Patient Selection and Partnership in Prostate Radiotherapy Spacing

In this video, Daniel Welchons, MD, explains that difficult anatomy cases benefit most from the extra time hyaluronic acid spacers allow, since physicians can probe, adjust pressure on the rectal wall, and add more product as needed rather than working against a short polymerization window. He argues that patients with the most challenging anatomy are often the ones who stand to gain the most from spacing, even though those cases are harder to perform. Aurelie Garant, MD, agrees and adds label-based context: Posterior extraprostatic extension excludes patients from hydrogel spacers, whereas T4 disease excludes hyaluronic acid spacer candidates. She describes patients with prior bowel reconstruction, such as a J-pouch, or inflammatory bowel disease as being especially motivated to preserve bowel integrity.

Asked about building a strong urology–radiation oncology partnership, Welchons emphasizes shared goals and open communication, describing a close working relationship where he can call or text his radiation oncologist about a challenging case. Both physicians agree the goal is not simply getting patients through treatment, but optimizing them beforehand through coordinated symptom scoring and joint planning, which he says consistently produces the best outcomes.

Looking ahead, Garant describes her center's work piloting a workflow that omits a separate simulation step, instead building a pre-planned SBRT off diagnostic MRI images and adjusting contours using an MR Linac on the day of treatment. Welchons notes that AI-assisted contouring paired with hyaluronic acid spacers' sculptability and larger separation margins could streamline this process further, easing anxiety for patients navigating multiple appointments while reducing workload for radiation oncologists reviewing plans.

In the next episode, "Managing BPH Before Prostate Radiotherapy: Options Compared," the conversation shifts to men with coexisting BPH undergoing SAbR, where Garant and Welchons weigh the sequencing challenges and compare minimally invasive treatment options.