Synchronous Insertion of Hyaluronic Acid-Based Biodegradable Rectal Spacer for Primary Prostate Cryotherapy

Abstract

Recently, biodegradable spacers have been introduced to reduce rectal wall toxicity during external beam radiotherapy for prostate cancer. Rectal wall damage with fistula formation is a major complication of primary and salvage prostate cryotherapy. In theory, biodegradable spacers can be used to protect the rectum from the damage associated with cryotherapy. We describe a case of rectal spacer insertion for primary cryotherapy in a patient with high-risk localized prostate cancer who was unsuitable for other radical treatments because of previous treatment of rectal cancer, detailing the rationale for spacer selection, technique, and outcomes. A 57-year-old man was referred, following a regional specialist multidisciplinary team discussion, for an opinion regarding possible primary prostate cryotherapy. He had a history of anterior resection with chemoradiotherapy, followed by local relapse treated with total colectomy with ileoanal pouch formation and suffering from major postoperative complications. After further assessment and because of concern regarding damage to the efferent pouch limb during freezing, the possibility of spacer insertion between the ileoanal segment was considered and discussed. A hyaluronic acid gel spacer was selected and offered “off licence” on a compassionate basis. The spacer was introduced immediately before cryotherapy. Recovery was uncomplicated apart from transient intermittent perineal pain, with good early functional and oncological outcomes. This is the first report of synchronous insertion of a hyaluronic acid gel spacer in prostate cryotherapy. We believe that the technique merits further investigation, with the potential to reduce complications and enhance freezing of the posterior aspect of the gland during cryotherapy.