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Percutaneous Fluoroscopically Guided Salvage of Misplaced Perirectal 125I Prostate Seeds—Easy Way Out
Surgical Techniques in Urology Percutaneous Fluoroscopically Guided Salvage of Misplaced Perirectal 125I Prostate Seeds—Easy Way Out Christopher Bangard, Robert Semrau, Henning Bovenschulte, and Klaus J. Lackner Permanent prostate implants are widely used as therapy for localized prostate cancer. Transperineal placement of 125I seeds can be directed safely by transrectal ultrasound imaging. Misplaced seeds can produce serious damage in various organs, especially in the rectal mucosa. The rescue of misplaced seeds can be performed with open surgery or with minimally invasive percutaneous intervention. We report a case of percutaneous fluoroscopically guided salvage of misplaced perirectal 125I prostate customized stranded seeds using an interventional angiographic catheter. UROLOGY 74: 924 –925, 2009. © 2009 Elsevier Inc.
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65-year-old man with prostate cancer (Stage T1c, Gleason score 3 ⫹ 3 ⫽ 6; initial prostatespecific antigen level 5.78 ng/mL) was treated with transperineal permanent prostate implantation1,2 using Rapid Strands (Oncura, Arlington Heights, IL). Despite transrectal ultrasound guidance,3 4 seeds lined up on a single strand were misplaced away from the prostate into the perirectal tissue (Fig. 1). Because of the near proximity to the rectal mucosa, the seeds had to be
Figure 2. Fluoroscopic image verifying that end of cannula has been put on distal seed (arrow) with loops of angiographic catheter in position to grab seed strand.
Figure 1. Computed tomography scan of pelvis shows 1 125 I seed (arrow) of strand of seeds misplaced next to rectum (asterisk).
From the Departments of Radiology and Radiation Oncology, University of Cologne, Köln, Germany Reprint requests: Christopher Bangard, M.D., Department of Radiology, University of Cologne, Kerpener Strasse 62, Köln D-50924 Germany. E-mail: [email protected] Submitted: November 11, 2008, accepted (with revisions): December 22, 2008
924
© 2009 Elsevier Inc. All Rights Reserved
removed to avoid the severe complication of a radiationinduced rectal ulcer.4,5 The asymptomatic patient was transferred to the interventional radiologic department the next day. Under general anesthesia, a transperineal approach was used to percutaneously introduce an 11gauge cannula of a bone biopsy set (Osteo-Site bone biopsy needle set, Cook, Bjaeversko, DK). Under fluoroscopic guidance, the end of the cannula was put onto the distal end of the strand (Fig. 2). The cannula as a metal tunnel separated the strand from the surrounding connective tissue as a precursor for good expansion of the loops of a “goose-neck” catheter (Entrio Snare System, 0090-4295/09/$34.00 doi:10.1016/j.urology.2008.12.023
Medical Device Technologies, Gainesville, FL). Threedimensional loops at the end of the catheter (Fig. 3) can be pulled back and are used in interventional angiography to grab guidewires or lost coils. The stranded seeds were extracted by pulling the catheter back, together with the cannula.
References
Figure 3. Image of end of “goose-neck” catheter. Note, three-dimensional loops. By pulling them back into cannula, lost stranded seeds can be grabbed and retrieved.
UROLOGY 74 (4), 2009
1. Bottomley D, Ash D, Al-Qaisieh B, et al. Side effects of permanent I 125 prostate seed implants in 667 patients treated in Leeds. Radiother Oncol. 2007;82:46-49. 2. Battermann JJ, Boon TA, Moerland MA. Results of permanent prostate brachytherapy, 13 years of experience at a single institution. Radiother Oncol. 2004;71:23-28. 3. Carey B, Swift S. The current role of imaging for prostate brachytherapy. Cancer Imaging. 2007;28:27-33. 4. Shah SA, Cima RR, Benoit E, et al. Rectal complications after prostate brachytherapy. Dis Colon Rectum. 2004;47:1487-1492. 5. Celebrezze JP Jr, Medich DS. Rectal ulceration as a result of prostatic brachytherapy: a new clinical problem: report of three cases. Dis Colon Rectum. 2003;46:1277-1279.
925
A
65-year-old man with prostate cancer (Stage T1c, Gleason score 3 ⫹ 3 ⫽ 6; initial prostatespecific antigen level 5.78 ng/mL) was treated with transperineal permanent prostate implantation1,2 using Rapid Strands (Oncura, Arlington Heights, IL). Despite transrectal ultrasound guidance,3 4 seeds lined up on a single strand were misplaced away from the prostate into the perirectal tissue (Fig. 1). Because of the near proximity to the rectal mucosa, the seeds had to be
Figure 2. Fluoroscopic image verifying that end of cannula has been put on distal seed (arrow) with loops of angiographic catheter in position to grab seed strand.
Figure 1. Computed tomography scan of pelvis shows 1 125 I seed (arrow) of strand of seeds misplaced next to rectum (asterisk).
From the Departments of Radiology and Radiation Oncology, University of Cologne, Köln, Germany Reprint requests: Christopher Bangard, M.D., Department of Radiology, University of Cologne, Kerpener Strasse 62, Köln D-50924 Germany. E-mail: [email protected] Submitted: November 11, 2008, accepted (with revisions): December 22, 2008
924
© 2009 Elsevier Inc. All Rights Reserved
removed to avoid the severe complication of a radiationinduced rectal ulcer.4,5 The asymptomatic patient was transferred to the interventional radiologic department the next day. Under general anesthesia, a transperineal approach was used to percutaneously introduce an 11gauge cannula of a bone biopsy set (Osteo-Site bone biopsy needle set, Cook, Bjaeversko, DK). Under fluoroscopic guidance, the end of the cannula was put onto the distal end of the strand (Fig. 2). The cannula as a metal tunnel separated the strand from the surrounding connective tissue as a precursor for good expansion of the loops of a “goose-neck” catheter (Entrio Snare System, 0090-4295/09/$34.00 doi:10.1016/j.urology.2008.12.023
Medical Device Technologies, Gainesville, FL). Threedimensional loops at the end of the catheter (Fig. 3) can be pulled back and are used in interventional angiography to grab guidewires or lost coils. The stranded seeds were extracted by pulling the catheter back, together with the cannula.
References
Figure 3. Image of end of “goose-neck” catheter. Note, three-dimensional loops. By pulling them back into cannula, lost stranded seeds can be grabbed and retrieved.
UROLOGY 74 (4), 2009
1. Bottomley D, Ash D, Al-Qaisieh B, et al. Side effects of permanent I 125 prostate seed implants in 667 patients treated in Leeds. Radiother Oncol. 2007;82:46-49. 2. Battermann JJ, Boon TA, Moerland MA. Results of permanent prostate brachytherapy, 13 years of experience at a single institution. Radiother Oncol. 2004;71:23-28. 3. Carey B, Swift S. The current role of imaging for prostate brachytherapy. Cancer Imaging. 2007;28:27-33. 4. Shah SA, Cima RR, Benoit E, et al. Rectal complications after prostate brachytherapy. Dis Colon Rectum. 2004;47:1487-1492. 5. Celebrezze JP Jr, Medich DS. Rectal ulceration as a result of prostatic brachytherapy: a new clinical problem: report of three cases. Dis Colon Rectum. 2003;46:1277-1279.
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