Hyaluronic Acid as a Tissue Spacer Between Prostate and Rectum to Aid Dissection During Radical Prostatectomy

Introduction: We demonstrate a novel method of spacer gel injection immediately before prostatectomy, displacing the prostate away from the rectum to aid later dissection. Post-pelvic radiotherapy prostatectomy is associated with more complex resection and higher surgical morbidity. Tissue adhesion between rectum and prostate caused by radiotherapy scarring increases the risk of rectal injury from 0.5% in primary prostatectomy to 6.9% during prostatectomy in an irradiated pelvis. Barrigel® is a nonanimal stabilized hyaluronic acid. It is anechoic and, therefore, identifiable when injected percutaneously into Denonvillier's space under transrectal ultrasound guidance. Patients at a high risk of rectal injury during prostatectomy may undergo on-table transperineal Denonvillier hyaluronic acid injection. Methods: The technique is demonstrated on a 72-year-old man with pT3bN0M0 prostate cancer with a history of pelvic radiotherapy and evidence of scarring of Denonvillier's fascia on preoperative MRI. The patient should be positioned in lithotomy with a transrectal probe in situ. A 20 cm 18-gauge needle is inserted into Denonvillier's fascia through the perineum. About 3 to 10 mL of Barrigel is injected under ultrasound guidance separating the rectum from the prostate. The patient can then be positioned, prepped, and draped for prostatectomy. In this demonstration, the patient underwent robot-assisted laparoscopic radical prostatectomy. Results: Barrigel is typically absorbed fully in 12 months. There was no evidence of rectal injury on leak testing and the patient had a noncomplicated postoperative course. Pathologic review confirmed clear surgical margins. Conclusions: We demonstrate a novel technique of injecting Barrigel percutaneously into Denonvillier's fascia. The dissection of the prostate from the rectum during robot-assisted laparoscopic prostatectomy was effective with no complications. No competing financial interests exist. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No funding was received. Runtime of video: 2 mins 11 secs