PROTOCOL FOR PREVENTING RECTAL INJURY IN ABLATIVE THERAPY FOR PROSTATE CANCER

PROTOCOL FOR PREVENTING RECTAL INJURY IN ABLATIVE THERAPY FOR PROSTATE CANCER




The following article was in the recent AUA newsletter. Although rectal injury is extremely rare in the HIFU patient. This article certainly merits for us to consider adopting a post HIFU protocol when treating previous failed radiation therapy patients. This protocol should also be adopted for all patient that have had a prior failed treatment such as prior HIFU, Brachytherapy, IMRT, RRP and Cryotherapy.


Correlation Exists Between Acute, Late Urinary, And Rectal Injuries In Prostate Cancer Patients Treated With RT.
MedWire (8/19, Guy) reported, "A significant correlation exists between acute and late urinary and rectal injuries in prostate cancer patients treated with radiotherapy (RT)." In fact, the "occurrence of an acute urinary or rectal event was associated with an approximately three-times higher risk for a late event in patients treated with RT alone or with RT after prostatectomy," according to an Italian study detailed in the International Journal of Radiation Oncology Biology Physics.


I would offer the following post HIFU protocol for prevention of fistula:
•Withhold voiding trial until minimum 2 weeks post HIFU.
•Maintain patient on prophylactic antibiotics while S.P. Catheter is in place.
•Place patients on anticholinergics for the first 10 - 12 days. ie: Vesicare 10 mg. Q day.
•Place patient on high residue diet for 2 - 4 weeks, or until voiding. This will need to be detailed and provided to patients. Their idea of high residue diet may not be the correct one.
•Add Metamucil daily/prn as a bulk forming laxative to combat potential constipation from anticholinergics. As well as a synergy to high residue diet.
•Urine culture and sensitivity several days before removing S.P. catheter to confirm no infection.
•Hold off removing S.P. Catheter if the culture is positive and/or resistant to antibiotic patient is taking.
•Confirm ability to void by filling the bladder via S.P. tube, measure volume infused, and then measure volume voided. Do not remove the S.P. tube if greater than 20% residual urine.
•Post-void residual determination by ultrasound or bladder scan at 48 hours after S.P. tube is removed. Confirm no residual of significant volume.
•Weekly nurse call to patient for the first 3-4 weeks on bi-monthly for the first 3 months, followed by monthly for the next 3 months.
•Absolutely "nothing per rectum" for 6 months.
•Absolutely no instrumentation unless under direct vision, and with appropriate antibiotic prophylactic ie: Gentamicin or Rocephin I.M.
•Emergency medic alert card with contact numbers to be mandatory carried at all times. Consider a wrist bracelet with contact information and telephone contacts. Provide back up emergency contact telephone in the event P.I. can not be reached.
•Patients should be urged to curtail any heavy excessive exercise or work.
•They should also be urged to not travel beyond the U.S. for the first six months.




George M. Suarez, M.D.