Dr. Eric Chenven
Appearances
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I like to do just basically a standard prep like we would for a transrectal biopsy with just three days of oral antibiotics and a shot of Rocephin. We get the patient on the table. We have stirrups. We use the G stirrups, which allow you basically their, I think a gynecologist created that really great invention.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
They're a boot that slides on to the standard heel stirrups, and it allows you to kind of really almost have like a standard stirrup like we use in the OR that just supports the leg a lot better and doesn't kill someone's heel, even in shoes and so on.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
We will shave the perineum if they're real hairy, and basically we will tape and elevate the scrotum up and out of the way, make the perineum a little taut, just a little easier to work with. And I think that's the setup. Is that kind of where you wanted to go with that?
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I don't think so. I don't think I've really seen any effects directly that I would attribute to the spacer implant or the marker implant and so on. Just like Nadim, I do that the exact same time and always the markers first. I'm numbing them up. The transrectal probe goes in. I do the deep needle.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
Then I'm going over, mixing up the spacer, then coming back to do the markers and then the spacer itself. And I really haven't seen any issues. A lot of these patients, if they're getting space or they're, they're still doing some patients with standardized standard course of IMRT.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
And so I think though that since we're doing the space or on the hypo frack, the SBRT cases, and we do have a cyber knife at one of our institutions nearby, uh, that a lot of these patients end up having, or at least looking to have, maybe not aggressive, but enough that we're going to give them hormones and so on.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
So I'm going to end up seeing them back in a month, checking a PSA, because we probably started the hormones at least a couple weeks before the spacer and so on was going in. And so I'm checking on them, and I really don't see much effect until my colleagues start frying their prostate, and maybe they have a little... Just a little weaker stream or something like that.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I don't think they've asked. I may have asked them and kind of tested the waters when the view came out. I guess the one question I have relative to what Nadim just said is, are there centers that are not giant academic centers and so on that don't have the benefit of of an MRI, right?
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
And I'm sure he really would prefer a three Tesla MRI, but you know, an MRI right around the corner that it is as easy enough to do that, that they still want to do hypo fractionation. But the caveat to that is, is that in the office,
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
When at least when your practice that is keeping track of your expenses and of course, you're some level of profit, God knows, at least covering your expense of this expensive gel. No, no, of course.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
Something I haven't experienced myself, but I imagine out there it has to is sort of that fear of COVID, which is sort of making a bit of a resurgence lately, at least down here in South Florida. Yeah.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
is that we have this, let's not even call it a six-month window, but more of a three-month window, again, depending on, I think, your experience, Nadeem, in terms of what the spacer is looking like somewhat further down the road. Have you encountered any of those patients that
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
Got the markers in the spacer put in and then ended up getting, of course, some kind of sickness lately being most commonly COVID where I have yet to have to re-space, even broach that issue with an insurance company, let alone the patient of re-spacing them. Have you had that at all?
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I've never had the issue. I'm surprised I've never had the issue, but it hasn't come up for whatever reason. I've got one patient now that I actually just saw, might've been yesterday, that it was, we did a biopsy, we diagnosed him and it disappeared for a little bit. came back having been diagnosed with colon cancer, and he's on chemo right now.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
Thankfully, he didn't have a horrible prostate cancer, but if we had gotten just a little farther down the road and then all of a sudden one thing led to another, that would have been a similar situation where I'm not sure what I would do in that situation, what I'd be, quote, allowed to do from the insurance standpoint. Great question. Who knows?
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
At some point, push is going to come to shove and it's going to break the system. And we've had issues like this and I've seen other urologists, been to talks and so on. And I think some sort of standardized letter is what I'm going to
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
come up with soon that's going to send in whether or not it has a friend of mine and their legal letterhead at the top, but that if the insurance company is taking on the legal liability and the responsibility of this patient receiving treatment, that they need to cure their cancer, that you need to give them
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
that they're not allowing the patient to have a protective measure and that if they develop, whether it be rectal bleeding, you know, prostatal rectal fistula, et cetera, et cetera, that it's going to be on their hands and on their head at every which way. I think we got to stand up for our patients and support them on something that, you know, really seems necessary in a lot of these people.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
How about you, Eric? I think long-term side effects, I haven't really had anything. I use the Boston Scientific sort of flip book to rip through the 18 extra pictures they have explaining to the patient of the procedure, just kind of showing them sort of the diagram and the anatomy.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
And, you know, it has on there that three months it starts to dissolve and I tell them by six months it should be gone. I have yet to see anything, let's say, on someone with a recurrence that ends up getting an MRI for some reason again or a PET. I've yet to really see anything, but it's probably pretty far down the line.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I've certainly started with the space ore and that became very comfortable with that pretty quickly. I have tried the barra gel and I've certainly heard from some and been told by others the attraction to it. I don't see the attraction. I like the way the space ore injects and kind of does not really diffuse through the tissue like the Barragel does.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
Not really. I don't think so. They're not doing it themselves other than maybe some, in our case, by me. So I think either they're not as familiar or just assume I know what I'm doing and so on and so forth. But I think from the marker standpoint, the only thing they might tell me is if it's going to be an SBRT for... For some reason, they want four markers as opposed to otherwise three.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I think only some of the other stuff that I sort of a think tank not long ago on spacing and so on that I watched sort of a panel of people discussing different things. And I think discussion about really making sure you get enough at the apex versus the other end all the way to the base being more important and so on. But I'd say that's about it.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
So Eric, anything else you want to add? Just a few things I think that I may have mentioned, but along the way, I think this, as both of us have said, this is definitely a procedure that people can do in the office. I think you just need to get a little comfortable working with a biplane or probe, working in two planes, very much just like many of us have done seeds and so on. And I think
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
Once you get comfortable with that, I think making your patients comfortable with enough lidocaine or some other methods of analgesia can help. Even to, I think we generally give the patients a couple of extra strength Tylenol, something I really just kind of picked up from a pain expert and so on.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
Thank you. Thank you.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
Just even the benefits when using in combination, just something simple as extra strength Tylenol, whether it be Pronox, Nitrous, or just the local stuff can make certainly a little bit of help.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I think expectations for the patient, I think like anything, anything we do, any procedures and so on, not only I think you should tell the patient what you're doing while you're doing it, anyone that sticks a needle in someone and they jump and you yell at the patient because you didn't tell them you were jamming them a needle into their body.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
It's just ridiculous, but I think also telling them ahead of time so they have not the fear of what might be or might not be, but I think that alleviates some of the stuff as well because sometimes the patients do want to ride the round a little bit and you got to sort of tell them, I've got a probe in you, you're messing everything up, we can't have you moving here, we need to keep everything on trajectory and accurate.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
The rest of it really just comes down to what I was saying before, which is unfortunate about the reimbursement and the insurance companies, not just reimbursement, of course, but even the coverage. And again, we all have some of these patients that you go do the slightest thing.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I think you know, Jose and Nadim too, you do a rectal exam on a guy and maybe once a year or every three or five years, you have a patient jump off the table and Like, well, you know, I had this done once or twice. I understand it's not pleasant here, but I didn't just cut a finger off. And there were just some people who they need some sedation.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
And, you know, I don't have the ability for anesthesia, just technically I do, but to come to my office so easily and so on. So the surgery center is sort of a perfect place. But unfortunately, with the cost of this spacer gel, and so it's not the markers that they almost make it impossible. And it becomes very difficult in some of these patients.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
So Eric, can you describe your practice? I would say since my fellowship, I joined a general urology practice. I joined two other urologists in Fort Lauderdale, Florida. I was the first urologist in about 10 years to join the practice. And that's now, I can't believe, 21 years ago. We practice at a level one trauma center, which is also a cancer center in Broward County, Florida.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
Well, when you don't work for the hospital, they refuse to assume the risk. And if they're smart enough, they say... some points, even to colleagues of mine, friends that are employed, they say, well, that's great. You want to do that and that's great, but you can't do that. We're not letting you do that, you know, because they're basically your, uh, your parent. That is a problem.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I think we need to go to our organizations, the AUA, American College of Radiation Oncologists.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
All right. We need the big guns. Well, thank you guys. Thank you very much. Appreciate it. Thank you.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
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BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
And really both hospitals actually have cancer center between Broward Health Medical Center and Holy Cross. I think I do the full breadth of general urology. I certainly like to have an emphasis, as many of us urologists do, in oncology.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I think in the end, if you, whatever you're using, if you do a good job and get adequate spacer where you want it to go, I just feel it's a little easier for me when I'm injecting the spacer. I know I can kind of direct it where I need it to go with the needle. And from there, it just, the Barragel, the changing back and forth, and then just the way it
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
Probably prostate cancer is the number one cancer that we deal with and treat and really have taken a lot onto ourselves, which has taken a little bit of getting used to, I think. Truly, you have become the oncologist, I think, for prostate cancer, many of the others that Certainly, we involve our radiation oncology colleagues and medical oncology and so on.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
But we're sort of, I think, the captains of the ship when it comes to the prostate cancer. I think we like having control over our patients and managing them all the way out to advanced disease. I still do full breadth of surgery from little stuff in the office to hospital, kidney stones and so on. I think that the robotic prostatectomies, we have one of the Dr. Gorbati in our practice.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
We hired out of his robotics fellowship about 12 years ago now. He's doing all the robotics at this point in our practice. I've kind of given way to that and decreased my stress level a little bit and so on. And Nassim, how about yours?
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
That's a decision that I make with our radiation oncologist and it's never something that I'm telling them. I think, you know, I sort of liken them to being the surgeon as running the show with the radiation and kind of guiding me what to do and we certainly do work as a team back and forth and I think I communicate very well.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
They they'll often text me, call me and we'll go over each of these prostate cancer patients. And I think that interestingly, we had gotten used to when I got
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
into practice in 2003 and we really got into doing all the IMRT, the image guided IMRT, all the stuff that we saw, thank goodness, the radiation cystitis and these people slowly bleeding to death, thank God that's really dried up quite a lot and the patients have been so happy having the radiation done.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
The way it doesn't really move the tissue so well until you've injected a lot of it just didn't sit well with me.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
They really haven't been having the tenesmus, the urgency, the diarrhea, very rare to see patients with all those with the standard IMRT, which is the eight weeks. But I think as some of the newer trials have come out in radiation oncology and not just SBRT, but moving into the hypo fractionated courses with five weeks of radiation, where again, they're pushing higher doses at each treatment.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I think that's when the spacers are really of value. But again, I think we're seeing our Radon colleagues doing a lot of hypofractionated when it comes to the IMRs.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I think I probably about seven, eight years ago went out to Colorado to train with one of the urologists out there and just started doing it. I myself have been comfortable in that space. I've done a lot of cryoablation. The brachy therapies we used to do is sort of a conjoined case with RADOC in the OR. We do those together, not really doing those anymore.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
But so it's just very comfortable in that space and kind of just fell into it. There really hasn't been, I think there's just a handful of urologists that are doing it sort of in my practice of three. I'm the one who's kind of taken upon myself and just kind of gotten that going.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
Which one are you using? I presume you mean space ore and barra gel. Have you tried both of them or just one of them? I've certainly started with the space ore and that became very comfortable with that pretty quickly. I have tried the barra gel. And I've certainly heard from some and been told by others the attraction to it. I don't see the attraction.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I inject sort of the reversal agent to sort of immediately dissolve it and so on. Beyond that, I've never really had a need to do that. So I think that I like the way the space ore injects and dissolves. kind of does not really diffuse through the tissue like the Barragel does.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
I think in the end, if you, whatever you're using, if you do a good job and get adequate spacer where you want it to go, I just feel it's a little easier for me when I'm injecting the spacer. I know I can kind of direct it where I need it to go with the needle. And from there, it just, the Barragel, the changing back and forth, and then just the way it,
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
The way it doesn't really move the tissue so well until you've injected a lot of it just didn't sit well with me.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
So, Eric, where are you doing the procedures? I do in the office. We all do them in the same, I'd say, as most urologists, transrectally. And I think that still most of us are doing those. There are certainly times, though, where one of my other partners happens to be the one who's the robotics guy. He is doing MRI fusion biopsies in the OR. And so the
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
This way, at least we have one guy for now who's got sort of building the most experience and can really focus on it. Because I think I don't feel comfortable doing a biopsy, even with cognitive fusion on an MRI and as good as the studies have shown. But if I've got a guy who's got an 80 to whatever, 150 gram prostate, my margin of error and my sampling error is going to be much higher.
BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
So at that point, I'm going to want him to really do a fusion biopsy to get a better result for the patient.