Would you ever consider focal brachytherapy treatment in a patient who have in-prostate recurrences after RT?

Yes, our preference is focal treatment for unilateral disease on imaging (PSMA, PET, and MRI) and concordant biopsies. Our data suggest that this is just as effective as whole gland treatment for recurrences with possibly less toxicity.

For patients b/l recurrent involvement after prior radiation tr...

Yes: Have been doing this since 2002. Over 100 cases.
No grade 3 or higher rectal toxicity. One patient with grade 4 urinary toxicity. It occurred after a false passage during catheterization.

Lessons learned:

Careful patient selection:

More difficult for local failure after brachytherapy than EBRT ...

Yes, but I take many factors into account:

1. Disease - should be unifocal site with concordant MR/PET and biopsies. If diffuse disease or other suspicious areas, would treat whole gland.
2. Patient - if the patient's disease is eligible for focal, I next consider the patient's baseline GU/GI function. I...

Yes

Yes. Confirmed with biopsy, PSMA PET, and directed by MRI. I typically place hydrogel immediately after the HDR implant.