance or watchful waiting is based on the recognition that some prostate cancers follow a nonaggressive course, and tend not to spread outside the prostate or become life threatening.
Radiation therapy, includes two types: interstitial prostate brachytherapy and external beam radiation therapy.
Other treatments, such as cryotherapy, have been used for the treatment of localized prostate cancer, but have not been widely used. Watchful waiting and active surveillance have two main advantages – low cost and no immediate complications. In watchful waiting, the prostate cancer is left as is, and treatment is initiated if there are signs that the prostate cancer is causing clinical problems.
Active surveillance may be a favorable choice in men who have low risk disease, including those who have longer life expectancies. The main disadvantage of watchful waiting and active surveillance is that over time the cancer may become worse and even untreatable. Interstitial prostate brachytherapy is a therapy that places radiation seeds within the prostate. External beam radiotherapy uses carefully directed radiation directed at the prostate in an effort to kill the prostate cancer cells. Both forms of radiation (prostate brachytherapy and external beam radiotherapy) may cause urinary or bowel difficulty, and can predispose to erectile dysfunction. The main benefit of this operation is that it offers the potential to remove all the cancer. The main disadvantages of radical prostatectomy are the hazards associated with the procedure.
Urinary incontinence (unwanted loss of urine) after radical prostatectomy occurs in a subset of men, but usually lessens or stops with time. This rat model is the most widely used animal model of hypertension and develops many features of human hypertensive end-organ damage such as cardiac hypertrophy, cardiac failure and renal dysfunction.
Spontaneous severe hypertension with blood pressure stabilization around 12 weeks of age (>160 mmHg). Figure 2: In vivo (left panel) and in vitro (right panel) evidence of erectile dysfunction in 12 week-old SHR. Exhibits abnormal bladder function: decreased bladder capacity and voided volume, increased urinary frequency, and occurrence of non voiding contractions associated with changes in the noradrenergic control of the micturition reflex. Childrens urology you can count on treating kids and toddlers urological issues such as bed wetting, urinary frequency, hernias and testicle issues. NC HIFU is a cutting-edge new treatment for men who have been diagnosed with Prostate Cancer and are seeking alternative treatments. As 21st Century medical technology improves, healthcare is more and more working with less invasive procedures that eschew the expensive cost of overnight hospital stays and negative side effects of trauma, risks and pain that come with surgery. Associated Urologists of North Carolina has been working in the Clinical Research industry for more than thirty years. About AUNCAssociated Urologists of North Carolina is one of the largest urology specialty group practices in North Carolina.
Urology is the branch of medicine and surgery dealing with the diagnosis and treatment of disease of the urinary tract (kidney, ureter, bladder, prostate, genitalia, etc.) Services available include diagnosis and treatment of infection, obstruction, bleeding, tumors or growths, urinary incontinence and urinary tract diseases in children.
Please see our Patient Education section for printable information on other urological conditions and treatment. With this technique, known as brachytherapy or interstitial radiation therapy, rice-sized seeds are implanted into the prostate.

Now, seeds can be used alone or in combination with external beam radiotherapy and hormonal therapy (see below) to treat clinically localized prostate cancer.
These include the stage and grade of the prostate cancer, the PSA level, and the size of the prostate. If these criteria are not met, then seed implant may be combined with external beam radiotherapy or hormonal therapy in the form of Lupron. The urologist and radiation oncologist jointly decide on the optimum form of therapy for an individual patient. Antibiotics are started several days in advance of the procedure to reduce the risk of infection. The hospital tells the patient when to arrive, which is typically two hours in advance of the procedure. It is normal to see blood in the urine or in the bowels on an intermittent basis for the first several weeks. It is about the size of a walnut and is located below the bladder and in front of the rectum. It is the second most common type of cancer found in American men and the second leading cause of cancer death among American men.
As the prostate enlarges, it can crowd the urinary pathway and make urination more difficult.
Urinary symptoms may be present but they are usually due to the prostatic enlargement described above. The digital rectal exam is a physical exam performed by a medical practitioner to feel the surface of the prostate (a lubricated, gloved finger is placed in the rectum to feel the prostate). PSA elevation is nonspecific, and an elevated PSA may be a due to prostate enlargement, inflammation (which can include urinary infection), or may be the first sign of prostate cancer. Grade can be used as a measure to assess how likely a prostate cancer is to grow and spread. Cancers that have spread beyond the prostate to the lymph nodes or bone have less favorable outcomes with treatment.
A man’s health may also help predict how likely he is to experience hazards related to treatment. Some men want their cancer removed, without consideration of age, grade or stage, and are willing to face potential hazards of surgery for the chance of complete resolution of their cancer.
PSA and a digital rectal exam need to be checked on a regular basis, and repeat prostate biopsies should be carried out at regularly scheduled intervals.
With interstitial prostate brachytherapy, small radioactive “seeds” are planted in the prostate.
Watchful waiting is used in men who have a short life expectancy, due to their other health problems, so they can avoid hazards related to treatment.
Factors which predict low risk disease include low Gleason score (6 or less), PSA level less than 10, and low volume disease (less than half the biopsies positive, and no more than 50% of any one biopsy core positive). It is not always possible to predict when a prostate cancer progresses and spreads beyond the prostate. The advantage of brachytherapy is that it is a single outpatient anesthesia-based procedure. Irritative urinary tract symptoms can include urinary frequency, urgency, and pain or burning with urination. Treatment by radical prostatectomy offers the man with cancer that has not spread outside the prostate the possibility of freedom from the disease for the rest of his life.
Other problems associated with radical prostatectomy include irritation of the bladder, gastrointestinal symptoms, bladder infection, and blockage of the urine flow from the bladder. High Intensity Focused Ultrasound (HIFU) is a revolutionary and minimally invasive urology procedure used to fight and remove prostate cancer with almost no side effects or inpatient hospital stays.
The new HIFU procedure uses Sonablate® ultrasound technology that removes cancerous cells in the male prostate without a single incision or scalpel, affecting only the unhealthy tissue.
The advantage of seeds compared to external radiation is the delivery of an increased dose of radiation to the prostate cancer cells in an effort to produce better long-term outcomes.
Stage refers to the anatomic extent of the prostate cancer (as outlined in the separate prostate cancer newsletter). Seed implant then follows several weeks after the conclusion of external beam radiotherapy. Even though patients are told not to eat or drink after midnight the night before the procedure, they should still take their antibiotic pill with a sip of water on the morning of the procedure itself. As the technique has become wide spread, it is clear that seed implant provides benefit for a majority of the patients who favor its minimally invasive nature. It forms the first part of the urethra, the tube that carries urine from the bladder through the penis. Once men reach the age of 40, they may start to notice changes in urination, which can include slowing of the urinary stream and increased frequency of urination both day and night. The best way to detect prostate cancer at its early stage is with screening, which currently includes an annual digital rectal exam (also called a DRE) and a PSA blood test.
The prostate can be assessed to determine if there may be a hard spot, or an area of asymmetry, which may be a sign of prostate cancer. Furthermore, PSA is not always elevated when prostate cancer is present and there may be prostate cancer even with a normal PSA (which is why the DRE needs to be done too).
Needle (core) biopsy of the prostate is taken in a grid-like systematic fashion to obtain samples of the prostate. The grading system most commonly used is called the Gleason score, which ranges on a scale from 2 to 10. Higher Gleason scores (8 through 10) indicate more aggressive tumors which have the potential to have spread beyond the prostate. When the cancer is low volume, and confined to a small area of the prostate, treatment outcomes are improved compared to those situations where the prostate cancer involves a significant portion of the prostate gland. For prostate cancer that is confined to the prostate, it may take several years until it spreads beyond the prostate and several more years after that before those areas of cancer spread can cause clinical problems.
Younger men are less likely to experience treatment-related changes in urinary or sexual function.
Others may be worried about the effect of treatment on their quality of life, and choose their treatment to minimize the risk of developing unwanted hazards of treatment, such as urinary leakage or erectile dysfunction. If during the monitoring period the cancer shows signs of growth or of becoming a more aggressive tumor, then treatment with surgery or radiation can be initiated. The seeds deliver radiation energy to the prostate over the course of four to six months which can “kill” the prostate cancer cells. The term “radical” means that the entire prostate and nearby tissues are removed through surgery.

Studies show that men with localized, low grade prostate cancer have a reduced risk of the cancer spreading in the first ten years after diagnosis. In men who have chosen active surveillance, and on follow-up are noted to have signs of progression of their prostate cancer, treatment can be initiated at that point, which can include radical prostatectomy or radiation to the prostate.
Hazards associated with treatment include urinary incontinence and erectile dysfunction, which may happen less frequently with radiation when compared with radical prostatectomy. As with other radiotherapy treatments, erectile dysfunction and urinary incontinence may develop. Radiation treatments are given on a daily basis, five days a week, for a seven- to eight-week treatment period. Patients are in the hospital for one to three days postoperatively and are sent home with a catheter (urinary drainage tube in the bladder) which is removed after one to two weeks. If the cancer has already spread beyond the prostate, then removing the prostate may not lead to cancer cure and additional therapy may be needed.
The chance of having erectile dysfunction depends on a man’s age and health, his sexual function before treatment, the stage of the cancer, and the ability to save the nerves that control erection during the surgery.
Rarely, scarring may occur at the junction of the bladder and the urethra and may require an outpatient procedure to address.
These research studies offer our patients medical alternatives and different procedures in the management of their health care. We provide the most advanced diagnostic treatment options for male, female, and pediatric urological problems. Grade refers to the histologic appearance of the prostate cancer cells and glands as visualized microscopically. There is some evidence which suggests that prostate cancer cells are more sensitive to external radiation when testosterone is absent. When the prostate is less than 50 cc, seed implantation is technically easier because the pubic bone is not in the way during the placement of the needs to introduce the seeds. If hormonal therapy is required, the patient typically receives a Lupron shot first and then begins his subsequent treatment within several months. Patients are also started on an alpha blocker to make urination less problematic postoperatively. Patients are in the recovery room for several hours after the procedure, following which they are discharged to home. Most men notice an increase in frequency and urgency of urination for the first several months after their procedure. The ultrasound does not specifically show areas in the prostate that are suspicious for prostate cancer. In general terms, there are five different recognized patterns of prostate cancer (five different ways it can look under the microscope). With the recognition that there may be a long timeframe for prostate cancer to cause trouble, older men who have other serious health problems may be less likely to suffer ill effects from advancing prostate cancer and so may not require treatment. However, the potential exists that the disease may have already spread beyond the prostate, and if so there is the potential for those men to suffer from progressing prostate cancer. Changes in urination may include increased frequency and urgency, and more frequent urination at night.
Current technology allows radiation to be delivered to the prostate while minimizing exposure to adjacent structures, such as the bladder and rectum. Younger men (those under 60 years of age) are less likely to have problems with their erections than are older men.
As we continue our research, we strive to be on the cutting edge of medicine in every possible way that benefits our patients and communities. Our patients can access our expertise through our offices in Raleigh, Cary, Wake Forest, Clayton, Dunn, and Clinton. For those men whose prostates are larger than 50 cc in size, pretreatment with Lupron may be carried out to reduce the size of the prostate to make subsequent seed implant easier. If external beam radiotherapy is part of the treatment plan, the patient typically receives his 4-5 weeks of external radiation followed by the seed implant procedure. An alpha blocker, such as Flomax, Uroxatral, Hytrin or Cardura, is started on a once-daily basis. However, for men who have a long life expectancy, who are likely to live for at least 10 more years, they are more likely to benefit from treatment, particularly if their prostate cancer is in a medium or high risk category of aggressiveness. External beam radiation therapy uses radiation delivered from an external source (an x-ray beam) to treat prostate cancer. Fortunately, current radiation therapy techniques are designed to minimize trauma to adjacent structures. On a side note, men who have underlying bowel disease, such as Crohn’s disease or ulcerative colitis, may be less suitable candidates for radiation therapy because of the increased potential for bowel difficulty.
If erectile dysfunction does occur after surgery, erections may return to normal over time.
Our continued participation in research proves our commitment to bring the latest urology technology to you, our patient. Loose bowel movements and increased frequency of bowel movements may occur during the first several months after treatment. Once the samples are removed, a pathologist can look at the prostate biopsies under a microscope to determine if cancer is present. One disadvantage of radiation therapy is the prostate remains, so it is possible for some cancer to persist and potentially progress in the future. Erectile dysfunction is less likely to develop in the period immediately after treatment but is more likely to develop over time. Hazards of biopsy include blood in the urine, stool or semen; infection and inability to urinate. In most cases, there is more than one pattern present, so the two most common patterns are identified.
The Gleason score is a summary of the two most common patterns (for example, if there are some areas of Gleason grade 3 and other areas of Gleason grade 4, the cancer may be assigned a Gleason score of 7).
Without testosterone, the PSA typically declines significantly and the prostate cancer cells become inactive.
Effects associated with Lupron therapy include loss of libido (sexual drive and interest) and diminished or absent erection.

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