Given the poor outcomes observed with radical prostatectomy (RP) and external-beam radiation therapy (EBRT), some in the urologic community contend that high-risk disease is not curable with currently available treatment strategies.[1,2] In fact, there is a growing contingent of clinicians who advocate the use of chemotherapy in conjunction with RP. With the established efficacy of brachytherapy, these efforts are likely excessive.
Wayne M. Butler, PhD
Permanent prostate brachytherapy with or without supplemental therapies is a highly effective treatment for clinically localized prostate cancer, with biochemical outcomes and morbidity profiles comparing favorably with competing local modalities. However, the absence of prospective randomized brachytherapy trials evaluating the role of supplemental external-beam radiation therapy (XRT) has precluded the development of evidence-based treatment algorithms for the appropriate inclusion of such treatment. Some groups advocate supplemental XRT for all patients, but the usefulness of this technology remains largely unproven and has been questioned by recent reports of favorable biochemical outcomes following brachytherapy used alone in patients at higher risk. Given that brachytherapy can be used at high intraprostatic doses and can obtain generous periprostatic treatment margins, the use of supplemental XRT may be relegated to patients with a high risk of seminal vesicle and/or pelvic lymph node involvement. Although morbidity following brachytherapy has been acceptable, supplemental XRT has shown an adverse impact on long-term quality of life. The completion of ongoing prospective randomized trials will help define the role of XRT as a supplement to permanent prostate brachytherapy.
Erectile dysfunction is a common sequela following potentially
curative local treatment for early-stage carcinoma of the prostate
gland. With larger studies and longer follow-up, it is clear that erectile
dysfunction following prostate brachytherapy is more common than
previously reported, with a myriad of previously unrecognized sexual
symptoms. Approximately 50% of patients develop erectile dysfunction
within 5 years of implantation. Several factors including preimplant
potency, patient age, the use of supplemental external-beam irradiation,
radiation dose to the prostate gland, radiation dose to the bulb of
the penis, and diabetes mellitus appear to exacerbate brachytherapyrelated
erectile dysfunction. The majority of patients with brachytherapy-
induced erectile dysfunction respond favorably to sildenafil citrate
(Viagra). Despite reports questioning the potency-sparing advantage
associated with brachytherapy, recent elucidations of brachytherapyrelated
erectile dysfunction may result in refinement of treatment
techniques, an increased likelihood of potency preservation, and
ultimately, improved quality of life.