BRACHYTHERAPY

GUIDELINES AND PATIENT INFORMATION TEMPLATES

A C I U R O L O G Y N E T W O R K - N U R S I N G

Developed and compiled by Colleen Macdonald, Meg Hughes and Dr Sandra Turner, Westmead Hospital, Sydney. Adopted by ACI (Formerly GMCT) Sept 2008. ACI revision, with thanks to Meg Hughes, June 2012

The following pages provide examples of clinical guidelines and patient information booklets to enable clinicians to develop their own resource material relevant to their hospital and Area Health Service. They have been compiled by clinicians for clinicians. If you wish to use this material please acknowledge those that have kindly provided their work to enable use by others. Revise all material with colleagues before using to ensure it is current and reflects best practice

⋅ Disclaimer: The information contained herein is provided in good faith as a public service. The accuracy of any statements made is not guaranteed and it is the responsibility of readers to make their own enquiries as to the accuracy, currency and appropriateness of any information or advice provided. Liability for any act or omission occurring in reliance on this document or for any loss, damage or injury occurring as a consequence of such act or omission is expressly disclaimed.

BRA CH Y THER AP Y GUIDELINES AND PATIENT INFORMATION TEMPLATES

CONTENTS

CONTENTS .................................................................................................................. 3

Consultations............................................................4 Tests .........................................................................4 Observations ............................................................4 Nutrition and IV therapy ..........................................4 Bowel preparation ....................................................4 Medications ..............................................................5 OP DATE .................................................................6 Patient education ......................................................6 Radiation precautions...............................................6 Catheter management .................................................. 7 If patient unable to void ............................................... 7 Follow up ....................................................................... 7 Patient Information booklet ........................................ 8 Prostate Therapy: Your guide Through the process 9

BRACHYTHERAPY IS A TWO-STAGE PROCEDURE ..................... 10

Low residue Diet examples ....................................... 15 Example 1 ............................................................................. 15 Example 2 ............................................................................. 19

ADDITIONAL RESOURCES ........................................................................ 21

PRE OP

(Including Pre admission clinic) OP DATE DAY 1

Consultations

• Admitting RMO • Anaesthetist • Nursing admission

• Radiation Oncology Nurse

• Registrar

Tests

• EUC / FBC • MSU • CXR Others as required

Observations

• TPR / PB • Urinalysis • Weight

• Hourly x 4 then 4th hourly TPR /BP

• Monitor patient void x 2 and record volume

• Strain all urine (patient to bring own strainer). If seed is passed it is NOT to be picked up with fingers. Use forceps of wet tip of cotton bud and place in to lead lined pouch provided

• QID BP / TPR

Nutrition and IV therapy

• NBM 8 hours pre op

• Diet as tolerated • Remove IV therapy once tolerating

oral intake • Push oral fluids

Diet as tolerated

Bowel preparation

• Low residue diet 4 days preoperatively (see diet sheet)

• Glycerine suppository the night before surgery and the morning of surgery

PRE OP

(Including Pre admission Clinic) OP DATE DAY 1

Medications

• Flomaxtra 400mcg daily to commence 3 days pre op. Script for Noroxin 400mg BD for 3 days provided for planning. Pt education- take one tablet night before procedure, morning of procedure and continue BD till all finished

• Flomaxtra 400mcg daily until review by Radiation Oncology team

• Trimethoprim 300mg daily for 7 days/ or Noroxin BD for 4 days

• Analgesia prn • Ural prn Outside script to be written by RMO

• As per operation day

PRE OP (Including Pre admission Clinic)

OP DATE DAY 1

Patient education

Given in Radiation Oncology Department by Brachytherapy Specialist Nurse: • Information booklet • Radiation precautions • Failure to void Risks associated with surgery • Infection • Bleeding Other post implant side effects can include: • Haematuria • Frequency • Bruising of perineum and/or scrotum • Pain at the implant site • Blood in the semen (Hematospermia). May last for several ejaculates. It is quite safe to resume normal sexual activity following an implant, however it is recommended to initially use a condom • Loss of ejaculatory volume: following implant, men can develop a dry ejaculate • Numbness of the penis can occasionally and

can last 1-2 months. The numbness will resolve without specific treatment

RADIATION PRECAUTIONS

• Strain all urine for 2 weeks post procedure

• If a seed is passed - DO NOT pick it up with bare fingers – instead use damp cotton bud or forceps and place seed in lead lined pouch provided

• As per operation day

PRE OP Including Pre admission clinic)

OP DATE

DAY 1

Catheter management

Possibility of catheter insertion discussed with patient pre op

IF PATIENT UNABLE TO VOID

• Insert 18g Bard Biocath with flip flow catheter valve

• Educate patient to empty bladder 3-4hrly

Notify Rad/Onc specialty nurse who will arrange a trial of void in 1-2 weeks

Follow up

Arranged by Radiation

Oncology nurse

CT scan 4 weeks post procedure

Radiation/Oncology clinic appointment following CT scan 8 weeks post procedure

PATIENT INFORMATION BOOKLET PROSTATE THERAPY: YOUR GUIDE THROUGH THE

PROCESS

This booklet is designed to assist you through your treatment of prostate brachytherapy. This will enable you to be an active participant in your care.

The booklet will provide a record of the continuum of care for all the various people involved in your treatment, including yourself. During the planning/treatment, you will be seen in three different departments in the hospital:

• Radiation Oncology • Pre-admission clinic • Urology ward

Please take this booklet with you whenever you have a visit related to brachytherapy. This will ensure that all the required preparation and after care is attended to.

What you will need for your treatment:

• Low Residue diet (information sheet supplied).

• Glycerine suppositories available from your local chemist (no script required)

• Oral antibiotics - script will be provided

• Flomaxtra - script will be provided.

• Fine tea strainer- to strain your urine (information follows). Please bring into hospital for the implant.

Flomaxtra is used to reduce urinary symptoms after treatment. Unfortunately the cost

is approximately $65.00 per month (may be required for up to 6 months). There is no

suitable alternative medicine on the PBS list.

BRACHYTHERAPY IS A TWO-STAGE PROCEDURE

Brachytherapy is a two stage procedure – both are performed under a general anaesthetic. First stage: Planning

This involves the trans-rectal ultrasound imaging of the prostate gland. It is a day-only hospital procedure. The session is required to plan the number and position of seeds that will be required.

Second stage: Seed implant.

The placement of seeds is generally 4 - 6 weeks after the planning stage. Seed placement usually requires an overnight stay in the urology ward

Bowel Preparation

Both first and second stages require bowel preparation. Please read the information in the coming pages. Any questions please ring the Urology Nurse.

Pre-Admission Clinic

Ph:

As part of your preparation for surgery you will be required to attend the Pre-admission Clinic. At the Pre-admission Clinic an anaesthetist and a nurse will assess you for your operation. You may have pre-operative tests and you will also be given admission instructions. It is important that you bring this booklet with you to the clinic

appointment and a list of your current medications

Prostate Brachytherapy: Planning

Tick each item off when done

Low fibre diet: start 4 days before procedure

Ring Day Only Ward night before procedure to confirm time

Start antibiotics night before procedure

Glycerine suppository night before procedure

Glycerine suppository morning of procedure

Take antibiotic morning of planning

Fast as directed Afterwards, you may feel some anal discomfort for a short period of time. This

usually does not require treatment but if required you can take paracetamol (e.g Panadol, Panamax).

You can eat and drink as normal (no need to continue on low fibre diet).

Prostate Brachytherapy: Seed Implant Check list

DATE FOR IMPLANT: ………………………..

Low fibre diet: commence 4 days before implant

Commence Flomaxtra 3 days before implant. START DATE: ..............................

Ring Day - Only Ward evening prior to procedure to confirm time. Ph:

Fast as per directions from pre-admission clinic

Glycerine suppository, the night before and the morning of implant

Attend day only ward at requested time.

PLEASE TAKE TEA STRAINER WITH YOU FOR USE WHILST IN HOSPITAL

You must complete your course of antibiotics

Following your Brachytherapy Seed implant

• You will spend the night in the urology to ensure that you can pass urine.

• You will be able to eat and drink as usual. Avoid lots of citrus fruits

• There is a small chance that a catheter may need to be inserted into your bladder before you go home. This will only be temporary (a few days up to a few months, although the latter is unusual). You will be given all the equipment and information to look after your catheter if needed.

• You will need to strain your urine for 2 weeks after the implant in case a seed is passed.

• You will be given a lead pouch to collect any seeds. Ensure you retrieve any seeds with a pair of tweezers, and not your fingers. If a seed is passed into the toilet, flush it away with a double flush.

• Please return the lead container, with or without seeds, to Radiation Oncology at your CT scan visit.

• You will receive a script for oral antibiotics – please continue these until completed.

• Continue Flomaxtra at least until the first review by your specialist.

• If bowels not opened in 3 days try ‘coloxyl with senna’ available without script from chemist.

• It is suggested that you place an ice pack on your perineum whenever possible for the first day or so. Some regular paracetamol (e.g Panadol , panamax), as directed, will also be effective if you are uncomfortable.

• There is no radiation risk to your family or anyone with whom you come in contact. The radiation is contained within the prostate.

• You may have intercourse after brachytherapy but should use condoms for protection for four ejaculates. The ejaculate may be discoloured or reduced and should be checked for seeds.

• You may experience urgency, frequency, nighttime voiding or irritated bladder for several months following the seed implant. You may use URAL (from chemist no script) to minimise these symptoms. Some patients find limiting fluids after 8pm will allow better sleeping.

• After your implant, you may return to work when you wish but avoid lifting or

strenuous activity for 1 week after implant.

Post Brachytherapy Care

An appointment for 4 weeks after implant will be made for you. This appointment is for a CT scan, to check the placement of the seeds (this is for quality assurance). The scan is done in the Radiation Oncology department.

Date of CT Scan: …………………………………………….

Your specialist will see you approximately 8 weeks after implant, in the Radiation Oncology department.

Date of follow up: ……………………………………………

Both of these appointments will either be given to you before discharge from hospital or you will receive a phone call a few days later with these appointment dates and times.

.

When to seek medical help:

• If you have fever and/or chills

• If you are having difficulty passing your urine

• If you are unable to pass any urine please go directly to the Accident and Emergency Department of your nearest hospital.

If you have other less urgent questions or problems during business hours please call the Radiation Oncology Department during office hours and ask for your Radiation Consultant or the Nurse Specialist or Registrar.

NOTE: Please notify your partner or a close family member, that you have had this procedure. It is important for them to be able to provide information to health care workers in the case of emergency where you cannot communicate.

The Team

As a patient of this unit you will have contact with several members of the team. We would be pleased to discuss any problems that may arise during your treatment or recovery

Consultant:

Registrar:

Urologist:

Registered Nurse:

Questions to ask the team:

LOW RESIDUE DIET EXAMPLES

EXAMPLE 1 Introduction The aim of this diet is to eliminate foods that:

a) provide any dietary fibre b) produces residue in the intestine by accelerating the growth rate of bacteria

Indicated for

1. Pre/post operative management of some gastrointestinal procedures 2. Management of certain complications of radiotherapy resulting in stenosis of the

intestinal lumen 3. Acute inflammatory bowel disease

Patients should not stay on this diet for more than 3 days without vitamin and mineral supplements Use the following tables to keep to a low residue diet. Serve sizes and recommended number of serves per day are indicated in brackets.

Foods Allowed (Low fibre foods)

Foods to Avoid (Higher fibre foods)

Cereals 2-4 serves Breakfast Cereals (3/4 cup) e.g cornflakes TM

Rice Bubbles TM , Strained Rolled Oats, semolina, Special KTM ,White Pasta (1/2 cup cooked) White rice (1/2 cup cooked)

Breads 2-4 Serves Bread (1 slice) White only White English muffin/white crumpet

Milk and dairy Products 1 serve No milk/milk products allowed Use 60mls cream mixed with water to replace milk for creeal/tea/coffee

All

Butter, Oil, Margarine 2 serves Margarine, butter or oil (1 teaspoon)

Meat and Meat alternatives 2 Serves Plain pork, beef, lamb, turkey, veal, chicken (120g cooked) Baked, boiled, roasted or grilled. Fish – Fresh, frozen, canned in water or brine (120g cooked) Edd- scrambled, poached, boiled, fried, Plain omelette

All others All dried peas, bean, lentils Baked beans

Vegetables

2-3 Serves Strained vegetable juice

All vegetables, fresh, canned, frozen

Fruit

2-3 serves Strained fruit juice

All fruit, fresh, canned, frozen

Cakes and Biscuits 1-2 Serves Plain biscuits e.g Milk coffee TM , ArrowrootTM Plain Sponge Cake

Donuts, commercial cakes, pastry or biscuits containing fruit or nuts High fibre biscuits e.g wheatmeal

Soups

1-2 serves Clear Broth e.g chicken/beef broth Bonox

All others

Beverages

6-8 glassess Water, tea or coffee, strained vegetable or fruit juices, carbonated drinks, cordials

Alcohol and prune juice

Condiments

As desired MarmiteTM, VegemiteTM, honey

Jam, marmalade, pickles, chutney, NutellaTM, lemon butter, herbs, spices

Miscellaneous

As desired Sugar, syrup, salt Boiled and jellied lollies Barley Sugar Plain jellies Icy poles

Chocolate, fudge, licorice, coconut, caramel, butterscotch, popcorn, health food bars. Potato crisps, dried fruit, nuts, seeds

Take away food

1 serve per week White Sandwich with allowed filling Plain white roll (no seeds) BBQ Chicken – no skin

Note: The low residue diet (minimum residue) is a liquid, low residue formula which can be nutritionally complete if taken in a large enough volume i.e VivonexTM

Sample Meal Plan Breakfast Rice bubbles and cream/water 2 slices white toast with margarine Vegemite/honey Strained fruit juice/ Black Tea/ coffee Morning tea Strained fruit/vegetable juice 2 Plain biscuits Lunch White sandwich with lean cold roast meat/chicken/salmon/egg Jelly Sparkling mineral water Afternoon Tea 2 Plain biscuits Strained fruit Juice/cordial Dinner Strained broth Lean meat/fish/chicken with gravy Boiled rice or pasta Strained vegetable juice Jelly Supper 2 Plain biscuits or 1 English muffin or white bread or toast with vegemite or honey Black Tea, coffee, water strained fruit juice, cordial, diet cordial or soft drink This information can be provided with individualised advice by an Accredited Practicing Dietician If you need more advice contact your Dietitian. Developed by the WSAHS Nutrition and Dietetic Services, July 2006

EXAMPLE 2 Compiled by: Department of Nutrition and Dietetics Email: ogccu@health.wa.gov.au Web site: http://wchs.health.wa.gov.au Produced by the Women’s and Children’s Health Service.

Low fibre Residue Diet– Preparation for surgery Introduction The procedure that your doctor has arranged for you requires that your bowel is free of food bulk. Before your admission to hospital for this procedure you are required to prepare your bowel by following a Low Fibre (low residue) Diet. On admission to hospital, you will be given a bowel preparation to complete the emptying of your bowel. A Low Fibre or Low Residue Diet contains a minimal amount of fibre. Fibre refers to those food substances that are not absorbed by the digestive system. It is found in foods from plants like fruit, vegetables, cereals, nuts and seeds. After the procedure you should resume your normal diet. It is not recommended that you follow a Low Fibre Diet for long periods. The diet requires that for each day you choose food from the following food groups. A sample menu is shown on page four. Breads and Cereals Each day choose five serves from the list: • I slice of white bread • 1 cup of cornflakes, rice bubbles or Special K • 1/2 cup cooked white rice, pasta or spaghetti Between meals you may wish to snack on a plain cracker, plain sweet biscuit, cake or scone (no fruit, nuts or coconut). Fruit Choose two serves from the list each day: • 1/2 cup pie apples • 1/2 medium banana • 1 small raw apricot • 1/2 raw peach • 2 small plums • 2 cups watermelon (no seeds) • 40 seedless grapes • 1 medium nectarine • 3 canned drained apricot halves • 1/2 canned drained peach • 1 cup honeydew melon Vegetables Have once per day.

You may choose Option 1 OR Option 2. Option 1 A salad including: • 1 large lettuce leaf • 1 asparagus spear • 2 thin slices capsicum • 1/4 peeled carrot • 1 celery stick (long) • 1/4 tomato • 5 slices cucumber OR Option 2 One small cooked potato plus any one cooked vegetable serve from the list below: • 1/2 cup beans • 1/4 cup carrot • 1/2 cup sliced mushrooms • 1/2 cup sliced zucchini • 2 boiled squash Milk, Cheese, Yoghurt You can eat your usual amount of these foods. Avoid dairy products containing fruit, nuts or seeds. Meat and other Proteins You can eat your usual amount of these foods. Avoid nuts, lentils, dried peas and beans. If making a casserole, only use the vegetables allowed for this diet. Miscellaneous You may choose the following foods freely as they contain no fibre: • Fats and oils • Water • Strained fruit or vegetable juice • Fruit juice drink, cordial, soft drinks • Tea, coffee, milo, Aktavite, drinking chocolate, Quik, Ovaltine • Clear soup, Bonox, Bovril • Sugar, honey, golden syrup, treacle • Plain chocolate, toffee, barley sugar • Jelly, custard, junket • Salt, spices, herbs • Vegemite • Tomato sauce

Sample Menu: Low Fibre Diet (Low Residue) Breakfast Strained fruit juice 1 cup of Rice Bubbles with milk and sugar 1 slice of white toast with margarine and honey or Vegemite Drink Morning Tea 1 slice white bread or plain Scone or biscuit Plain yoghurt Drink Lunch White bread sandwich with margarine Lean meat, cheese or egg 1 serve fruit Drink Afternoon Tea 1 slice white bread or plain Scone or biscuit Plain yoghurt Drink Dinner Lean meat, fish or poultry Salad or vegetables 1 serve fruit with ice-cream or yoghurt Cracker biscuits and cheese Drink Supper 1 slice white bread or plain scone or biscuit Plain yoghurt Drink

ADDITIONAL RESOURCES

Oncura also produce a booklet: Prostate Brachytherapy Information for patients Oncura Pty Ltd Australia PO box 4720 North Rocks NSW 2151 Ph+61 2 96305696 Fax+61 2 9630 6247