LDR Prostate Seed Implant Procedure Note

Date of Service: [Date]

Procedure Start/Stop Times: [Start time] – [Stop time]

Location: [Facility/OR/procedure suite]

Primary Proceduralist(s): [Name(s), credentials]

Anesthesia Provider: [Name(s), credentials]

Medical Physicist/RSO: [Name(s), credentials, role]

Procedure(s) Performed: [Transperineal TRUS-guided permanent prostate brachytherapy (LDR seed implant) / related procedures]

Primary Diagnosis: [Diagnosis]

Indication and Oncologic Context

[Indication and treatment context] (State why the procedure was performed, specify monotherapy vs boost vs salvage, treatment intent, and any concurrent or planned therapies such as ADT or EBRT with sequencing. Do not infer risk group if not explicitly documented.)

• Clinical Stage: [cT/cN/cM]
• Gleason/Grade Group: [Gleason score and Grade Group]
• PSA at Diagnosis: [Value and date]
• Therapy Context: [monotherapy / EBRT boost / salvage]
• Planned/Concurrent Therapies: [ADT details, EBRT sequencing] (Only include if explicitly documented)
• Risk Group: [Risk group as documented] (Do not infer; state "not documented" if absent)

Consent and Pre-Procedure Verification

[Informed consent attestation] (Document that informed consent was obtained for permanent prostate brachytherapy with radioactive seeds. Summarize that the nature of the procedure, expected benefits, key risks including urinary retention, bleeding, infection, rectal/urinary toxicity, erectile dysfunction, seed migration, and radiation exposure precautions, and alternatives were reviewed. Reference location of signed consent if stored separately.)

[Time-out and verification] (Attest that pre-procedure verification and time-out were performed confirming correct patient, procedure, site, availability of plan, and team agreement. Reference time-out record location if documented elsewhere.)

• Anticoagulation Management: [Details] (Only include if explicitly documented)
• Antibiotic Prophylaxis: [Agent, timing] (Only include if explicitly documented)
• Bowel Preparation: [Details] (Only include if explicitly documented)
• Baseline Urinary Status: [IPSS, catheter status, prior TURP] (Only include if explicitly documented)
• Pre-operative Prostate Volume: [Volume in cc] (Only include if explicitly documented)

Written Directive and Regulatory Elements

[Written directive status] (State that a written directive was completed prior to implantation. Document that required post-implant completion elements were documented before the patient left recovery, or specify pending elements with responsible owner and timeframe.)

• Treatment Site: [Prostate – whole gland / focal with region specified]
• Radionuclide: [I-125 / Pd-103 / Cs-131]
• Total Source Strength Planned (pre-implant): [Value with units, e.g., mCi or U]
• Number of Sources Implanted: [Count] (If pending verification, note as provisional with owner and timeframe for reconciliation)
• Total Source Strength Implanted (post-implant): [Value with units] (Do not derive from count unless physicist-verified)
• Date of Implantation: [Date]

Source placement evaluation, brachytherapy medical event determination, and documentation will be completed per institutional and regulatory protocols.

Anesthesia

• Type: [general anesthesia / spinal or neuraxial anesthesia with sedation]
• Perineal Block: [Details] (Only include if performed by proceduralist)
• Intraoperative Events: [Anesthesia-related events affecting procedure] (Only include if applicable)

Procedure Details

[Positioning and prep] (Describe positioning, typically dorsal lithotomy, perineal skin prep, and sterile draping.)

[Imaging setup] (TRUS probe placement and imaging approach. Foley catheter placement with size and balloon fill content if used.)

[Planning approach] (TRUS-guided transperineal template technique. Specify planning method: preplan-only, intraoperative real-time planning, or dynamic dose calculation. Document any intraoperative plan modifications and rationale such as edema, pubic arch interference, or needle deflection.)

[Implant delivery] (Template/grid alignment, needle placement strategy including peripheral loading and urethral-sparing approach as applicable, seed deposition method and sequence.)

[Intraoperative verification] (Real-time TRUS confirmation, fluoroscopy if utilized, cystoscopy findings if performed.) (Omit modalities not used)

Full implant coordinates and plan details are stored in the treatment planning system.

Implant Summary

• Radionuclide: [I-125 / Pd-103 / Cs-131]
• Seed Model/Manufacturer: [Model, manufacturer]
• Seed Strength per Source: [Nominal and/or assayed value with units]
• Total Seeds Implanted: [Count] (If pending physics verification, note provisional count and reconciliation plan)
• Number of Needles: [Count]
• Stranded vs Loose: [stranded / loose / mixed]
• Total Source Strength Implanted: [Value with units]
• Prescription Dose: [Dose in Gy] to [prescription isodose/coverage definition]
• Intraop Prostate Volume: [Volume in cc]
• Seeds Discarded/Not Implanted: [Count and disposition] (Only include if applicable)

Findings

• [Prostate size, shape, and median lobe prominence]
• [Pubic arch interference and mitigation] (Only include if applicable)
• [Intraoperative edema] (Only include if applicable)
• [Prostatic calcifications or anatomic variants] (Only include if applicable)
• [Technical limitations affecting coverage] (Only include if applicable)
• [Cystoscopy findings] (Only include if cystoscopy performed)

Complications and Post-Procedure Status

• Intraoperative/Immediate Complications: [None observed / complication(s) with description, management, and notifications]
• Estimated Blood Loss: [Amount] (Only include if clinically meaningful)
• Foley Catheter: [removed prior to discharge / left in place with removal planned on specified date]
• Urine Appearance at Conclusion: [clear / light hematuria / gross hematuria with clots]
• Patient Status: [Condition, pain control, voiding status]
• Disposition: [PACU / discharge home / admission with level of care]

Post-Implant Dosimetry Plan

[Dosimetry follow-up plan] (Specify imaging modality: CT-based with or without MRI fusion. Timing window per radionuclide and program standard. Responsible service for acquisition and review. Planned dose metrics: prostate D90, D100, V100; urethral metric; rectal metric. If post-implant scan not yet scheduled, include scheduling task with owner and target date.)

Results will be reviewed by the radiation oncologist and management considered per institutional practice if coverage is inadequate.

Follow-up Plan

• Radiation Oncology Follow-up: [Target date/timeframe and purpose]
• Urology Follow-up: [Timing] (Include especially if Foley catheter in place)
• Post-Implant Dosimetry Review: [Target date/timeframe, responsible clinician(s)]
• PSA Monitoring: [Schedule, e.g., every 6–12 months for 5 years, then annually]

Attestation and Linked Documents

Proceduralist: [Name, credentials, signature] — [Date/Time]

• Written Directive: [Completed per record / pending completion by owner by date]
• Treatment Planning System Plan: [Plan name/ID and location]
• Physics Seed Accountability Record: [Location/reference]
• RSO Counseling Documentation: [Location/reference]

(If any regulatory document is pending, specify the owner and expected completion timeframe. Do not attest completion unless verified.)