BackTable Urology
Ep. 191 Optimizing Radiation Therapy: Role of Perirectal Spacers with Dr. Eric Chenven and Dr. Nadim Nasr
Tue, 01 Oct 2024
What does recent research say about the role of perirectal spacers in prostate cancer treatment? In this episode of the BackTable Urology Podcast, host Dr. Jose Silva discusses the use of perirectal spacers for prostate radiotherapy with guests Dr. Eric Chenven, Chief of Urology at Broward Health Medical Center, and Dr. Nadim Nasr, a radiation oncologist at Arlington Radiation Oncology. --- This podcast is supported by: Boston Scientific SpaceOAR Hydrogel https://www.spaceoar.com/about-spaceoar-hydrogel/how-spaceoar-hydrogel-works/?utm_source=google&utm_medium=cpc&utm_campaign=uro-ph-us-spaceoar-dtp&utm_content=nf-cs-prostatecancer_search_en_us_brand_conversion_dtp_uro-spaceoar-651995397243-res&gad_source=1&gclid=CjwKCAjw9eO3BhBNEiwAoc0-jTE63KEHSnZ1soXre9ovVRqweY2QctIuZ_iN2QUjk6Px4k6fK1757BoCVNgQAvD_BwE --- SYNPOSIS Their conversation delves into the use of Boston Scientific’s SpaceOAR hydrogel to reduce radiation exposure to the rectum. The experts elaborate on the techniques and logistical challenges of placing spacers, as well as their effects on patient outcomes. They also discuss insurance hurdles, use of sedation, fiducial marker placement, and the impact of large prostate size on treatment efficacy. Finally, they touch on Barrigel, the newest spacer option. This episode emphasizes the need for collaboration between urologists and radiation oncologists to improve patient care. --- TIMESTAMPS 00:00 - Introduction 06:33 - Importance of Perirectal Spacing 11:17 - Techniques and Protocols 13:00 - Barrigel: The New Option 14:58 - Challenges and Practical Considerations 24:55 - Future Directions --- RESOURCES Boston Scientific SpaceOAR https://www.bostonscientific.com/en-US/products/hydrogel-spacers/spaceoar-hydrogel.html URO108 - Minimizing Radiation Therapy Side Effects https://www.backtable.com/shows/urology/podcasts/108/minimizing-radiation-therapy-side-effects URO123 - Perfecting Rectal Spacer Placement for Optimal Care https://www.backtable.com/shows/urology/podcasts/123/perfecting-rectal-spacer-placement-for-optimal-care
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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.
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
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.
Hello, everyone, and welcome back to Backtable Urology Podcast, your source for all things urology. You can find all previous episodes of our podcast on Apple, Spotify, YouTube, and on backtable.com. Now a quick word from our sponsors. Today's Backtable podcast is sponsored by Boston Scientific's Urology Division.
Boston Scientific is dedicated to transforming lives through innovative medical solutions that improve the health of patients around the world. This includes absorbable hydrogel spacers that are intended to temporarily position the anterior rectal wall away from the prostate during radiotherapy for prostate cancer.
Bustle Scientific SpaceOR hydrogel system is a polyethylene glycol-based hydrogel design to temporarily create space between the prostate and the rectum and reduce the radiation dose delivered to the rectum during radiation therapy. SpaceOR hydrogel has been clinically shown to help reduce the side effects of radiation.
For prostate cancer patients undergoing radiation therapy, maintaining quality of life may be just as important as treating the cancer. Minimize side effects, maximize patients' quality of life. Now, back to the show. Hello, everyone. I will go back to Backtable Urology Podcast. This is Jose Silva, your host this week, and happy to introduce our guests.
We have Dr. Eric Chenven and Dr. Nassim Nasser. Dr. Chenven, he's a certified American Board of Urologists and is a member of the American Urological Association, American College of Surgeons, End Urology Society, and the American Medical Association.
He did his urology residency at Robert Wood Johnson Medical School in New Jersey, then completed fellowship in endorheology and laparoscopy at the Thomas Jefferson University in Philadelphia. Dr. Chen then is the chief of urology at Broward Health Medical Center.
He sits on the cancer committee and the surgical quality assurance committee, where he was formerly also medical director for laparoscopy and minimally invasive urology. Dr. Nasser is a trained radiation oncologist. He completed internal medicine residency at Virginia Commonwealth University School of Medicine.
He then went on to do his radiation oncology residency in Georgetown University Hospital, where he's still a clinical assistant professor. Currently, he's part of Arlington Radiation Oncology in Virginia. Gentlemen, welcome to the back table.
Thank you. Thank you.
So let's start by knowing each of your practice, essentially looking to see what's the relationship between the urology and radiation oncologist.
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.
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.
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.
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.
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?
Is it mainly urology-based, or what are you doing in your practice?
So I joined the practice here in 2010, so I've been here for 14 years now. We started out as a small practice of two radiation oncologists. We've now, over the last 14 years, expanded to two centers. They're both hospital-based, community hospital-based, and there's four of us in the group.
I am the one that does the vast majority of the prostate cancers in the group, but I do treat really everything else. We have the full gamut of options for treatment, including external beam, brachytherapy, and SBRT. A significant portion of my training at Georgetown was in SBRT, and so I've got a lot of experience in treating SBRT, especially for prostate cancer.
And Asim, as radiation technology gets more and more precise or more accurate, in the past few years, we have seen all the perirectal spacing. Is there a true need for perirectal spacing?
I think there is. And the main reason is that if you look at the changes in the NCCN guidelines, especially over the last four or five years, what you're seeing is a lot more inclusion of SBRT as opposed to IMRT in the treatment of prostate cancer. And with SBRT, you are using such higher doses per treatment that it's really important to try to spare that anterior rectal wall.
And now with the use of PSMA PET scans to further narrow down which patients are good candidates for prostate-directed therapy, we're really doing more and more of that. And I think that there is really a large need for perirectal spacing in the majority, but not all patients.
And Eric, who is a candidate for prurictal spacing? Is it any type of radiation or is it just some specific type of radiations?
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.
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
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.
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.
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.
Nasir, how about your practice? Are you doing periectal spacer for most everybody?
Well, I want to agree with Eric. I think that we've mostly moved away from standard fractionation for prostate cancer. If you look at radiobiologic studies, what they actually show is that most prostate cancers respond a lot better to higher doses per treatment. And so I think we're going to see a significant move towards hyperfractionation in almost, you know, most of these cancers.
And again, in my own practice, I can't remember the last time I treated a prostate in nine weeks. Most of my prostates, even the IMRT, are done in the five and a half to six week courses of treatment. And again, in those cases, having a spacer in place really does cut down that docety into your rectal wall.
The only patients that I do hesitate in placing them, and I place my own spacers and fiducials. It's not our urologists that do them. The only patients that I hesitate in are the patients where we suspect some extension outside the prostate on the MRIs that they had before the biopsies. Those are the ones that I do hesitate in putting in spacers.
Any specific reason?
So there is some data in the radiation oncology literature that suggests that placing a spacer when there is extraprostatic extension could potentially push some of those malignant cells away from the prostate and away from the high-dose region, especially if you're using very conformal techniques like SBRT.
Now, where that is going to end up, and we don't really know, we're going to have to see what the future of the data holds, but Those are the cases where I might hesitate a bit in putting in spacer initially and might consider putting it down the road if my initial dosimetry shows that I'm compromising coverage to spare the rectum.
And Eric, are you doing your own or you're putting the rectal space in yourself or the radiation oncologist doing it?
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.
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.
And Eric, there's two type of peripheral spacers out there.
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.
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.
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,
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.
Nasir, how about you? Same question. I mean, what's your experience with both regular spacers?
My experience parallels Eric's in terms of seven or eight years ago, we started using Spacer and You know, we're really doing, I mean, I probably end up doing somewhere between 50 to 100 cases a year. I did try the Baragel. I felt that the entire process of switching the tubes and the needles was a little clunky.
And I never really liked the end result of how the gel separated versus doing the hydrodissection and knowing that, well, you've got a nice space and you can go. The only time that I feel, at least in my experience, that there may have been a slight advantage
is in patients who we are retreating with radiation, where there's a lot of scar tissue in that perirectal space, and it will simply just not hydrodissect with the saline. I have used Baragel in those cases where I knew where the positive nodule was in the prostate to try to get some separation behind it.
But that's really, I mean, I would say, you know, less than three cases that I've done in that. The vast majority that we're doing is Spacor.
And for example, for patients, I mean, now you mentioned that type of patient, for patients that do a salvage after prostatectomy, are you using rectal space in those cases? No, there's no space. There's no space, okay.
There's no prostate, so...
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
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.
So at that point, I'm going to want him to really do a fusion biopsy to get a better result for the patient.
Yeah. You have an 8-gram prostate, 5-millimeter lesion. I mean, very difficult to get that lesion just cognitive. So definitely the MRI helps there. Nassim, where are you doing the racial spacing?
So we have a procedure room in the office and we do it all in the department itself. I would say it's about 50-50 whether we do it with local numbing versus getting anesthesia involved for some sedation for the procedure. I really leave it up to the patients. I mean, from my end, it's really the same procedure. I agree.
I think the vast majority of patients tolerate it very well with really just minimal discomfort. Some men do have about 10 to 15 minutes of some rectal pressure. feeling like they have to have a bowel movement, which dissipates in most of them. And we've had our share of a couple of guys who had a little vagal response and we had to wake them up a little bit.
But, you know, the guys who end up having some light sedation with anesthesia down in our department, by the time they wake up, they really have no symptoms whatsoever from it.
Yeah, the ones that I have done, and I'm not doing that many, most of them are doing by the rat on right now. I did them in the OR with IV sedation and the patient did good. So let's go and talk a little bit about technique. Eric, can you walk us through the procedure per se?
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.
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.
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?
No, exactly. Yeah, yeah. So people out there that are not familiar to how we do this, they understand. Nassim, any difference from what Eric's mentioned or any insight or anything that you do differently?
No, and honestly, we do almost a mirror image of what you guys do. We do three days of Cipro leading up to the fiducials and the spacer at the same time. Very similar in terms of setup. They do an enema the morning of before coming in, and we go from there for the actual procedure. And do you do the fiducials first and then the gel? I do the fiducials first.
I did make the mistake once of trying to put the spacer first, and what I didn't realize is that the ultrasound image It's completely distorted once that spacer goes in and you really cannot see where you're going with the fiducials. So I always start out with the fiducials first and then go with the spacer second.
And if the patient asks, I mean, what are the possible side effects from this procedure? Nassim, what do you tell them?
I mean, I tell them that obviously if they're still awake during the procedure, if it's not a sedation procedure, that they're going to have a little discomfort while I'm putting in, you know, numbing them up, putting the markers in, putting the spacer in. And I talk them through it step by step as I'm doing it. And most men honestly tolerate it just fine.
I warn them that once that spacer goes in, they will have feeling of rectal fullness, feeling like they have to have a bowel movement. I remind them that they just had an enema a little while ago and there's really nothing to come out. and so that tends to relax them.
Once we finish the procedure, we tend to get their legs down, tend to get their legs to bend their knees up a bit, and I think that helps them a little bit with that sensation, and it generally goes away within a few minutes. I do warn them that they may see a little bit of blood in the urine or stool for a day or so after treatment.
Obviously, most of these gentlemen have had a prostate biopsy not too long before, and so they're pretty familiar with that. And that's really about it for the side effects. I mean, I prepped them and most of our talk obviously is on the side effects of the radiation, not necessarily this.
And Eric, for patients that with big, big prostate that might already have some urinary symptoms, does it affect or does it make it worse, the urinary symptoms afterwards?
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.
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.
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.
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.
And I see we have the space overview and the regular one. How important is CT visibility to be able to see on a CT scan prior to the radiation?
Because we're moving to so much SBRT now, all of those patients, and we have a CyberKnife as well. That's our main SBRT unit. All of those patients are planned with both CT and MRI imaging. When we do our treatment planning, we're doing a CT simulation in our department And then they're going straight to radiology for an MRI right away in the same day.
And then we fuse those images based on the fiducial markers. And so you get a nice registration of the two images. And you can see that hydrogel very nicely on those MRIs. And where will there be a benefit using the spacer view? There was a short time period where we were doing a lot of spacer and we were still doing a lot of IMRT that was purely CT based for planning.
And I did use it for a brief amount of time there. But again, now that most of what we're doing is based on both CT and MRI imaging, I don't really use it anymore.
And Eric, how about your experience? Does your colleagues ask you for the view or one or the other?
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?
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,
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.
So you mentioned already that sometimes you went even by placing it. So, I mean, you don't want to continue losing money. Nadeem, I mean, have you had that issue in your practice?
So we're a little bit different. I mean, we're a hospital-based group in the sense that we contract out to the hospital to do all their radiation professional services, but the technical fees still go to the hospital, including a lot of the technical fees for the equipment, the medications, the gels, and things like that. So that's a loop through the hospital process.
But we're, of course, conscious of that. Where our challenges come in are some of the insurers in the area will not cover a spacer, or at least not initially. And so in those cases, what we've started doing is placing the fiducial markers, planning the patient, and then if it looks like there's absolutely a need for spacing because of compromise on either coverage or
or rectal dose, then we'll go ahead and make a request to put in the spacer. So those are the challenges that we face on our end.
And how important is it for the spacer to maintain its shape? And for how long will you prefer it?
You know, with SBRT, generally from the time of fiducial and spacer placement till treatment is about at most three to four weeks in our practice. And my experience is the spacers really held its shape and integrity very well. I've not had any problems with that. And even back when we were doing longer courses of IMRT, I didn't even see any issues even up to about two months out.
at least with spacer. So my experience has really been that it does maintain its integrity and shape.
And for large prostate, you might want to do Lupron to trigger the prostate a little bit. I mean, does it matter?
Large prostates, it absolutely matters. But again, it matters on the particular anatomy. Is it a large prostate with some separation between the prostate and the rectum, or is it one of those prostates where the rectum is draped across the backside and on top of the prostate? Obviously, if somebody has a large prostate or they have higher risk disease, we are putting them on ADT.
And again, if they're having a lot of urinary symptoms or they have a large prostate, I will put them on ADT for a couple months before treating them versus if they don't really have any of that, we'll go ahead and start ADT and then within a few weeks treat them.
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.
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
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?
I have not had an issue with re-spacing. I have had the issue of having to re-scan and re-simulate for planning just to confer. And I think the longest we had was about a three-month gap, and it still looked very good. I mean, I think it was a little bit small. I compared it back to what we had seen before.
I think the spacing was a little bit less, but it wasn't so much as I would have considered re-spacing. I think they were perfectly fine proceeding with treatment. Luckily, though, they had good anatomy as well. And that was three months after original placing? Three months after placement, whereas usually we'll scan usually about two weeks after spacing.
So, Eric, did you run into that problem in 2021 or back with COVID that you had a few patients that you had put the spacer?
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.
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?
This is a big reason why we're the ones that are putting a lot of these spacers and fiducials in and not the urologists that send them to us. A lot of the urology groups that we get patients from have standing stentors. They're their own practices, and I think they're very happy not dealing with it, honestly.
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
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
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.
No, I absolutely agree. No, I mean, and that's why I asked one of the first questions. I mean, is this standard? Is it the way it should be? And I think the answer is yes. I mean, if it was my prostate, that's what I'd want. Of course. Long-term side effects. So you do the radiation. I mean, eventually the gel just continues to slowly dissolve. That's how it is.
I mean, if a patient asks, what do they tell them?
I mean, that's exactly what I tell them is, you know, the gel will dissolve. I think they will end up with a lot less perirectal scarring in that area. And, you know, I've gotten some feedback from the gastroenterologists that we work with, really just for my own curiosity as to what they're seeing on colonoscopies on some of these patients, you know, routine colonoscopies. And
They do tell me that they're seeing a lot less telangiectasias in that anterior rectal wall. They're seeing a lot less post-radiation changes. I mean, they're still there. I don't think it's going to go away. We're still getting a decent dose of that anterior rectal wall, but it's certainly not something that I think has long-term consequences.
When we first started doing the spacer back in, I think it was 2016, 2017, when it first came out, most of the data was on external beam and IMRT. And there was actually very little data on SBRT. So we had some residents rotating through that put together some of our data for us. And essentially what we did was we did a comparison of rectal dosimetry for CyberKnife between patients that...
had spacer versus ones who did not have spacer and we tried to match patients up based on prostate size which was the one factor that we we thought would equal things out and essentially what we saw was anywhere between a 50 to 70 percent decrease in dose to the interior rectal wall and specifically a lot of the higher dose points, not just sort of the average lower dose, but the higher doses.
So that's what convinced me to start using it really routinely.
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.
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.
And Eric, in terms of your colleagues, the radiation oncologists that are sending you the patients for the spacer, are they giving you any specific instructions? Like, for example, Nadim said that he likes to do it himself, just depending on the size, depending on how it looks. It might vary.
So in your case, are they giving you some instructions on what they want or when they want the spacer to be placed?
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.
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.
So Nadeem, any special comment to urologists that are doing this from the radiation oncology side? What do you guys expect? Like every special in the apex? I mean, is there something specific that you want to look when you're putting the spacer?
Honestly, on the spacer, I feel like once it's in that perirectal space, it's going to go sometimes where it wants to go. And as long as I've got some separation, that's really all I need. I'm much more particular about the fiducial or marker placement, especially for CyberKnife SBRT, since the imaging for that is really based on 45 degree plane films of the pelvis.
So you really want to have those four markers separated in two separate planes, actually really three separate planes. So we do four fiducials now for everyone, just because we end up with the two markers in each needle that are tethered together. So you get a lot less migration of the markers and you can really separate them in terms of their planes.
But I'm much more particular about the fiducial placement than the actual spacer placement. With the spacer, I'm just happy if I get any separation.
Why are you looking specifically for the fiducial markers?
So for the fiducial markers, you really want to put them in in separate planes so that no marker is blocking another one. If you can imagine taking 45 degree x-rays to the pelvis. And so you want one set that's a little bit deeper than the other if you're looking from a transperineal standpoint. And you want one set that's a little bit more anterior, another one that's a little bit more posterior.
And as long as you do that, you are going to see four separate markers. Now, we only need three to track. And so the other one is thought of as our spare. So in case you have any shadowing of one marker versus the other, or one marker is really just out of bounds because of distance, you can just turn it off and track based on the other three.
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
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.
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.
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.
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.
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.
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.
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.
So, yeah, just like Nadim was saying, I mean, then you make the hospital assume the risk.
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.
And I leave any, anything you want to add? Yeah, no, I mean, I think we are lucky in the sense that we do have the capability of getting anesthesia down for some light sedation. And I always lead it off with my patients and asking them how they had their biopsy done and how they specifically did with the biopsy.
Guys who are telling me they were awake for the biopsy and it was fine or slightly uncomfortable, but fine. I tell them that they're probably going to do very well with this and they don't necessarily need anesthesia, which of course comes with spending the entire day at the hospital, of course. But from time to time, I have guys who say that the biopsy was very uncomfortable and that
Those are the guys that I try to say, well, maybe we should have you sleep for this procedure. It certainly makes it a lot more efficient on my end to get these things in.
Well, thank you guys for the time. I definitely enjoyed this. Eric, hopefully you'll get some more support from other urologists in the community trying to make that happen. Send the letter, I think, if If we band together and everybody does their part and send the letter to the insurance, I mean, at some point, something is going to give and hopefully is for the best.
I think we need to go to our organizations, the AUA, American College of Radiation Oncologists.
It's the American Society of Radiation Oncologists, but it's termed ASTRO. It was a lot more complicated than they simplified it.
All right. We need the big guns. Well, thank you guys. Thank you very much. Appreciate it. Thank you.
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