Trans-Rectal Ultrasound-Guided Trans-Perineal
Implants of the Prostate
Using ¹²⁵I and ¹⁰³Pd and HDR (¹⁹²Ir).

CHAPTER 10

STERILE LOADING OF RADIOACTIVE MATERIALS INTO NEEDLES

Remember, by regulation, the needles cannot be left unattended
in the OR once they are loaded.

• Materials Required
  
  
  • Material Supplied from Radiation Oncology
    
    
    1. Radioactive Seeds
    2. Needles
    3. Spacers
    4. 2 Long Forceps
    5. 1 Notched Forceps
    6. 1 Notched Tweezers
    7. 3 steel rulers
    8. 1 Loading Box
    9. 1 Storage Box
    10. 2 Mesh Baskets
    11. L-Block on rolling cart, light L-block packaged and sterile, or Lead bricks
    12. Cutie Pie
    13. GM Survey Meter
    14. Implant Diagram
    15. Survey record
    16. sterile badges and rings for dosimetrists, physicians, and physicists
    17. Bone Wax (or hydrocortisone acetate if rapid strand is used)
    
    
  • Material Supplied from Surgery or Urology
    
    
    1. Large drape for work area/table
    2. Small drape for L-Block
    3. Gowns/gloves/etc..
    4. Bone Wax
    5. Sterilizer (autoclave) and test kit
    6. Sterile towels
    
    
• Loading Procedure - General Rules
  
  
  1. Standard O.R. sterile technique will be observed at all times, in accordance with O.R. policy and procedures.
  2. Physics/Dosimetry personnel will wear scrubs, gowns, gloves, etc. and scrub according to O.R. Nursing policy and procedures.
  3. All physics items to be sterilized will be done by the manufacturer's recommended method.
  4. All radioactive material except Rapid Strand will be flash sterilized in its original container, except that the container will be opened, will be inside a small lead pig, which will be inside a stainless mesh basket with a cover. Rapid Strand seeds arrive sterile in package and do not require re-sterilization.
  5. All radioactive materials will be flash sterilized on a 10 min. cycle at 270 F.
  6. No needles other than 18g x 20 cm needles specifically for prostate implants will be used. Currently we are using model 500518200 18g x 20 cm pncf with echogenic tip supplied by Medical Device Technologies, Inc (MDTech). Note: These are NOT the same needles used for other templates, such as Syed-Niblett. DO NOT use that type of needle; they won't work.
  7. ALL loading will be accomplished behind the Lblock, using standard radiactive material handling precautions.
  8. All loading personnel will wear their film badge and ring at all times while working with radioactive materials.
  9. Rings must be cold gas sterilized before use.
  
  
• Preparation of Sterile Loading Area
  
  
  1. Drape a table and L-block with a large drape. If the light weight L-Block is used, it should be gas sterilized, and can be placed on top of the draped table. If the heavy L-Block is used, it must remain on its own cart and must be draped separately.
  2. Unwrap the loading and needle storage boxes and place them immediately adjacent to the L-Block. The loading box should be behind the L-block.
  3. Open 1 box of needles, one package of bone wax, and one package of sterile gut spacers.
  4. Open one sterile notched forceps and one notched tweezers.
  5. Open gown and gloves.
  
  
• Sterilization of Loose Seeds
  
  
  1. Seed Quality Assurance (activity verification) should have already occurred in Radiation Oncology prior to bringing seeds up to the Urology Center.
  2. Place the loading diagram in a holder at the loading area so it can be seen easily while working behind the L-Block.
  3. Seeds will be in small plastic vials, inside of small lead pigs. Open one pig.
  4. Remove vial from pig using forceps. Be careful, they are slippery.
  5. Remove completely any remaining plastic shrink wrap using the forceps. Never handle the seeds or plastic vials containing seeds directly.
  6. Remove cover from vial.
  7. Return uncovered vial to small pig and place pig and its lid in a mesh basket.
  8. Repeat for all seed vials.
  9. Place the mesh basket inside the autoclave with a test strip. BE CAREFUL NOT TO SPILL THE SEEDS.
  10. Seal the autoclave and run a 10 minute, 270F flash cycle.
  11. While seeds are sterilizing, SCRUB, gown, and glove.
  12. From this point on, carefully observe standard O.R. sterile procedures.
  
  
• Waxing the Needles
  
  
  1. Open a packet of bone wax.
  2. Stick the tip of each needle into the wax and wipe the excess off across the cut end of the needle, ensuring that the tip of the needle is filled. Do not overfill the tip. 1-2 mm is enough.
  3. Wax all the needles which are required for the implant.
  
  
  
• Loading loose ¹²⁵I or ¹⁰³Pd Needles
  
  
  1. Obtain two sterile towels, folded.
  2. ENSURE YOU ARE WEARING YOUR BADGE AND RING
  3. HAVE SOMEONE ELSE OPEN THE AUTOCLAVE FOR YOU.
  4. Using the sterile towels as hot pads, remove the mesh basket from the autoclave and place it on the sterile loading table. Observe radiation precautions with open pigs/vials of seeds.
  5. Have the non-sterile person survey the autoclave, recording time and reading.
  6. Verify that the test strip indicates sterile.
  7. Open one packet of spacers and place them in one of the shallow holes on top of the loading box, behind the L-Block.
  8. Using sterile forceps, remove one vial from its pig and empty its contents CAREFULLY into the second shallow hole of the loading box. Some water may be inside the vial and may pour into the hole with the seeds. Don't worry, it will dry quickly. You may blot them with a sterile towel if they are extremely wet.
  9. Confirm visually that all seeds are out of the vial.
  10. Notify personnel in the suite that radioactive materials are now being used, and that they should observe radiation safety precautions.
  11. Place one needle vertically in the small center hole of the loading box.
  12. Using the notched forceps or notched tweezers, load the first needle, alternating seeds and spacers, until the proper number of seeds is loaded according to the loading diagram. Always start with a seed and end with a spacer.
  13. Insert an obturator into the needle until it touches the last spacer. DO NOT PUSH HARD OR THE NEEDLE WILL UNLOAD.
  14. Using a ruler, measure the length of obturator remaining outside of the needle. There should be one centimeter for each seed+spacer in the needle. Verify that the correct number of seeds are loaded in this needle.
  15. Place the loaded needle into the deep hole of the loading box which corresponds to the number of seeds loaded in that needle.
  16. Repeat for all remaining needles on the loading diagram.
  17. Open additional spacers and seed vials as needed.
  18. Load three extra needles with two seeds in each, and one needle with the maximum number of seeds used in any other needle. These are for addition of seeds under fluoroscopy, or in case a needle gets bent and cannot be used.
  19. Verify that all needles in each deep hole (i.e. having the same number of seeds)have the same length of obturator sticking out.
  20. Sort the needles from the loading box into the storage box according to the loading diagram.
  21. Place the extra needles in the storage box in a far corner of the grid. Insure that they cannot be mistaken for other needles in the template.
  22. Place the loaded storage box onto the sterile O.R. instrument cart in its appropriate position, or in a sterile area sufficiently far from the loading table to be able to conduct a survey of the table without interference.
  23. Place any unused seeds into the vial, close it, and place it back in its pig. Tape the lid of the small pig in place, and mark it with the remaining number of seeds.
  24. Using the GM Survey meter, survey the loading area for lost seeds. Record the time and readings.
  25. Dispose of unused spacers from open packages. Dispose of unused needles in an appropriate sharps container or carefully save for repackaging and cold gas sterilization.
  
  
• STORAGE AND HOT HANDLING OF NEEDLES
  
  
  1. Loaded needles will be stored in the Shielded Vertical Needle Storage Box until used.
  2. Loaded needles will be attended at all times by trained Radiation Oncology personnel.
  3. Exposure rates around storage boxes will be confirmed to be less than 2 mR/hr, or appropriate distance and shielding will be enforced to achieve this level at closest approach to the box by non-radiation trained personnel.
  4. The sterile, loaded needles in the sterile storage box will be placed on the OR instrument table after OR personnel have finished setting up all other materials, to ensure that they are not exposed while working.
  5. Hot needles and radioactive materials will be handled, loaded, unloaded, or modified only by Radiation Oncology personnel or the Urologist.
  
  
• Checklist of Items brought to OR for Prostate Implants form: Use the checklist of items to account for all materials brought to OR for loading and insertion of prostate implants (see page 10-6).
  
  

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  ITEMS BROUGHT TO O.R.
  FOR PROSTATE IMPLANTS
  

  __________ 1. Needles- sterile

  __________ 2. Bone Wax or HydroCortisone Acetate- sterile

  __________ 3. Spacers- even if using Rapidstrand- sterile

  __________ 4. Mesh Baskets with tight-fitting lids

  __________ 5. Table bars/bracket assembly

  __________ 6. Loading boxes

  __________ 7. Patient chart and preplans

  __________ 8. Poster with Ultrasound images

  __________ 9. Geiger counters and Cutie Pie

  __________ 10. Ring badges- sterile

  __________ 11. Seed forceps- sterile

  __________ 12. ¹²⁵I or ¹⁰³Pd seeds

  __________ 13. Planning Diagrams

  __________ 14. L-Block

  __________ 15. Rulers- sterile

  __________ 16. Survey Log sheet

  __________ 17. RadioActive Materials Warning Signs - 3

  __________ 18. Bottle Forceps

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• RAPID STRAND - Still under construction