prostate cancer becomes one of the most common cancers in developed and developing countries [ 13 ] .
it is because life expectancy rised ; age is one of the prostate cancer risk factors .
moreover there is wide availability of prostate - specific antigen ( psa ) serum test , which makes possible to diagnose clinically silent , low stage disease .
number of such patients is growing and makes management of this disease even harder in every day oncology care ; optimal management is still controversial .
there is a wide range of treatment methods and one of the most important outcome risk factors is local tumor control .
there are risk categories , in which are propositions of treatment ( table 1 ) .
very low risk category was introduced by national comprehensive cancer center ( nccn ) in 2010 . 
 
risk categories and treatment options according to nccn   prostate specific antigen density if predicted probability of nodal involvement is  2% neoadjuvant , concomitant or adjuvant in selected patients without fixation radical prostatectomy ( rp ) remains one of basic curative therapy for prostate cancer , especially for low and inermediate risk patients .
complications include perioperative short- term side effects as blood loss , wound infection or from anesthesia , and long - term , postoperative , as incontinence or impotence [ 58 ] .
three - dimensional conformal radiotherapy ( 3dcrt ) , dynamic techniques like intense - modulated ( imrt ) or arc radiotherapy and extracranial stereotactic techniques allow to prepare normal tissue sparing plans with clinical target volume ( ctv ) high dose prescription . not only photon beams , but also particles , e.g. protons are used for highly conformal irradiation . every day
image - guided radiotherapy ( igrt ) use , especially with intraprostatic seed markers , makes possible dose escalation and less toxicity with smaller margins contouring .
brachytherapy , combined with external - beam radiotherapy ( ebrt ) or alone , remains one of best tools for absolute dose escalation inside prostate .
due to low alpha / beta ratio for prostate cancer these protocols are favorable , in which hypofractionation is used .
both low - dose ( ldr ) and high - dose rate ( hdr ) brachytherapy ( bt ) are used in prostate cancer patients .
27 kev , half - life : 59 days ) or palladium-103 ( pd ; mean photon energy  21kev , half - life : 17 days )
hdr brachytherapy is , particularly , based on iridium-192 ( ir ; mean photon energy  400 kev , half - life : 74 days ) stepping source , which is driven into temporary implant catheters by computer - controlled unit .
it also makes high dose escalation possible , but interstitial implant is needed [ 12 , 13 ] .
radiotherapy complications are acute and late , mostly in bladder and rectum , like incontinence , diarrhea , urinary stricture , impotence and proctitis .
outcome is similar to surgery , however tolerance of treatment seems better for radiotherapy excluding proctitis rates , which are higher in irradiated patients .
patient for rt are usually those , who can not undergo surgery , older than 65 years or with locally advanced disease , e.g. extracapsular spread [ 5 , 14 , 15 ] .
patients with shorter life expectancy or inconvinced to treat their disease are recommended for psa testing at least every six months , digital rectal examination ( dre ) at least every twelve months and , especially those with longer life expectancy , for repeated prostate biopsy at least every year . if there is disease progression observed , then patient should undergo clinical evaluation to choose optimal treatment option .
although clinical progression is still not well defined and requires physician judgement and treatment option should be chosen wisely after patient discussion with his doctor [ 5 , 16 ] .
comparative analysis of psa free survival outcomes by prostate cancer results study group has been published , recently .
it contains comparison of results from 848 articles selected from over 18000 published between 2000 and 2010 .
only radical treatment was considered containing bt ( including hdr ) , ebrt ( including imrt ) , rp , proton thereapy , hifu and cryotherapy .
pcrsg agreed unanimously for study inclusion criteria as : patient stratification into pretreatment groups ( according to d'amico , zelefsky or nccn ) , psa free time endpoint ( astro , phoenix , psa < 0.2 ng / ml for rp ) , both clinical and pathological staging , minimum of 72 gy ebrt ( imrt or 3dcrt ) , results published in peer - review journals only , minimum median follow - up of 5 years .
morover minimum patients number for each risk group was accepted as 100 for low and intermediate and 50 for high risk group .
results of this study suggest that bt alone , particularly seed implant , provides superior psa free survival in low risk patients .
ebrt combined with bt seems to be equal to bt alone , and better than ebrt alone or rp , in intermediate risk group .
combined irradiation ( ebrt with bt ) with or without androgen deprivation therapy seems to be superior for high - risk patients .
although these results are encouraging to choose bt as an element of managment , it should be remembered that selection bias may play main role , mostly in intermediate risk group . according to lack of large , randomized studies these may help to choose ultimate treatment decision both for physician and his patient .
bt seems to be superior option for dose escalation and psa control in prostate cancer patients .
this is also reason to recall guidelines of european and north american societies on prostate cancer brachytherapy , both hdr and ldr .
european association of urology states that transperineal bt alone qualification criteria are : clinical stage between t1c and t2a , without nodal involvment or metastases , six or less gleason score diagnosed with sufficient number of random biopsies , initial psa level of 10 ng / ml or less , no more than 50% of biopsy cores with cancer , prostate volume of less than 50 cm and a good ipss ( < 20 fair tolerance ; < 9 good tolerance ) . ldr - bt is recommended both by eau and gec / estro as safe and effective in low risk group of prostate cancer patients with life expectancy longer than 5 years .
post - turp patients should avoid this procedure , however if turp was performed several years earlier some patients can undergo ldr - bt after careful evaluation .
hdr - bt is recommended as a dose escalation technique combined with ebrt for patients with intermediate or high risk of failure with life expectancy longer than 5 years .
the exclusion criteria are : prostate volume bigger than 60 cm ( hormonal downsizing to reduce benign prostate hyperplasia is indicated ) , transurethral resection of prostate within six months , infiltration of external sphincter of the bladder neck , significant urinary obstructive symptoms ( residual urine volume > 50 cm , ipss > 12 and qmax < 15 cm / s ) , technical issues ( pubic arch interference , trus prostate - rectum distance less then 5 mm , lack of proper positioning of patient , anaesthesia or complementary ebrt contraindications ) .
moreover these guidelines state that hdr - bt alone should be considered as an investigational treatment with proper fractionation .
salvage hdr - bt should be also performed in a prospective clinical trial , only .
abs states that hdr - bt provides highly conformal treatment with less irradiation for pelvic organs - at - risk and excellent outcome .
all patients should be considered for these aproach , particularly for intermediate and high relapse risk patients as an irradiation boost or as a monotherapy for low risk patients .
prior rectal surgery or pelvic irradiation , i.e. rectal cancer treatment , in prostate cancer patients should be carefully evaluated and complications and outcome risk factors should be discussed with special hdr - bt center expertise .
inflammatory bowel disease patients should be considered for hdr - bt if not suitable for rp , asymptomatic and not required treatment for at least 0.5 to 10 years .
hdr - bt alone seems to be better than ebrt alone or combined with hdr boost , because of smaller bowel volumes irradiated .
turp should be performed at least 90 days before hdr - bt , an aerated gel should be given into urethtra to outline its shape and special attention should be given to not exceed 110% of prescription dose .
most feasible glands for hdr - bt are those beneath 50 cm , but abs guidelines allow to treat larger ones .
pubic arch interference , baseline urinary function and application technique ( fixed template or freehand ) should be carefully considered .
patients should be informed about potential risks of erectile dysfunction or acute and late urinary side effects .
abs states that absolute contraindications include preexisting rectal fistule , impossibility of anaesthesia and no proof of malignancy .
absolute contraindications include poor performance status and life expectancy shorter than 10 years , spinal or general anaesthesia not possible , large post turp defects and lack of rectum , which makes trus impossible .
ipss value over 20 points can correlate with increased urinary toxicity and needs careful evaluation .
prostate volume over 60 cm is not a contraindication and even with pubic arch interference can be considered for ldr - bt with short adt course ( 3 - 4 months ) to downsize the gland .
also freehand implantation is acceptable , but experienced practitioners should perform ldr - bt in such cases .
abs states that ldr - bt alone should be done in low risk patients and as option for intermediate group .
ebrt and permanent seed combination is considered as standard of care for high risk patients .
hdr - bt , according to gec / estro - eau recommendations , should be done under trus guidance with template , its proper fixation and treatment planning software .
additional imaging with ct or mri after implantation may be used . clinical target volume ( ctv ) for hdr - bt can be whole gland (  prostate surface ) with homogenous needles distribution or with addition of visible tumor boost inside ctv .
prostate surface dose prescription differs among cancer centers and is between 6 to 10 gy per fraction with total dose of 12 - 20 gy in 2 to 4 fractions combined with ebrt of 45 to 54 gy in 6 - 7 weeks .
organs - at - risk doses should not exceed 120% of mtd for urethra and less then 6 gy per fraction for rectum . those doses should be precisely stated and valuated in clinical trials with long follow - up including penile bulb maximum dose .
proximal tips of catheters should be visualized and images should be taken at least 9 mm above and below ctv .
organs - at - risk should be confined including rectum , urethra , bladder and penile bulb .
minimum of 14 catheters should be placed or more , particularly if  boost within boost is planned . especially urethra piercing should be avoided .
at least 90% of ctv should be covered with prescribed dose with aiming 95% of ctv .
hdr - bt boost is given in one to six and hdr - bt alone in three to six fractions .
due to wide heterogeneity of fractionation schedules , oar constraints are based on experienced hdr centers references , e.g. from less then 105% to less then 125% for urethra .
ldr - bt should be performed under trus guidance according to gec / estro guidelines . if possible gross tumor volume ( gtv ) should be delineated on pre - treatment scans .
ctv should contain whole prostate with 3 mm margin in all directions except posterior ( rectal wall ) and cranial ( bladder neck ) if needed .
dose prescription to 100% isodose should be 145 gy for i and 125 gy for pd seeds .
at least 95% of ctv should be covered with 100% isodose with no more than 50% of ctv with isodose 150% .
maximum dose in 2 cm for rectal wall should be no more than 145 gy and in 0.1 cm less than 200 gy .
150% of prescribed dose should cover less than 10% of urethra volume and 130% of this dose should cover less than 30% of its volume .
it should be done as a preplanning , either as a separate procedure or on the implanting day in operational room .
main procedure should be performed with trus and template ; patient position and probe angle should be similar to preplanned .
minimum is biplanar , high resolution ( 5 - 12 mhz ) trus with dedicated planning software .
team should consist at least of trained radiation oncologist and qualified medical physicist , but presence of urologist , certified dosimetrist or other supportive staff is appropriate .
abs does not suggest any seed deposition technique , however it should have excellent outcome , be reproducible and with optimal dosimetry . both stranded and loose seeds can be chosen for implantation .
i and pd implants showed excellent outcomes , so abs do not favor any of them .
ldr - bt alone prescription dose to ptv should range from 140 - 160 gy for i seeds and 110 - 125 gy for pd .
if combination of ebrt and seed implantation is planned , i ptv dose should be between 108 - 110 gy and pd ptv dose should be between 90 - 100 gy .
ebrt dose should be 41.4 - 50.4 gy ( 1.8 gy / day , but 2 gy / day is also acceptable ) .
ldr - bt is usually performed 0 - 8 weeks after ebrt , but there is no evidence for optimal sequence of these .
reverse approach is also accepted , which may theoretically be better , because of simultaneous irradiation from implant and ebrt and possibility of adjusting ebrt if needed .
dose constrains for organs at risk should not exceed 150% of prescribed dose in 5% and 125% of prescribed dose in 30% of urethral volume in the preplan .
prescribed dose should be in less then 1 cm of rectum on day 1 dosimetry and in less then 1.3 cm on day 30 .
although ct performed immediately or one day after the implantation has several positives , e.g. early detection of dosimetric problems , but after implant oedema can derive dosimetric underestimations .
it is 12 - 20 days after implantation for pd and 23 - 37 days for i. erectile function organs at risk e.g. penile bulb are still not agreed , though there are no recommendations on these .
both ldr and hdr - bt patients should be seen 6 weeks after implantation ( last one for temporary implants ) according to gec / estro recommendations .
should be examined every 3 months , every 6 months until 5 years after treatment and then annually .
dre , psa test , side effects evaluation ( urinary , rectal , potency toxicity and ipss ) and trus should be done [ 18 , 20 ] .
abs suggests to follow - up hdr - bt patients every six months for first 2 - 3 years , and then at least annually .
it should consist of dre , psa test and toxicity evaluation ( urinary , rectal and sexual function ) .
phoenix definition of biochemical relapse is recommended , although case individual assessment is required and patient should be informed about psa bounce .
ldr - bt patients should be seen every six to twelve months with regular intervals .
post bt rectal biopsies or urinary instrumentation should be avoided and all of the risks and benefits should be considered [ 21 , 22 ] .
brachytherapy is supreme tool in prostate cancer management with a wide range of options in every risk group ( table 2 ) .
excellent outcomes and relatively small irradiated volume seems more beneficial than any risk of intraoperative implantation , particularly in wisely selected patients .
feasibility of seeding or catheterization is basic for choosing appropriate candidates for bt , however there are articles describing series of patient with non - fitting anatomy , i.e. prostate smaller than 20 cm or bigger then 50 cm or post turp patients [ 24 , 25 ] .
assesment should consist of careful clinical examination including dre , patient 's history ( i.e. urologic , prior pelvic rt , surgery or trauma , inflammatory bowel disease , connective tissue dissorders ) , pretherapy psa serum level , biopsy proven cancer with gleason score and clinical staging .
trus stays basic imaging , but ct and mri are also very useful , either before procedure and as a planning guidance .
new abilities of mri , i.e. spectroscopy and diffusion , and 11c pet - ct should be discussed more in next recommendations [ 2628 ] .
gec / estro and eau recommendations on prostate cancer treatment with temporary implants with stepping sources are from 2005 and on permanent seeds from 2000 with 2007 update .
although general approach for bt , both hdr and ldr , has not particular differences across the world , european recommendations need an update . 
 
recommendations comparison for gec/ estro and abs [ 18 , 2022 ] under investigation for high risk patients to institutional review board 
 prostate cancer , due to wide availability of psa tests , is very often diagnosed in early stage , nowadays . 
 this makes management of this disease even harder in every day oncology care . 
 there is a wide range of treatment options including surgery , radiotherapy and active surveillance , but essential question is which treatment patient and oncologist should decide for . 
 due to recent publication of prostate cancer results study group , in which brachytherapy is one of supreme curative options for prostate cancer , we decided to overview most present european and north american recommendations . 
 national comprehensive cancer network , american society for radiation oncology , american brachytherapy society , european association of urology and groupe europen de curiethrapie of european society for therapeutic radiation oncology guidelines are overviewed , particularly focusing on hdr and ldr brachytherapy . 
Purpose
Patient selection
Application and treatment planning
Follow-up
Summary