I came home from the HDR brachytherapy last night (Tuesday), 2.5 days and 2 nights in hospital. Hopefully that marks the end of my radical treatments except for the ongoing HT.
Went in Sunday 3pm. Lots of medical questionnaires, blood tests, etc. There were 3 of us for the procedure, and we were processed as a production line (plus a 4th woman for cervical cancer, although I didn't see her at any point - women have to have 5 consecutive days of brachy, which must be horrendous). We were interviewed by a nurse, a doctor, and an anesthetist that evening, and nil by mouth from midnight, except any morning medication which had to be taken before 6am with a minimum of water.
I was to be woken at 6am to take a shower. I was in a bay where two of the other patients were on 24 hour chemo with pump drivers, and there were many more pump drivers audiable further away on the ward. These make a continuous noise, and whilst unplugged so the user can wheel them to the toilet (frequently), they let out a continuous warning sound like a mobile ringing, so I got no sleep. The sound reminded me of the eerie silence after the collapse of the World Trade Center towers with just the firemen's alert bleepers sounding. Given I couldn't sleep, I decided to head for the shower early, as there was only one shower.
The consultant came to see each of us at 8am. My blood tests from the night before showed an out-of-range creatinine level (part of the renal function tests), so he asked me for my copy of my medical notes as he knows I have all my blood test results in a table back to 2011, and it's the same value in all of them, so he was happy. The anesthetist had also looked through my copy of my medical notes the night before, and said "Wow - I wish everyone did this". The pharmacist came to ask what drugs I'm on, so I handed him a copy of a sheet I keep which lists all my prescribed and self-medicated drugs. Again, "Wow - I wish everyone did this". One problem I have encountered is that when they see Metformin, they instantly assume I'm diabetic, even though the sheet explicitly says why I'm on Metformin (better cancer treatment outcomes and reduction in some ADT side effects).
Then, one at a time, we were wheeled to theatre, where the procedure takes 40-60 mins. I had 18 brachy needles inserted, and one of the others had 20. As I'm waking up in recovery, the nurse proudly tells me they closely monitored my blood sugar, and it stayed on 5.3 throughout without them needing to control it. I again point out I'm not diabetic, and explain why I'm on metformin. You wake up with a complicated urinary catheter fitted, although at this point it's just draining into a bag - the complicated bit is for later. Initially, it makes you feel like you badly need to pee, but as you wait in recovery, your body gets more use to it. During the operation, the catheter and bladder are filled with some fluid that shows well on ultrasound, so they can see your urethra clearly while inserting the needles using rectal ultrasound guidance - ideally they want the brachy needles to be a specific distance from the urethra so the prostate is fully dosed, but less gets into the wall of the urethra, as that can lead to a stricture (scarring that eventually blocks the urethra - happens in around 8% of cases). The brachy needles are a discomfort and have all the flexible ends hanging out of your perineum, but not painful. From this point, you have to stay laying on your back.
After maybe an hour more (I had no sense of time), I was wheeled for a MRI scan and a CT scan, to accurately record where the needles are, and then it's back up to the ward. The scans go off to medical physics who then calculate how long the single high dose radioactive source has to spend at each position in each brachy needle, and the consultant then signs off the plans. This takes some hours. When they've completed the task, it's expected the prostate will have swollen, so you have to have another CT scan which is passed to medical physics again so they can make minor corrections.
Then it's down to the brachy machine. After 23 sessions of EBRT, I'm well used to being locked in rooms with 10 foot concrete walls while everyone else goes and stands in a safe place outside, and this is yet another one of those. The brachy machine has 24 ports on it, of which 18 are used in my case. These are connected via clear plastic tubes to the 18 flexible ends hanging out of my perineum. Then all the staff retire behind the 10 foot walls and lock me in. The machine starts... It initially pushes a dummy load fully down each tube in turn, to make sure it can. I can feel a couple of the tubes which are touching my legs move as it does so, but there's no sensation from the ends inside my body. Then it starts a second cycle. For each tube, it again pushes the dummy load down the tube and back, but then it repeats with the HDR brachy seed. The HDR seed is pushed to the first position and held there for some seconds, and then moved a bit further and held again, etc. I didn't time it, but the period it was held in place varied from perhaps 2 to 6 seconds before being moved a bit further in the tube. Also, the number of individual stopping points varied widely between the tubes from perhaps 2 to maybe 8, depending how much prostate that tube penetrated. Most people say you don't feel anything. I did - my prostate gradually started stinging more and more as the HDR brachy seed accumulated time in the prostate. The whole procedure took about 20 minutes, and perhaps another 20 minutes setup beforehand. I got the nurses to take a couple of pictures of the brachy needles whilst I was still connected to the machine, but they aren't allowed to take a picture of the brachy machine. They disconnect the machine, and quickly pull the needles out, which is a bit painful but only takes a few seconds.
Then it's back to the ward for what's called continuous bladder irrigation - the more complicated part of the catheter. The catheter has 3 ports. One used to blow up the balloon which holds it in place, and two separate additional separate tubes into the bladder. One drains the bladder, and the other simultaneously fills the bladder with saline from giant drip bottles. I didn't realise why this was necessary until the consultant drew me a picture the next morning, but the brachy needles pass right through the prostate and go into the bladder. This is because they need to be able to get the HDR seed right to the edge of the prostate, but wouldn't be able to do that if the needle stopped at the edge of the prostate. So the needles continue into the bladder. Needless to say, when the needles are withdrawn, a lot of blood runs in to the bladder, and this mustn't be allowed to form large clots which could block the urethra, so the continuous irrigation should wash the blood out before it clots. That worked fine for the other two patients, but my catheter kept blocking with clots. It was already blocked by the time I got back to the ward, and it blocked a couple more times during the night, mainly due to the drip bottles running out and not getting changed in time. The other two patients got their catheters removed first thing the following morning. Mine stayed in until midday because the irrigation water was still going pink if I moved around.
One possible side effect of brachy is a loss of sensation on one or other side of the penis, which is sometimes permanent. I checked this and it was fine, but I'd completely lost sensation on large parts of the scrotum. I was reflecting that didn't seem so bad, but it was fully back by the next morning.
The final hurdle is to fill a cardboard urine bottle, before they'll discharge you. I was drinking loads, but nothing was coming out, and I didn't have the sense there was anything in my bladder. Looking back now, I think this may be a side effect of a general anesthetic which I've seen before - kidneys not ejecting excess water from blood. Eventually, I filled the bottle, and my brother drove me home.
The kidneys started running overtime to make up for the backlog of water I'd drunk, and I had to run the the front door and make a bee-line for the toilet. This continued hourly all night, during which I nearly filled a 4 pint milk bottle from the water that was stored in body. My bladder capacity was around 100ml at the start of the night but was up to around 200ml by the end of the night. Also, by the end of the night, urine was clear of blood except first few cc's - this suggests bladder has stopped bleeding, but blood still coming from prostate. Also, at the beginning of the night, I had no sensation of peeing, and found I'd already started by the time I'd pulled down the disposable pants, but that got better through the night and is mostly fixed now, but still wearing disposible pants as there's still blood dripping from the urethra, from the prostate. Apparently, this will probably get worse before it gets better.
I'd had no pain whatsoever since the catheter came out, but it started stinging today. Then I realised that I'd forgotten to drink the cranberry juice I got. Costco had a special offer at the beginning of my RT, and I bought 36 litres of the low sugar one, which I've been drinking every day - even took a couple into the hospital. Indeed, the glasses of pink cranberry juice I was drinking were exactly the same colour as contents of the urine bag, which caused a number of passers by to do a double take. After a glass of cranberry juice just now, the stinging has gone. Wonderful stuff (but mustn't be drunk by anyone using Warfarin blood thinner).
So far, I've got very little bruising, only covering about half the area the needles punctured, much less than the bruising following the transperineal biopsy, but as I recall from the biopsy, the bruise can get much worse before it goes, as leaked internal blood makes its way to the skin.