Treatment without general anaesthetic?

I had general anaesthetic for brachytherapy HDR.

I don't think HDR is much more invasive than a biopsy so I don't think they knock you out due to the pain. I think the procedure takes about four hours, and I don't think they could trust a patient to sit still all that time, so they knock you out for that reason. 

With HDR the isotope is inserted by a robot with no one else in the room. With LDR it is safer for the staff to be in the room, so maybe that can be done under local.

Maybe if you promised to sit still it could be done.

The painful bit is the brachytherapy catheter insertion. That's the only part Mount Vernon knock you out for (or nowadays, just do the regional anesthetic). It takes about 40 mins. Even when they did used to use a GA, you were awake for all the rest of it including the radiotherapy part, which isn't painful. Yes, you have to stay in bed without sitting up for around 6 hours (or 24 hours if having HDR as a monotherapy, so two sessions on two consecutive days).

Some places knock patients out for 4 hours, but that has a number of downsides, such as ruling out more patients from the procedure who can't do a 4 hour GA, and usually meaning they only do one patient in that time, versus the 4 patients which Mount Vernon do on a production line each time.

Edited by member 18 Apr 2023 at 07:50  | Reason: Not specified

Many thanks for the various useful comments & suggestions.

Old Barry  -  yes indeed!.  I was trying not to mention the current hospital as I'm still hoping they might get past the  obstacle to anaesthesia.  It has necessitated referral to another department, and various tests have been done quickly, but as the non-prostate medical issue gives no symptoms except under anaesthesia, and might not in itself need any treatment, it isn't seen as urgent for followup.   The result is more months of uncertainty and delay while urology await the outcome of referral to the other department.

Microcolei - I'm comforted by your experience of EBRT with Linac machine but I would still be happier with brachytherapy inside my actual prostate, preferably in the one lobe, since unlike you I'm not thought to have cancer anywhere else, not even locally.                                                                                                                           Well not yet anyway but the longer it's left untreated........

Andy62 & others:  how long a wait can I expect, if I ask to be referred on for brachytherapy at Mount Vernon?  (under NHS).                                                                                                                                                                             If it's really long, how expensive would private be for brachy?  At Mount Vernon, Birmingham or elsewhere.  Private hospitals seem reluctant to reveal self-pay charges but I've heard that any form of radiotherapy might be £40k+ !

Please H O, choose the option that has the best chance of removing your cancer at this early stage based on weighing up the advice of a urologist and an oncologist. Thorough early treatment stands a better chance of avoiding the need for salvage work of one sort or another later plus it gives you a better chance of survival.

Jules

Focal brachytherapy does exist, but I never came across anyone who's had it, and I don't know of a hospital which does it. A really big consideration would be what followup treatments might be possible if cancer developed in the rest of the organ, which is probably quite likely, as prostate cancer is usually multi-focal (starts in more than one place). Further radiotherapy would probably not be possible. That leaves you with salvage prostatectomy with not good QoL outcomes, and maybe salvage HIFU, or life-long hormone therapy.

Having said that, brachytherapy dose is sometimes varied across the prostate, being higher where the known cancer is, and lower in the rest of the prostate.

Hmmmm...... I had assumed, perhaps naively, that the radioactive seeds - whether permanent low dose or temporarily inserted high dose- would be put into the one lobe where the cancer definitely is.   (I have read that prostate cancer is usually multifocal but in my case all the rest of the 30 cores extracted during biopsy were clear.)

However, on thinking about it: -  even if some seeds are  put elsewhere in the prostate, the radiation they emit will be primarily absorbed by (potentially future cancerous) prostate tissue, rather than first hitting other tissue and then only the attenuated radiation reaching the prostate.

And as Old Barry says, there may be differences in terminology across the Atlantic. 

I get the feeling that you have figured out a process in your own mind that you believe will work better than the advice you might receive from an oncologist.

Jules

Your Gleason score is 7 and your psa has risen sharply in the last few months. You haven't mentioned anything about the size of your prostate or whether you have any other urinary symptoms but these are factors to be considered. It looks as though LDR brachytherapy on its own might be an option BUT it could be marginal and since you've said earlier that your tumor isn't low risk I'm guessing you might have been told it's high risk [?]. If that's the case and you have other significant urinary issues, you could well be at the point where an oncologist would rule out LDR brachytherapy and recommend EBRT followed by brachytherapy, or just EBRT.

If you are in a position where you can never have anaesthesia, you will not be able to have a prostatectomy so you're limited to the various RT options with the risk that if round one fails you might not be able to have a second go.

Obviously, I'm not an oncologist but with your cancer at an early stage and still quite treatable, I'd suggest you can't be half hearted about your treatment options.

Have you spoken to an oncologist yet and if so what did they recommend?

Jules

Edited by member 20 Apr 2023 at 22:17  | Reason: Not specified

Thanks Lyn

Excellent post o d. That gives a much wider view of where you stand.

In regard to this:

Do you have any specific reasons to have worries on that concern? Your hesitancy and visits to the toilet overnight are not unusual in your situation. I haven't seen any figures on how frequent and serious inflammation issues are for men having RT but I can certainly say that for me [age 76] it wasn't an issue, though a sample of one is fairly meaningless.

Jules

The (NHS) surgeon who would have done the HIFU told me that unlike some surgery (such as birth by C section) a HIFU requires such fine precision (for ?hours on end) that it wouldn't be done under regional/spinal/epidural anaesthesia. He said this was because of the possibility of slight movement.  

Picking up Andy62's hint that what the urologist really meant was "the way we do it here is under general anaesthetic only" :   I have seen some publicity material for private HIFU at other hospitals claiming they use regional rather than general anaesthesia, at least in some cases.  I'm trying to find out who, where and charging how much.  But as this may well be a blind alley, I'm also looking into  EBRT or brachytherapy.

 Though I'd still prefer HIFU with my current team if they can find some other workaround for my anaesthesia problems. 

Urine retention - I have had not-quite-complete but painful urine retention issues previously, in circumstances too complicated to explain fully here but they include after anaesthesia in the past, for unrelated surgery years ago before my present problem developed.

Meanwhile I note Lyn telling us what nobody else has told us about what happens during anaesthesia for RP!  

Yes I guess the stereotactic option might work for me but NHS guidance published in 2016 implies it's not available in the UK, at least not with the NHS.   https://www.england.nhs.uk/wp-content/.16013/P                              And anything involving nuclear medicine would presumably cost a fortune privately.  (Any information to the contrary gladly received.)

The NHS 'clinical commissioning policy' usefully explains that the shortness of this kind of RT results from targeting a tumour with radiation beams from different angles AT THE SAME TIME.   As opposed to an emitter  rotating around the person and firing at his prostate from different angles one at a time.   The latter implying a month or two of RT daily except for weekends. 

The title of the NHS document says Stereotactic Ablative Radiotherapy SABR but the detailed text uses both this term and the American version Stereotactic Body Radiotherapy SABR.   I assume the UCLA (and Australian) references do indeed refer to the same thing although it isn't made entirely clear. 

Both SABR and EBRT versions of RT imply the prostate gets radiation which has been attenuated by passing through other tissue first.  Albeit the prostate gets some radiation from every direction, whereas the other tissues get the radiation from only some directions. 

On that logic I still might prefer brachytherapy, under which non-prostate tissue gets only the radiation that has been attenuated by passing through prostate tissue.  But I remain open to information and persuasion on this and any points. 

Edited by moderator 06 Jul 2023 at 13:19  | Reason: Not specified

Hi Lyn. I have just read your comments on Open Surgery being ‘kinder to the heart’ than keyhole. This interested me because I suffer from AF and as such asked the question of my surgeon if this might cause complications. His reply was that other than the usual complications associated with surgery I would just need to stop taking the blood thinners for a few days. No mention of body positioning.

I would be grateful if you could provide me with the source from which you gleaned this information so that I might check it out and so ask the question at my next meeting. Thanks in advance.

Alf

Proton beam prostate treatment is fired in from just two angles, and that's horizontally through each hip. As such, it's a bit like the old IMRT treatment, although that was usually 3-5 beam angles.

I don't believe it's available at all in the UK, except possibly as part of a trial. The private Rutherford Cancer Centres in Wales, Reading, and somewhere up north all went bust.

There isn't a source - that is just how it is done. Once the patient is asleep, the operating table is tilted a bit so that your head is lower than your feet - gravity pulls the bladder & other organs away from the prostate to create some space to operate in. The abdominal cavity is also filled with gas to create more space. 

I assume that being tipped head down for a few hours is only a problem for men with serious heart problems - there are a number of men on here with AF who had LRP.  

Edited - sources:

https://www.google.com/search?q=keyhole+radical+prostatectomy+head+tipped+down&rlz=1C1PRFI_enGB894GB894&sxsrf=APwXEde2S1fHzF1VjCMK5YfJt8OiYRZGEw:1682548911039&source=lnms&sa=X&ved=2ahUKEwiEo6ORz8j-AhXMEcAKHXFPARYQ_AUoAHoECBAQAg&biw=1920&bih=937&dpr=1

Edited by member 26 Apr 2023 at 23:50  | Reason: To add further info and hyperlink