High Dose Rate Brachytherapy With Ring and Tandem for Patients with Gynecological Cancers


Radiation therapy is a treatment for some cancers. One way to give radiation is to place a radioactive source inside the body. The source is placed in or near the tumor. This is called brachytherapy. You will be getting high dose rate (HDR) brachytherapy. It will be delivered with an applicator (ring and tandem) through a small thin tube that is stitched in the top of the vagina, and will include four treatments of radiation. You will be admitted to stay overnight for the placement of the applicator in addition to receiving two HDR treatments. The exact procedure will be repeated the following week with the final two treatments.

Most patients also get external beam radiation therapy (EBRT). That treatment is described in a separate booklet. The number of treatments vary between 25-28. Radiation is delivered Monday through Friday.

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Before the Procedure


  • Your doctor’s office will schedule the HDR treatments and tell you the dates to come in.
  • If you develop a cold, fever, flu-like symptoms, or a rash, call your doctor as soon as possible. We may have to reschedule the treatment.
  • Review the aspirin card. It lists medicines that have aspirin and non-steroidal anti-inflammatory medicines (NSAIDs). Stop aspirin five days before each HDR treatment. Stop NSAIDs 24 hours before each treatment.
  • You will meet with someone from the brachytherapy team about one week before the first HDR treatment. He or she will review the details of the procedure with you.
  • You will also have presurgical testing (PST). You will see a nurse practitioner and a patient care technician. Please bring a list of all medicines that you take. Include prescription and over-the-counter medicines and herbals. The nurse practitioner will review them with you and tell you what to take on the days you will have HDR treatment. You will have routine blood tests, an electrocardiogram, and a chest x-ray.
  • A care partner must take you home after the treatment. Please arrange to have someone do this. We also recommend that you have someone help you at home for the first 24 hours after the treatment.
  • By the time you get your HDR treatment you may have started to have diarrhea from your external beam radiation therapy. However, we still want your bowel to be fairly empty of stool the day of your treatment. Follow the instructions below on how to change your diet the day before the procedure.

The Day Before the Procedure

  • Take your usual medicines.
  • Eat a light breakfast.
  • Start a clear liquid diet (see below) after breakfast and continue it all day and evening up until 12 midnight.
  • To prevent dehydration and a feeling of weakness, have at least eight to ten, 8-oz servings of liquids.

Clear Liquid Diet

Food Category

You May Have

You May NOT Have


  • Clear broth or bouillon
  • Clear consommé
  • Any other soups

Sweets and Deserts

  • Gelatin
  • Flavored ices
  • Honey, sugar, sugar substitutes
  • Hard candy
  • Any other sweets or deserts


  • Water
  • Clear fruit juices, such as apple, cranberry, or white grape, Kool-Aid®
  • Gatorade®
  • Black coffee or tea (in limited amounts, no more than 2 cups)
  • Juice with pulp or nectars
  • Carbonated drinks or soda, such as ginger ale, 7-Up®, Sprite®, seltzer, cola
  • Alcoholic beverages
  • Milk or cream

Instructions for eating and drinking before your procedure

12 ounces of water

  • Do not eat anything after midnight the night before your procedure. This includes hard candy and gum.
  • Between midnight and up until 2 hours before your scheduled arrival time, you may drink a total of 12 ounces of water (see figure).
  • Starting 2 hours before your scheduled arrival time, do not eat or drink anything. This includes water.
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The Day of the Procedure

  • You may have to give yourself a Fleet® enema before the procedure. Your nurse will let you know if you need this. If you do, give it to yourself first thing in the morning. Follow the instructions on the package.
  • Take a shower before you come to the hospital. You may brush your teeth.
  • Take your usual medicines, except those for diabetes, with a small sip of water.
  • Wear clothing that is loose-fitting and comfortable.

Do not wear any makeup or nail polish. You will need to remove glasses, hearing aids, and dentures if you wear them. Bring cases for them so they will be safe. Do not wear contact lenses.

Come to the 1275 York Avenue entrance and take the B elevators to the 6th floor. The nurses there will get you ready for the procedure.

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The Ring and Tandem Procedure

Positioning of the Applicator and Treatment Planning

  • You will be taken into the operating room.There, you will be put to sleep so that you will have no discomfort.
  • Your doctor will place a catheter into your bladder to drain urine.
  • Next, the applicator (ring and tandem) is placed into your vagina, and passed through the tube in your cervix and into your uterus. It is fixed in place so it will not move.
  • A CT scan and/or x-rays (images) are taken to make sure the applicator is in the correct position. These images are used to plan your HDR treatment. This planning takes one to two hours. Once the plan is ready, the HDR treatment will be delivered.

Delivery of Treatment

  • The doctor will attach a cable to the applicator. The other end of the cable is attached to the HDR brachytherapy machine. The radiation source is stored in the machine. The computer sends the radiation source through the cables into the applicator.
    • The treatment lasts 10 to 20 minutes.
    • You will be monitored with television cameras and an intercom system the entire time. The treatment can be stopped at any time if needed so the doctors and nurses can return to the room.
    • After the treatment, the radioactive source is moved back into the machine. The doctor will disconnect the cables and the applicator will remain in place.
  • Next, you will be sent back to the recovery room. Once you are awake, you will be transferred to your inpatient room. You will remain on bedrest overnight with the applicator in place.
  • The following morning, the second treatment will be given. When you finish the second treatment, the applicator (ring and tandem) will be removed. However, the small, thin tube that was stitched into the cervix will remain in placed until treatments are complete.
  • After your second treatment is complete, you will return to your inpatient room. The catheter in your bladder will be removed.
  • You will be able get out of bed slowly with help.
  • The inpatient surgical team will deliver your discharge orders.

This procedure will be repeated the following week for your third and fourth treatments.

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After Your Discharge

  • Do not schedule other activities during that day.
  • Do not drive or use heavy machinery for 24 hours after each treatment.
  • You may notice strings coming from your vagina. These are the sutures holding the tube in your cervix in place. The tube and strings will be removed after your last treatment.
  • You can go back to your usual diet.
  • You are not radioactive from the treatment.
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Possible Side Effects and How to Manage These

  • You may have cramping for a day. Ibuprofen or Tylenol® (acetaminophen) can help.
  • You may have vaginal spotting or bleeding. It should not be more than you have with a monthly period. You can use pads, but do not use tampons or douche.
  • The vaginal or anal area may become irritated. Sitz baths with plain warm water will be soothing. You can buy a plastic sitz bath at a drug store. It fits into your toilet. You can also fill a tub with warm water. Sit in the water for 15-20 minutes and repeat as needed for your comfort.

You may have side effects for four to six weeks after treatment is done. Your nurse will tell you how to care for yourself.

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Call Your Doctor or Nurse If You Have:

  • Vaginal bleeding that is more than light spotting.
  • Cloudy or foul smelling urine.
  • Blood in your urine.
  • Fever greater than 100.4° F (38° C).
  • More than three watery bowel movements a day that are not relieved by medicine.
  • No bowel movement in three days.
  • Rectal bleeding.
  • Nausea or vomiting and are not able to keep food down.
  • Abdominal or pelvic pain that does not go away after you take your pain medicine.
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