Paletsky Prostate Seed Implantation
PREOPERATIVE DIAGNOSIS:
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POSTOPERATIVE DIAGNOSIS:
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POSTOPERATIVE CONDITION:
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TYPE OF PROCEDURE:
PROSTATE SEED IMPLANTATION
PROCEDURE:
The patient was brought into the operating theater and was placed under general
anesthesia in the dorsolithotomy position. Great care was taken at this time to make sure
the patient was situated in a symmetrical ara on the operating tale so that each of the leg
stirrups were brought in and out, and descended in a position that kept this patient
identically symmetrical so that there would be no disparity in the seeds. The
anesthesiologist was instructed to keep the patient under anesthesia so that he would not
move, and therefore we would not have to reassess him once we found the location of the
bladder neck and a reference point which we could relate to his mapping study.
The scrotum was taped up. I had then brought the base and the working tripod to the end
of the table. A standard measurement was made from the tripod to the base of the table,
and this was recognized both on the right and the left sides, measuring it to the table so
that it would be flat toward the table and would not be turned. I elevated the tripod to an
area which would accommodate where the seeds would be placed, and where the probe
could be inserted.
At this time, I removed the air from the inner protective rubber on the 7.5 Mhz probe from
the Proscan unit. Care was taken that air bubbles were removed.
I then placed a well-lubricated condom over this and wrapped it around the ultrasound
probe. The working carriage was placed over this and tightened in an appropriate fashion.
I had examined the patient's rectum at this time finding that there was no stool. The probe
was inserted and I tried to put a significant amount of grease into the patient's rectum to
accommodate this. I then placed the probe/carriage on to the working tripod.
At this time, I had scanned this patient, going from the bladder base to the apex of the
prostate. I tried to seek out the hypoechoic area which represented the carcinoma in this
patient. I then placed the probe near the bladder base noting the seminal vesicles,
urogenital diaphragm, and the base of the prostate. I then went inward to get a better
representation of the prostate with a clearer ultrasonic picture.
The present picture was approximated to the mapping study performed at the time of
dosimetry. I then performed a separate mapping dosimetry study by first referencing the
entire prostate from the base to the apex while the patient was under general anesthesia.
An accurate representation of where the base of the prostate was, was carefully
ascertained. At 0.5cm increments I then retracted the stepping device and traced the
outline of the prostate margin so that I could clearly get a second evaluation of the prostate
for dosimetry purposes. We made our calculations on a retraction plane of 0.5cm. Care
was taken that there would be no abnormalities of this reference point, and that it was
clearly marked as to the base, every succeeding 0.5cm increment, and the apex of the
prostate.
The seeds were then brought into the room in the pre-studied dosimetry package, and
conformed to the present dosimetry package performed at this time while the patient was
under anesthesia. We then placed the template guide on the ultrasound at 65
magnification which was used for the original dosimetry scheduling for gross volumetric
measurement, and the same magnification for the present dosimeter's more accurate
measurement.
In short, we tried to make this patient immobile and to try to be precise in the location of the
prostate in relationship to where the template was located, and to where the seeds are to
be implanted.
At this time I had placed the seeds in the following fashion.
I had used the pre-loaded needles with wax at the end through the template in a
predetermined area. I had first checked the needles to make sure there was wax on the
ends and that the needles were not devoid of seeds. The needles were implanted in such
a manner so their bevel would be angled toward the direction necessary to be in a precise
location. We had run across the most anterior portion of the prostate going from the
patient's right side to the left side, going from the highest elevations (anterior surface) to the
most posterior portion of the patient, which was the lowest area. In this manner, we had
less interference with the seeds as noted on the ultrasound. If stones of prostate were
noted, we tried to make note of these so that we would not misinterpret these stones as a
seed or misinterpret the end of the needle with the stone.
Each needle was placed in the patient to where it was seen on the ultrasound. I then
retracted and brought the needle in further, changing the bevel into the direction where one
needed to be for an exact location of the seed as noted in the template guidance scheme
relating to the ultrasound. Once getting into this area, I pushed the needle in approximately
0.5cm and then retracted it, and then spun it around so that there would be no upward or
downward deflection of the prostate, allowing seeds to remain in their exact location.
I then placed the hub of the needle against each of these seeds, without pushing it through.
This was affixed to the ultrasound probe itself so that it would be immobile, and so that it
would not be brought forward or backward to displace the seeds when they were allowed to
be implanted. I then retracted the hub of the needle into the base in order to drop the
seeds in the prostate fossa in the proper fashion.
Throughout this procedure, care was taken to get these seeds into the precise location. I
conferred with a radiation oncologist and physicist to help me make this determination, and
on occasion some seed were changed to accommodate the dosimetry package.
If and when the pubis was hit, we re-angulated the needle so that we could get this area of
the prostate as well as possible.
The seeds were implanted to encompass the entire prostate in a diffuse pattern. No
portion of the prostate was left untreated. We had tried to go very close to the rectal area,
being approximately 2-3mm away from this. Each seed was attempted to be placed within
1-2mm from the template/ultrasonic guidance point.
At this time, we felt secure that there was good location of the seeds. I then removed the
ultrasound probe and removed the tripod with the associated base away from the patient.
A KUB was taken to affirm that the seeds were in a good location. We had also checked
for any cold spots of this area.
At this time, a careful evaluation of the perineum failed to show any seeds extruded.
The next portion of the procedure included a cystoscopy and removal of any foreign bodies,
that is to say, any seeds.
The patient ws re-prepped and draped, leaving him in a dorsolithotomy position, and then
removing the scrotal support. He was prepped with Betadine solution and appropriately
draped at this time. I had catheterized the patient with the 21 Storz Cystourethroscope
under direct vision. At this time, the findings were as noted in the prior cystoscopies that
the patient had.
The urethra was normal. The prostate was as noted on prior cystoscopy. The bladder was
again investigated. Any seeds in the bladder were then removed. The number of these
were subtracted from the overall seeds implanted into the patient. We had counted the
number of seeds on the KUB and compared that to the number which we thought we had
implanted. We had also subtracted the number that was taken out of the bladder and
prostate fossa. The overall number of seeds was then noted by the radiation oncologist in
his records.
At this time, a calibration of the urethra and prostatic fossa was determined using bougie a
boule's. This was performed after the cystourethroscope had been removed.
The patient tolerated the procedures well and was taken to the recovery room after being
carefully monitored. No operative complications were noted. The estimated blood loss
was indeterminate since this was just a needle placement and the patient could have bled
into the prostate fossa. In essence, the blood loss was felt to be insignificant. The
perineum was again checked to ensure there would be no significant bleeding in the
perineal areas.
The patient tolerated this procedure well and was taken to the recovery room in satisfactory
condition, as noted.
The patient was instructed to see me in the office in two to three weeks and is instructed to
follow up with Doctor. ? ? in his office in two to three weeks.
Ultimately, as discussed with the patient, we will be performing additional rectal
examination every six months. We will also be performing a PSA level every six months.
We will be performing a prostate ultrasound on a yearly basis.
The patient is discharged on CIPRO 500mg 1 B.I.D. times one week, refill times one.
The patient is instructed that if he cannot urinate, that he is to call me. We have discussed
postoperative urinary retention, and the patient is to contact me if such is the case.
The patient is instructed to call if any problems arise, or if he has any additional questions.
He may call me at any time of the day or night, as noted to him.
The patient is also instructed that he may have some perineal discomfort with this, but
should not see any significant mass lesion. A minor amount of ecchymosis and swelling is
expected.
The patient will also need a CAT scan as determined by Dr. ? ? . His other prescription will
be for Percocet 1Q 3-6H P.R.N. pain, and he will be getting approximately 35 of these
tablets.