Acute Urinary Retention (AUR) after permanent seed prostate brachytherapy.

There is a small risk of acute obstruction (requiring continued use of the Foley catheter) after the implant, particularly if the gland was large or the patient had some obstructive problems (slow urination) already. We generally use Decadron at the time of the implant and Flomax afterwards to lower the risk. In one study the prostate volume was significantly larger in men with AUR (39.8 cm3 vs. 34.3 cm3), and the mean number of seeds was higher (112 vs. 103).

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Only about 10-15% of men have to have their catheter left in place after a seed implant, and even then it usually can be removed in week or two, a few patients have to leave the catheter in for weeks as in the study below from Bucci.

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Seed Implant Retention Score Predicts the Risk of Prolonged Urinary Retention After Prostate Brachytherapy

 IJROBP Volume 76, Issue 5, Pages 1445-1449 (April 2010)

To risk-stratify patients for urinary retention after prostate brachytherapy according to a novel seed implant retention score (SIRS).A  total of 835 patients underwent transperineal prostate seed implant from March 1993 to January 2007; 197 patients had 125I and 638 patients had 103Pd brachytherapy. Four hundred ninety-four patients had supplemental external-beam radiation. The final downsized prostate volume was used for the 424 patients who had neoadjuvant hormone therapy. Retention was defined as reinsertion of a Foley catheter after the implant.

Results

Retention developed in 7.4% of patients, with an average duration of 6.7 weeks. On univariate analysis, implant without supplemental external-beam radiation (10% vs. 5.6%; p = 0.02), neoadjuvant hormone therapy (9.4% vs. 5.4%; p = 0.02), baseline α-blocker use (12.5% vs. 6.3%; p = 0.008), and increased prostate volume (13.4% vs. 6.9% vs. 2.9%, >45 cm3, 25–45 cm3, <25 cm3; p = 0.0008) were significantly correlated with increased rates of retention. On multivariate analysis, implant without supplemental external-beam radiation, neoadjuvant hormone therapy, baseline α-blocker use, and increased prostate volume were correlated with retention. A novel SIRS was modeled as the combined score of these factors, ranging from 0 to 5. There was a significant correlation between the SIRS and retention (p < 0.0001). The rates of retention were 0, 4%, 5.6%, 9%, 20.9%, and 36.4% for SIRS of 0 to 5, respectively.

Conclusions

One point was scored for each of the following: no supplemental external-beam radiation, neoadjuvant hormone therapy, baseline α-blocker use, or prostate size of 25–45 cm3. Two points were scored for prostate size >45 cm3 for having the highest rate of retention. There was a significant correlation between the SIRS and retention. The rates of retention were 0 of 30, 9 of 225 (4%), 17 of 303 (5.6%), 18 of 199 (9%), 14 of 67 (20.9%), and 4 of 11 (36.4%) for SIRS of 0 to 5, respectively

The SIRS may identify patients who are at high risk for prolonged retention after prostate brachytherapy. A prospective validation study of the SIRS is planned.

 

Risk factors for acute urinary retention requiring temporary intermittent catheterization after prostate brachytherapy: a prospective study

Jacob Locke William Ellis Kent Wallner, and John Blasko. International Journal of Radiation Oncology*Biology*Physics, 2002;52:3 : 712-719

We prospectively investigated prognostic factors for men undergoing transperineal radioactive seed implantation for prostate cancer at the University of Washington. Between February and April, 1998, 62 consecutive unselected patients were prospectively followed after brachytherapy for early-stage prostate adenocarcinoma. Pretreatment variables included age, American Urological Association (AUA) score, uroflowimetry, and prostate volume by ultrasound. Urinary retention rate at one week was 34% (21 of 63 patients). At one month, 29%; at three months, 18%; and at six months, 10%. Preoperative flow rate and post-void residual did not predict for retention (p = .48 and p = .58). Use of alpha blockers, hormonal therapy, type of seed (103Pd or 1251), or external beam radiotherapy had no impact on risk of retention at any followup point. Preimplant volume and AUA score predicted for retention on univariate analysis, but on multivariate analysis only postimplant volume remained significant (p = .02) for predicting retention risk and duration.

Conclusion: Patients with large prostate size (>36 g) and higher AUA score (>10) appear to be at greater risk of risk of retention as well as duration of retention as defined in our study.|

The increasing number of patients undergoing brachytherapy for early-stage prostate cancer has been accompanied by a greater awareness of complications including urinary morbidity. This awareness has been augmented by recent literature observing an assortment of morbidities. Obstructive uropathy requiring catheterization has been reported in 5 to 22% of patients in prior brachytherapy series .What can be done in the perioperative or postoperative period to reduce retention? A decrease in needle trauma by using increased seed activity may result in decreased retention. There is no clear association of risk of severe morbidity and seed type as demonstrated by Gelblum. There is a learning curve involved in any technical procedure Improved peripheral loading technique and decreased periurethral dose are likely to favorably impact on retention risk. Patients developing symptoms should be medically managed for at least 3 or 4 months and preferably as long as 6 months before surgical intervention such as TURP. The continuously declining risk and the risk of incontinence with surgery are compelling reasons to adhere to this policy. One approach to reducing perioperative swelling as a contributing factor to urinary retention is by giving perioperative steroid therapy. Speight et al. have documented improved DVH associated with steroid use ; however, no differences in rate of retention have been observed (personal communication). We did not utilize steroid therapy in any of our patients and therefore cannot comment on its impact.

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