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High-Dose Brachytherapy
For Treating Prostate Cancer:
Nursing Considerations
Joan Colella
Suzanne Scrofine
P
rostate cancer is the most
common cancer, excluding skin cancers, in
American men with the
incidence higher in AfricanAmerican men (American Cancer
Society [ACS], 2003). Survival
rates are excellent when the cancer is detected in the early stages.
In men, the digital rectal examination may be used to screen for
prostate cancer. Often this is
done in conjunction with a blood
test, which measures the amount
of the prostate-specific antigen
(Aetna Intelihealth, 2001). If
there is an abnormality in either
of these exams, the patient is
referred to the urologist who will
perform a biopsy of the prostate
tissue. Based upon the biopsy
results, the tumor tissue samples
will be graded on potential for
aggressive growth and metastasis. The Gleason grading system
(see Table 1), a method of classifying prostate cancer cells, provides a score or sum indicating
the aggressiveness of the prostate
tumor. The higher the score, the
greater the biologic aggressiveness
Joan Colella, MSN, RN, MPA, LNHA,
ARNP-BC, NP-C, is an Advanced
Practice Nurse, Prostate Cancer
Institute of The Cancer Center,
Hackensack University Medical Center,
Hackensack, NJ.
Suzanne Scrofine, BSN, BS, RN-BC,
OCN, is a Clinical Nurse Coordinator,
Radiation Oncology, The Prostate
Cancer Institute of The Cancer Center,
Hackensack University Medical Center,
Hackensack, NJ.
Radiation oncology nurses must be adequately educated on the care
and management of patients and families undergoing high-dose rate
brachytherapy for early-stage prostate cancer. The application of
advanced assessment skills, while incorporating the treatment
aspects of radiation, provides a framework for standards of nursing
practice in this field. Current methodologies of radiation therapy are
recommended for overall professional growth and improvement of
patient care.
of the tumor (American Urological
Association Measurement Committee, 1999).
Treatment of prostate cancer
can include surveillance, “watchful waiting,” androgen hormone
ablation, internal or external radiation, surgery, chemotherapy, or a
combination of any of these
modalities. Treatment decisions
should consider the patient’s age,
medical history, tumor stage, and
contributing family medical history. The risk/benefit ratio of each
treatment option should be considered and discussed thoroughly
with the patient and his significant other(s) (see Table 2).
The purpose of this article is
to discuss the treatment of
prostate cancer with external
radiation 5040 cGy (cGy =
centigray, Gy = Gray – reflecting
measured amounts of radiation
absorbed by the body) combined
with internal radiation, specifically, high-dose rate brachytherapy (HDR), and the nursing management for this therapy. Since
high-radiation doses cannot be
sustained to kill the cancer without damaging other organs, a regular course of external beam radiation is administered prior to
UROLOGIC NURSING / February 2004 / Volume 24 Number 1
HDR radiation.
High-dose rate brachytherapy implant gives the advantage of
applying a higher dose of radiation directly to the tumor while
sparing healthy tissue and surrounding organs (Nucletron,
2000). Through the treatmentplanning computer, the position
of the catheters is entered along
with the location of the bladder
and rectum. The computer calculates the radiation doses within
and around the implant, and
adjustments can be made to
achieve the shape and doses that
the physician wants to deliver to
the tumor and nearby structures
(California
Endocurietherapy
Cancer Center, 2003).
High-Dose Rate Prostate
Brachytherapy
The term brachytherapy
(short-distance therapy) refers to
internal radiation and dates back
to 1931. In the 1980s, improved
imaging technology such as
transrectal ultrasound (TRUS)
and computerized tomography
(CT) enhanced imaging of the
prostate gland (Nag, 1997).
Radiation therapy produces free
radicals that severely damage the
39
Table 1.
Gleason Grades: Histopathologic Grade G
GX
Grade cannot be assessed
G1
Well differentiated (slight anaplasia)
G2
Moderately differentiated (moderate anaplasia)
G3-4 Poorly differentiated or undifferentiated (marked anaplasia)
American Urological Association Measurement Committee (1999)
Table 2.
Benefits and Risks of HDR
Benefits
•
•
•
•
•
•
•
Eliminates prolonged hospitalization
No radiation precautions after treatment
Minimal side effects to patient
Less acute urethritis
Dose optimization
Treatment delivered within minutes
No side effects associated to the treatment such as nausea or hair loss
Risks
• Physics intensive
• Side effects such as rectal bleeding, urinary burning, frequency,
urgency
• Patient inconvenience (overnight hospitalization, positioning requires
patient flat on back throughout hospitalization)
• No long-term data on outcomes of treatment
• Equipment is expensive
Kelly (1998)
DNA of cancer and normal cells
resulting in cell death (ACS,
2000).
High-dose rate therapy requires
administering more than 600 cGy
per hour or 10 Gy per minute to a
particular site. It can be administered only by remote control due
to the high-radiation exposure.
High-dose rate radiation delivered over minutes is more potent
than lower rates delivered over
months (Kelly, 1998). Radiation
most effectively attacks the
reproducing cells. It is thought to
work by damaging the DNA in
the cells, which is responsible for
the division and growth of the
cells. High-dose rate radiation
therapy allows a higher radiation
dose to be given with greater precision in a small area than the
normal tissues could otherwise
tolerate (ACS, 2000).
HDR is delivered by inserting
multiple plastic flexible catheters
interstitially through the perineal
area into the prostate gland
under trans-rectal ultrasound
40
guidance. The radiation oncologist places these flexible catheters
strategically throughout the prostate gland to optimize radiation
coverage into the prostate gland
and seminal vesicles or around
the pubic arch. The goal in radiation therapy is to deliver the
highest possible dose to the
tumor while minimizing morbidity in the normal tissue (Nag,
1997). Treatment planning (dose
planning) occurs after the HDR
catheters are placed in the operating room and the patient has
completed a CT scan.
During the CT scan, the radiation oncologist can adjust the
catheters, if necessary, prior to
beginning treatment. The CT
scan information is entered into a
computer-planning program that
determines how much radiation
will be given through each
catheter. The catheters are divided into “dwell positions” every
0.5 cm and the computer determines the position and amount
of dwell time for the radioactive
seed in each catheter. An iridium-192 radioactive seed (gamma
ray energy) is attached to a thin
wire from the source machine,
providing the radiation through
transfer tubes, which are connected to the plastic catheters
(Glasgow & Anderson, 1994).
Dose adjustments can be made so
the tumor receives the higher
dose and surrounding organs
receive lower doses. Iridium-192
is the radioactive source used
since it delivers concentrated
HDR with minimal exposure to
surrounding tissue.
In the combined therapy, the
patient usually receives external
beam radiation therapy prior to
the interstitial brachytherapy
(internal radiation) with HDR
catheters. Indications for HDR
radiation therapy are typically
stage T1-2 tumors (clinically
localized, low-risk disease), a
prostate volume of 35 cc or
greater, large TURP defect, and a
pretreatment score of 8 or greater
on the American Urological
Association International Prostate
Symptom Score Scale (I-PSS) (see
Figure 1). The I-PSS is based on
patient answers to seven questions
concerning urinary symptoms.
The higher the rating, the more
severe the urinary symptoms
(American Urological Association
Measurement Committee, 1999).
Usually patients with an I-PSS
score of 8 or greater before treatment are at risk of developing urinary obstructive disease with permanent seed implants. This is due
to the number of radioactive seeds
required for effective radiation
coverage in treating the cancer.
Pre-Implant Phase
Treatment planning begins
with a volume study, done on an
outpatient basis, about 1 to 2
weeks prior to the scheduled procedure date. The patient is given
instructions for specific diet and
bowel preparations for the procedure. The patient is placed in dorsal lithotomy position. It is important that the patient be positioned
so that shoulders are in straight
alignment with the buttocks to
provide appropriate prostate imaging. Information from this proce-
UROLOGIC NURSING / February 2004 / Volume 24 Number 1
Less than 1
time in 5
Less than half
the time
About half the
time
More than half
the time
Almost
always
0
1
2
3
4
5
Frequency
Over the past month, how often have you had to
urinate again less than 2 hours? After you finished
urinating?
0
1
2
3
4
5
Intermittency
Over the past month, how often have you found you
stopped and started again? Several times when you
urinated?
0
1
2
3
4
5
Urgency
Over the past month, how often have you found it
difficult to postpone urination?
0
1
2
3
4
5
Weak Stream
Over the past month, how often have you had weak
urine stream?
0
1
2
3
4
5
Straining
Over the past month, how often have you had to push
or strain to begin urination?
0
1
2
3
4
5
1-Time
Nocturia
Over the past month, how many times did you most
typically get up to urinate from the time you went to
bed at night until the time you got up in the morning?
0
1
4-Times
5-Times
or more
Score
3-Times
Date of Birth_____________ Date Completed __________
2-Times
Patient Name ______________________________________
Not at all
Incomplete Emptying
Over the past month, how often have you had a
sensation of not emptying your bladder completely
after you finished urinating?
None
Figure 1.
International Prostate Symptom Score (I-PSS) (0-5 scoring)
2
3
4
5
Mostly
Dissatisfied
1
2
3
4
5
Terrible
Mixed
0
Unhappy
Mostly
Satisfied
If you were to spend the rest of your life with your
urinary condition just the way it is now, how would
you feel about that?
Pleased
Quality of Life Due to Urinary Symptoms
Delighted
Your Total I-PSS Score
6
American Urological Association Measurement Committee (1999)
UROLOGIC NURSING / February 2004 / Volume 24 Number 1
41
Figure 2.
Nucletron High-Dose Rate
Radiation Equipment
Table 3.
Latent Side Effects of HDR Brachytherapy
•
•
•
•
•
•
Irritative voiding symptoms
Persistent urinary retention
Rectal urgency
Bowel frequency
Rectal bleeding or ulceration
Prostatorectal fistulas
Source: DiBiase and Jacobs (2003)
Figure 3.
High-Dose Rate Catheters with
Perineal Template Sutured in Place
dure guides the radiation oncologist in making the
final treatment decision whether to proceed with
HDR catheters or permanent seed implants, depending on prostate volume.
The HDR preparation and procedure, including
pre-operative anesthesia requirements, are
reviewed in detail with the patient and his significant other(s) at the time of the volume study
Pre-admission. Testing depends upon physician
preference or hospital protocol, and may include
complete blood counts, bleeding times, blood
chemistries, electrocardiogram, chest X-ray, and
medical clearance.
Intraoperative Phase
Figure 4.
Special Mattress for HDR
Catheter Procedure
General or spinal anesthesia is administered. An
intravenous line is started and prophylactic antibiotics are given intraoperatively. Trans-rectal ultrasound guidance is used during the procedure for needle placement. Closed-end trochar pointed needles
are inserted into the prostate according to a predetermined pattern. After all the steel needles are inserted,
they are replaced with plastic hollow flexible
catheters containing metal stylets. The radiation is
delivered through the hollow plastic catheters (HDR
catheters) after treatment planning is completed (see
Figure 2). The number of catheters varies by the size
(volume) of the gland; however, on average 15 to 24
catheters may be placed. Following catheter insertion, the detachable portion of the template is sutured
to the perineum in order to hold the template and the
catheters in position (see Figure 3). The patient is
placed in a supine position on a special mattress (see
Figure 4) and a flexible cystoscopy is performed to
check HDR catheter positioning. Upon completion of
the cystoscopy, the urologist inserts a three-way
Foley catheter with continuous bladder irrigation.
Possible immediate side effects after catheter
implant include the possibility of perineal bleeding
or discomfort, latent effects of anesthesia such as
nausea/vomiting, urethral bleeding and bladder
spasms due to the urinary catheter, and musculoskeletal discomfort due to required supine positioning (see Table 3).
Postoperative/Treatment Phase
Upon transfer to the radiation oncology department post implant, the radiation oncology nurse
42
UROLOGIC NURSING / February 2004 / Volume 24 Number 1
Table 4.
Patient Education for High-Dose Rate Brachytherapy
Volume Study
Approximately 3 weeks before the implant procedure,
your radiation oncologist will make a map of your prostate
gland from a trans-rectal ultrasound (TRUS). This is called a
volume study, which will determine the volume, size, and location of the prostate gland.
A nursing staff member will escort you into the examination room, and you will be asked to change into a patient gown.
You will be asked to lie down on the examination table, slide to
the end of the table, and place your feet in stirrups or holders
for your feet. Numbing jelly will be placed around and into the
rectum prior to the insertion of the ultrasound probe. Images of
your prostate, which look like underdeveloped pictures, will be
projected onto the ultrasound screen. You may feel the probe
moving and a clicking sound of the machine when the probe is
adjusted to obtain different pictures of the prostate gland. The
machine records and prints these pictures, which are used as
part of your treatment chart. The procedure takes approximately 10 minutes.
Procedure
Day Before the Implant. You will take a bowel preparation
drink to empty stool out of your intestines. This is called
Golytely® and you will begin taking 8 ounces every 20 minutes,
starting at 5 pm the evening before the procedure, until the gallon is finished. It is important that you take this so you will not
experience abdominal bloating or stomach cramps during your
hospital stay. You will be on a full liquid diet starting the day
before your high-dose rate (HDR) procedure. No food, medication, or drink can be taken after midnight, unless you have been
instructed differently by the urologist.
Day of the Procedure. You will report to the admitting
office and follow their directions to the Day Accommodation
Area. You will be asked to undress, removing all clothes, jewelry, dentures, and removable teeth (such as bridges), hearing
aides, and contact lenses. You will be dressed in a hospital
gown and placed on a stretcher. Spinal anesthesia will be the
anesthesia of choice and a small catheter will be placed in your
back through which pain medication will be given. You will
have an intravenous. A tiny machine with a push button will
provide you with pain medication both automatically and as
you need. This is called patient-controlled epidural analgesia or
PCEA pump. This pain medication will be automatically administered or self-administered by pushing a button, as you need
medication to relieve pain. You cannot overmedicate yourself
since this pump is pre-set by the anesthesiologist, controlling
doses and timing frequency of administration.
Next, your skin will be cleaned with a special solution and
your legs will be placed in stirrups or leg holders to position
you for the procedure. A rectal ultrasound probe (same equipment used for your volume study) will be inserted into your
rectum and an image of your prostate will be projected on a
screen showing your bladder, prostate gland, seminal vesicles,
urethra (urine passage tube), and rectum. This rectal probe will
be attached to a stepping unit, which will hold the probe still for
a good image and be moved in or out of the rectum by the
physician turning a knob on this machine. The physician will
place metal needles through the template, which is attached to
your perineal area (skin under the scrotum). The metal needles
will be removed and HDR catheters will be inserted into the
prostate gland. The number of HDR catheters inserted for your
radiation treatments depends on the size or volume of the
gland. The template will be sutured, in each corner, to hold the
plastic catheters so they cannot move. Your legs will be taken
out of the stirrups and the urologist will then insert a flexible
cystoscope (thin tube with a light) through the penis into the
bladder to check the placement of the catheters. The cystoscope is then removed and a urinary catheter will be placed in
your bladder. An irrigant (cleansing solution) will be attached to
UROLOGIC NURSING / February 2004 / Volume 24 Number 1
the urinary catheter to keep the tube open and urine draining.
You will then be transferred to the recovery room for a
period of time until you are awake, or if you have spinal anesthesia, until you have movement in your legs. Special stockings
called venodynes, will be placed over the support stockings on
your lower legs to promote good circulation and prevent blood
clots from developing. These stockings will be attached to a
machine, which inflates and deflates on a timed basis, creating
a feeling of tightness and looseness on your legs. After the
recovery room, you will be brought by stretcher to the radiation
oncology department and remain there for about 1.5 to 2
hours, until the treatment plan is completed. A CT scan will be
done to check the HDR catheter placement and for radiation
dose treatment planning. It takes about 1 hour to complete. At
the time of the CT scan, you will be placed on a special blue
mattress, which has a hole in the center for the HDR catheters,
so there is no pressure on that area. You will remain on this
mattress until the HDR catheters are removed and you should
not be taken off the carrier with the blue mattress throughout
your hospital stay.
Once the dose planning CT scan is finished, the information is given to the physicist to plan and calculate the proper
radiation dose through a special Nucletron treatment-planning
computer. This produces a computerized plan for your treatments. The radiation oncologist will review, change if needed,
and give the final approval of your treatment plan. You will
receive one radiation treatment after the planning is completed
and then return to your nursing unit. You will return in 6 hours
for a second treatment, which is given on the first day. Once
you return to the nursing unit, you will be given something to
eat and begin receiving any medication your physician has
ordered. The diet is a low-residue, low-fiber diet. You should try
to drink fluids throughout your hospital stay and use the
breathing machine (incentive spirometer) frequently to reexpand your lungs. You will be given a medication (Lomotil®),
which will constipate you during the hospital stay. This will
cause constipation that will be reversed the day after your last
radiation treatment (treatment #4).
You will have a total of four treatments during your
overnight hospital stay (typically two on the day of the procedure and two the next day). During your radiation treatment,
the catheters are attached to a special machine in the radiation
room, which delivers the internal radiation (temporary seeds).
The radiation unit pushes a single radioactive pellet into each
catheter, one by one, for a precise amount of time and distance,
determined by your treatment plan. The treatment does not
cause pain and you will not feel anything. You will be asked to
keep your legs in a bent position during the treatment, since
the catheters are attached to tube-like wires, which deliver the
radiation. The treatment time takes 15 to 20 minutes and you
will need to lie still. You will be observed on a TV monitor outside the room and an intercom will be on so you can communicate with the physician, physicist, and nurse, as the need arises. After your last (4th) treatment, the HDR catheters will be
removed. You will be brought into a treatment room and be
given medication for pain to relax you and make you comfortable. The four sutures will be removed as well as the template
and HDR catheters. You may have a small amount of bleeding
from the HDR catheter site and a pressure dressing will be
applied to the area. There will be no dressing to this site when
you go home. After approximately 20 to 25 minutes, you will be
taken off the special blue mattress. You can then turn, sit up,
and move. Your urinary catheter will remain in place for at least
24 hours; therefore you will go home with a urinary catheter. In
the nursing unit, instructions will be given to you related to the
care of the urinary catheter before you are discharged. You will
be given an appointment to return to the radiation oncology
department to have the catheter removed by the nurse.
43
Table 4. (continued)
Patient Education for High-Dose Rate Brachytherapy
Discharge Instructions
There is no radioactivity present; no radiation precautions need to be taken.
• You will need to arrange transportation home, someone to drive you home.
• Rest for the next 24 to 48 hours.
• Apply ice to perineum as needed for discomfort. You may experience soreness, tenderness, or bruising at the site of the
catheter insertion for the next 3 to 4 days.
• Return for scheduled appointment 24 to 48 hours (1 to 2 days) after procedure for urinary catheter removal.
• Take antibiotic prescribed until finished.
• Take pain medication prescribed as needed for discomfort. Do not take blood thinners, aspirin, or ibuprofen products for 48
hours (2 days) unless your medical doctor has advised you to do so.
• Return to normal activities (work and exercise) as tolerated. Heavy lifting (over 20 pounds) or strenuous activity should be
avoided for 7 to 10 days following the procedure to allow healing.
• Return to your normal diet.
• You will be given Milk of Magnesia® to stimulate a bowel movement prior to leaving the hospital, and can repeat a dose the
following day. You will be constipated initially due to anesthesia, pain medication, and antidiarrheal medication.
Once urine catheter is removed:
• Drink plenty of water for the next 24 hours (about 8 glasses), unless you are on a fluid restriction.
• Expect to pass your urine within the next 2-hour period after the catheter is removed. If this does not happen, call the physician.
• Urine may be blood tinged, brown tinged, or contain small clots due to the procedure. If you experience bright red blood or
large blood clots, call the physician immediately.
• Burning, pain, urgency, and frequency may occur when you urinate. This should end in a few days.
• If you develop a fever or drainage (yellowish or bloody), redness, or swelling at the HDR catheter site call the physician.
• Sexual activity can be resumed within 2 weeks. A condom should be used for 4 weeks. There may be old blood in the ejaculate initially.
• Schedule a followup appointment with the radiation oncologist for 4 months after the procedure.
• Schedule an appointment with your urologist.
Reprinted with permission from The Prostate Cancer Institute of New Jersey of The Cancer Center, Hackensack
University Medical Center, Hackensack, NJ.
Table 4 may be photocopied for patient education purposes.
assesses the patient for adequate
pain control, patency of the intravenous and indwelling catheter,
urine color and characteristics,
operative site bleeding, and vital
signs. Typically, routine postoperative orders include IV fluids,
vital signs, progressive diet from
clear liquids to a low-residue diet
when tolerated, parenteral analgesics, antiemetics, antidiarrheals, antibiotics, and maintaining the continuous bladder irrigation with normal saline to keep
the urine clear. Antidiarrheals
are given to chemically constipate the patient while the
catheters are in place.
As an initial part of the treatment planning phase, a CT scan,
with contrast of the prostate, is
ordered to develop the radiation
treatment plan. In addition, the
radiation oncologist can better
visualize the inferior border (apex)
of the prostate to assure proper
dose planning, thus avoiding
underdosing the prostate gland
(Mate, Kovacs, & Martinez, 1994).
44
The CT scan further identifies the
margins of the gland in order to
avoid excessive doses to the urethra and rectum. The HDR
catheters and template grid are
marked to assist with visual verification of catheter positioning during subsequent treatments. The
metal stylets within the plastic
catheters are removed once the CT
scan positioning is completed. The
lumens to the HDR perineal
catheters must be dry for the highdose rate machine (Nucletron,
2000) to provide the treatment. If
they become wet, the machine will
default and not deliver radiation
through the catheter lumens. The
entire HDR treatment would need
to be aborted if this occurs and the
patient returned for re-implant of
the HDR catheters.
Upon completion and approval of the treatment plan, the
patient is brought to the treatment
room for the first of four treatments. Radiation treatment time
takes approximately 20 to 25 minutes, depending on the number of
catheters. The HDR catheters are
connected to the remote after-loading machine, which is the radioactive source unit. The temporary
radioactive seed placed into each
catheter is iridium-192. By incorporating computer technology that
controls both the position and time
of the iridium-192 source, the target volume and dose distribution
to each catheter can be tailored to
the patient’s individual plan (Mate
et al., 1994). While the treatment is
in progress, monitoring by the
nurse continues from outside the
treatment room via cameras and an
intercom system. When the treatment is completed, the physicist
surveys the patient and room for
potential levels of radioactivity by
using a dosimeter. The physician
disconnects the after-loading
cables from the HDR catheters.
Radioactivity is present only at the
point of treatment, therefore the
patient is not radioactive.
Patients are typically treated
twice on the first day and twice on
continued on page 52
UROLOGIC NURSING / February 2004 / Volume 24 Number 1
High-Dose Brachytherapy
continued from page 44
the second day of hospitalization.
On each day, four treatments of
500 cGy for a total of 2,000 cGy are
given 6 hours apart on each day for
maximum effectiveness and tolerability.
All catheters are removed
simultaneously with the perineal
template, and sterile abdominal
pads are immediately applied to
the perineum with manual pressure for hemostasis. Vital signs are
immediately obtained and the
bladder irrigation is titrated until
the urine color is clear. A pressure
dressing is maintained to the perineum for approximately 30 minutes. The urinary catheter remains
in place post procedure for an
additional 24 hours to prevent urinary obstruction resulting from
inflammation of the urethra due to
intra-operative manipulation of
the prostate gland (Mate et al.,
1994). The patient is discharged
without a dressing to the perineum.
Conclusion
High-dose rate brachytherapy
for early-stage prostate cancer is
considered one of the most
52
advanced treatment technologies
currently available. It was introduced at Kiel University in
Germany in March 1986 (Nag,
1994). High-dose rate radiation
treatment for prostate cancer is
limited due to physician training
required to perform the procedure.
The advantage of this therapy is
the ability to deliver high-dose
radiation to a small area with no
remaining radioactivity once the
temporary radioactive source is
removed. The disadvantage is that
only a small volume of tissue can
be treated. Longitudinal studies on
quality of life related to urinary,
bowel, and sexuality issues must
be continued to evaluate the longterm effects of this treatment and
its impact on the patient’s life.
Comprehensive nursing management for patients before, during,
and after the procedure is necessary to achieve high-quality outcomes and patient satisfaction (see
Table 4). •
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Recommendations of the International
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(2003). What is high dose rate (HDR)
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Kelly, D. (1998, January 22). Dr. Kelly’s
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(1994). High dose brachytherapy of
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UROLOGIC NURSING / February 2004 / Volume 24 Number 1