Benign prostatic hyperplasia, or BPH, is a non-cancerous enlargement of the prostate. As the prostate enlarges, its lateral lobes may compress the urethra and obstruct the flow of urine from the bladder.

Common lower urinary tract symptoms include:

• A weak or interrupted urinary stream
• Difficulty starting urination
• Straining to pass urine
• Urinary frequency and urgency
• Getting up repeatedly at night
• Dribbling after urination
• A feeling that the bladder has not emptied properly

Medication is usually the first treatment offered to men with troublesome symptoms. However, tablets may provide insufficient relief or cause dizziness, tiredness, reduced libido, erectile problems or altered ejaculation.

The UroLift procedure—also called a prostatic urethral lift or PUL—is a minimally invasive surgical therapy, or MIST, that may provide an alternative to long-term medication and conventional prostate surgery.

What is a MIST procedure?

Minimally invasive surgical therapies are designed to improve urinary symptoms with less tissue damage, less bleeding and a shorter recovery than conventional procedures such as TURP or prostate laser surgery.

Different MIST procedures work in different ways. Some use steam or other forms of energy to destroy prostate tissue. Some temporarily remodel the urinary passage. UroLift mechanically moves the obstructing prostate tissue away from the urethra using small permanent implants.

Its principal attractions are:

• No cutting or removal of prostate tissue
• No heat, laser or steam
• Rapid improvement in many patients
• Usually brief catheterisation, if any
• Short recovery
• A low reported risk of new erectile or ejaculatory dysfunction

The trade-off is that symptom improvement is generally more modest than after a tissue-removing operation, permanent implants remain within the prostate, and some patients will eventually require further treatment.

How does UroLift work?

The UroLift system uses small implants to hold the enlarged lateral lobes of the prostate away from the urethra.

Each implant consists of:

• A small capsular tab placed on the outside of the prostate
• A stainless-steel urethral end-piece
• A permanent suture connecting the two components

The implant compresses and retracts the obstructing prostate tissue, widening the urinary channel without cutting, burning or removing tissue.

Most patients require several implants. The exact number depends on the length, size and shape of the prostate and the degree of obstruction. These implants remain permanently in position.

Who may benefit from UroLift?

UroLift may be considered for men who:

• Have moderate or severe urinary symptoms caused by BPH
• Have obtained inadequate relief from medication
• Cannot tolerate the side effects of BPH medication
• Prefer not to take daily medication indefinitely
• Want a less invasive alternative to TURP or laser surgery
• Place a high priority on preserving forward ejaculation
• Want a relatively rapid return to normal activities
• Have prostate anatomy suitable for a prostatic urethral lift
• Understand the possibility of future retreatment

It is particularly attractive for sexually active men who wish to improve their urinary symptoms while minimising the risk of dry or retrograde ejaculation.

What prostate size is suitable?

Clinical guidelines and manufacturer labelling are not identical.

Current European Association of Urology guidance recommends offering prostatic urethral lift to men interested in preserving ejaculation who have prostates smaller than 70 mL and no obstructing middle lobe.

American Urological Association guidance supports the procedure for selected men with prostates approximately 30–80 mL and without an obstructing middle lobe.

Manufacturer and regulatory indications may extend to prostates as large as 100 mL and may include selected median-lobe anatomy in some jurisdictions. However, treatment outside the populations best supported by clinical guidelines requires careful patient selection and counselling.

Prostate volume alone does not determine suitability. The shape of the prostate, length of the prostatic urethra, bladder-neck anatomy, degree of obstruction and strength of the bladder muscle must also be considered.

What about an obstructing median lobe?

The median lobe is prostate tissue that projects upwards towards the bladder and may act like a ball valve over the bladder outlet.

UroLift can be used to treat selected obstructing median lobes, and the MedLift study reported encouraging outcomes. Nevertheless, major guideline recommendations remain more conservative because the strongest long-term randomised evidence relates mainly to lateral-lobe obstruction.

A large, mobile or unusually shaped median lobe may be better treated with TURP, laser surgery, Rezūm, Aquablation or another procedure capable of removing or reducing the obstructing tissue.

This is an important anatomical caveat to discuss before choosing UroLift.

Assessment before treatment

Not every urinary symptom is caused by BPH. Infection, urethral stricture, bladder weakness, overactive bladder, neurological disease, medication and prostate or bladder cancer may produce similar symptoms.

Assessment may include:

• Medical history and examination
• International Prostate Symptom Score
• Urine testing
• PSA testing when appropriate
• Urinary-flow measurement
• Ultrasound measurement of residual urine
• Prostate imaging or ultrasound
• Flexible cystoscopy
• Urodynamic testing in selected patients

Cystoscopy may be particularly useful because it allows the urologist to assess the lateral lobes, bladder neck, median lobe and length of the obstructing prostate.

Any urinary infection should be treated before the procedure.

Patients taking aspirin, warfarin, clopidogrel, apixaban, rivaroxaban or other blood-thinning medication require an individual plan. Do not stop blood-thinning medication without instructions from your prescribing doctor and urologist.

How is the UroLift procedure performed?

UroLift is usually performed as a day procedure under local anaesthetic with sedation or a short general anaesthetic.

A cystoscope and specialised delivery device are passed through the urethra. No external incision is required.

The urologist:

1. Examines the urethra, prostate and bladder.
2. Positions the delivery device within the prostatic urethra.
3. Moves the obstructing prostate tissue away from the urinary channel.
4. Deploys an implant to hold the tissue in its new position.
5. Repeats the process at selected points until an adequate channel has been created.
6. Inspects the bladder outlet and controls any bleeding.

The procedure commonly takes less than an hour, although this varies with prostate anatomy and the number of implants required.

Because no prostate tissue is removed, there is usually no specimen for laboratory examination.

Will I need a catheter?

Many men can pass urine after the procedure and go home without a catheter. A catheter may nevertheless be required if there is:

• Significant prostate swelling
• Inability to pass urine
• Pre-existing urinary retention
• A weak bladder muscle
• Bleeding or clot formation
• A high residual urine volume

When required, the catheter is usually temporary. Patients with chronic retention or poor bladder function have a greater risk of failing an early trial without a catheter.

What should I expect after UroLift?

Temporary urinary irritation is common during the first few days.

You may experience:

• Burning or stinging when passing urine
• Urinary urgency and frequency
• Pelvic, perineal or penile discomfort
• Light blood in the urine
• Bladder spasms
• A temporarily weaker or more irregular stream
• Increased night-time urination
• A feeling of incomplete emptying

These symptoms generally improve over several days, although urinary irritation may occasionally persist for a few weeks.

Some men notice an improved stream soon after treatment. For others, the benefit develops over the following two to six weeks as swelling and irritation settle.

Managing pain and urinary discomfort

Discomfort after UroLift is usually mild to moderate.

Management may include:

Paracetamol

Paracetamol is commonly sufficient for mild discomfort. Take it according to the instructions provided by your doctor or the directions on the packet.

Avoid accidentally taking additional paracetamol contained in cold, influenza or combination pain medicines.

Anti-inflammatory medication

Ibuprofen or another anti-inflammatory medicine may help when medically appropriate. These medicines may not be suitable for patients with kidney impairment, stomach ulcers, certain heart conditions, bleeding disorders, anti-inflammatory-sensitive asthma or anticoagulant medication.

Check with your doctor or pharmacist before taking an anti-inflammatory medicine.

Medication for urinary symptoms

An alpha blocker may be continued temporarily to assist urine flow while swelling settles. Medication for bladder spasm or urinary burning may occasionally be prescribed.

Practical measures

It may help to:

• Maintain normal hydration without forcing excessive fluids
• Limit coffee, tea, alcohol, fizzy drinks and energy drinks
• Avoid constipation
• Avoid heavy lifting and vigorous exercise for several days
• Take pain relief before discomfort becomes severe

Severe or worsening pain should be reported rather than simply tolerated.

Possible complications

Most side effects are mild and temporary, but complications can occur.

Common temporary effects

These include:

• Pain or burning during urination
• Blood in the urine
• Urinary urgency
• Increased frequency
• Pelvic discomfort
• Temporary urinary leakage associated with urgency

Urinary retention

Some men cannot pass urine after the procedure and require temporary catheterisation. The risk may be greater in patients with high residual urine volumes, chronic retention, severe obstruction or a weak bladder muscle.

Urinary tract infection

Infection may cause worsening burning, cloudy or offensive urine, fever, chills or feeling generally unwell. Antibiotics may be required.

Bleeding

Light haematuria is common. Significant bleeding, clot retention or the need for further intervention is uncommon but possible.

Implant-related problems

Potential implant complications include:

• Incorrect placement
• Implant exposure within the bladder
• Encrustation or stone formation
• Migration or loosening
• Persistent pelvic discomfort
• The need to remove an implant
• Difficulty or irritation during later prostate surgery

Implants placed too close to or within the bladder are more likely to develop encrustation and may require endoscopic removal.

Persistent symptoms

UroLift treats obstruction but does not correct every cause of lower urinary tract symptoms. Urgency, frequency and nocturia may persist when they are caused by bladder overactivity, excessive night-time urine production, sleep apnoea, fluid intake, diabetes or other medical conditions.

Need for further treatment

Some patients obtain insufficient relief or develop recurrent symptoms as the prostate continues to enlarge. Further treatment may involve medication, additional implants, removal of exposed implants or another procedure such as TURP, GreenLight laser, HoLEP, Rezūm or Aquablation.

When should I seek urgent help?

Contact your urologist or attend an emergency department if you:

• Cannot pass urine
• Develop fever, shaking or chills
• Feel generally unwell or confused
• Pass large blood clots
• Have heavy or persistent bright-red bleeding
• Develop severe or increasing pelvic pain
• Cannot keep fluids down
• Experience pain that is not controlled by the recommended treatment

Does UroLift affect erections or ejaculation?

Preserving sexual function is one of the main reasons patients choose UroLift.

The pivotal L.I.F.T. study reported no new sustained erectile or ejaculatory dysfunction during five years of follow-up. Because the bladder neck, prostate tissue and ejaculatory pathways are not routinely cut or heated, the risk of retrograde ejaculation is substantially lower than with conventional TURP and many tissue-removing procedures.

However, no treatment can guarantee unchanged erections, sensation, orgasm or ejaculation in every patient.

Men who already have erectile or ejaculatory difficulties should not assume that UroLift will correct those problems. It is primarily a treatment for urinary obstruction.

How effective is UroLift?

Clinical studies show meaningful average improvement in:

• Urinary symptom scores
• Quality of life
• Peak urinary-flow rate
• The patient’s perception of urinary function

Symptoms may improve quickly because the urethra is mechanically opened during the procedure.

However, the average improvement in urinary flow and symptoms is generally less than that achieved with TURP or prostate enucleation. UroLift is therefore best understood as a compromise: less invasive treatment and better preservation of ejaculation in exchange for more modest de-obstruction and a greater chance of later retreatment.

How long does UroLift last?

The implants are permanent, but the symptom relief is not necessarily lifelong.

The pivotal L.I.F.T. study demonstrated sustained average improvements for five years. The reported surgical retreatment rate was approximately 13.6% over five years, or roughly 2–3% per year.

Retreatment estimates vary among studies and real-world populations. The need for further treatment may be influenced by:

• Prostate size and anatomy
• Median-lobe obstruction
• Implant position
• Severity of the original obstruction
• Bladder function
• Continued prostate growth
• The definition of retreatment used in a study

Patients should distinguish between an implant remaining in position and the treatment continuing to control symptoms. A permanent implant does not guarantee permanent symptom relief.

MRI considerations

UroLift implants are classified as MR Conditional, meaning MRI can generally be performed under specified scanner conditions. Patients should tell the radiology service that they have UroLift implants and provide the implant information card whenever possible.

The metallic components can create image artefact, particularly during prostate MRI. This may obscure portions of the prostate and reduce the diagnostic quality of an MRI used to investigate suspected prostate cancer.

This caveat is particularly relevant for:

• Younger men with a long future need for prostate surveillance
• Patients with an elevated or rising PSA
• Men already undergoing prostate cancer monitoring
• Patients likely to require prostate MRI or targeted biopsy

Appropriate prostate cancer assessment should be completed before UroLift when clinically indicated.

Can prostate surgery still be performed later?

Yes. TURP, laser surgery, HoLEP and other BPH procedures can be performed after UroLift.

However, the surgeon must account for the permanent implants. Clips may be encountered during resection or enucleation, may affect instruments or laser fibres, and may require removal. Some surgeons therefore consider later surgery technically more complex than treatment of an implant-free prostate.

UroLift does not close the door to future treatment, but it does leave permanent material that the future surgeon must manage.

Who should not undergo UroLift?

Manufacturer contraindications include:

• Active urinary tract infection
• Current visible or gross haematuria
• Urinary incontinence caused by an incompetent urinary sphincter
• A urethral condition that prevents safe insertion of the delivery device
• A prostate larger than the maximum permitted by the applicable product labelling

UroLift may also be unsuitable or less predictable in men with:

• Severe chronic urinary retention
• A poorly contracting bladder
• Very high residual urine volumes
• Urethral stricture disease
• Bladder stones
• Recurrent urinary infections
• Significant ongoing bleeding
• A very high bladder neck
• A large or unfavourably shaped median lobe
• A very large prostate
• Suspected or untreated prostate cancer
• Symptoms primarily caused by overactive bladder rather than obstruction
• A need for maximal and durable removal of obstructing tissue

Advantages of UroLift

Potential advantages include:

• Minimally invasive day procedure
• No prostate tissue removed
• No laser, heat or steam
• Rapid relief in many patients
• Short recovery
• Catheter often avoided
• Low reported risk of new erectile dysfunction
• Low reported risk of dry or retrograde ejaculation
• Future BPH treatments remain possible

Limitations and important caveats

Patients should understand that:

• Several permanent implants remain inside the prostate
• Symptom and flow improvements are usually less than after TURP or enucleation
• Retreatment is more common than after tissue-removing surgery
• Not all median lobes are suitable
• UroLift does not prevent continued prostate growth
• Urgency and nocturia may persist if they have a bladder or medical cause
• The implants may reduce the quality of future prostate MRI
• Later prostate surgery remains possible but may be technically more complicated
• Prostate cancer should be appropriately assessed before treatment
• UroLift does not provide prostate tissue for laboratory examination

Is UroLift the right option for me?

UroLift can be an excellent option for a carefully selected man who wants meaningful improvement in urinary symptoms, a rapid recovery and a low risk of ejaculatory dysfunction.

It may be less suitable for someone with severe obstruction, chronic retention, weak bladder function, unfavourable median-lobe anatomy or a need for the most powerful and durable improvement possible.

The decision should take account of:

• Prostate size and shape
• Presence of a median lobe
• Severity of symptoms and obstruction
• Bladder strength and residual urine
• PSA and prostate cancer risk
• Previous treatment
• General health and medication
• Importance of preserving ejaculation
• Acceptance of permanent implants
• Willingness to undergo future retreatment

A urological assessment allows UroLift to be compared fairly with medication, iTind, Rezūm, Aquablation, TURP, GreenLight laser, HoLEP and other appropriate options.

This information is intended for general education and does not replace individual medical advice. Treatment suitability, availability and costs vary. Always follow the instructions provided by your treating urologist.

References

1. European Association of Urology: Management of non-neurogenic male lower urinary tract symptoms.
2. American Urological Association: BPH clinical guideline.
3. Roehrborn CG, et al. Five-year results of the prospective randomised controlled prostatic urethral L.I.F.T. study. Canadian Journal of Urology. 2017;24:8802–8813.
4. Rukstalis D, et al. Prostatic urethral lift for the treatment of an obstructive median lobe: 12-month results of the MedLift study. Prostate Cancer and Prostatic Diseases. 2019;22:411–419.
5. UroLift manufacturer safety information.
6. Benidir T, et al. Impact of the UroLift device on prostate magnetic resonance image quality. Journal of Urology. 2023.

If you are troubled by lower urinary tract symptoms but are not yet ready to farewell your forward ejaculation, come and see your Brisbane urologist, Dr Jo, Uro-Jo, to discuss whether UroLift may be an appropriate option for your BPH.

Creating a temporary safety zone between the prostate and rectum

Radiation therapy is an effective treatment for many men with prostate cancer. Modern radiation techniques are remarkably accurate, but there is one anatomical challenge: the prostate sits immediately in front of the rectum.

This means that while radiation is directed at the prostate, part of the rectum may also receive radiation.

One approach to reducing this exposure is to temporarily create a small space between the prostate and rectum before radiation treatment begins.

Barrigel® is a biodegradable hyaluronic acid rectal spacer designed specifically for this purpose.

Why does the rectum need protection?

The prostate and rectum normally sit almost against each other, separated by only a thin layer of tissue.

During prostate radiation therapy, some radiation therefore inevitably reaches the anterior wall of the rectum.

This can contribute to bowel symptoms such as:

• increased bowel frequency
• urgency
• loose stools or diarrhoea
• rectal discomfort
• mucus discharge
• rectal bleeding
• radiation proctitis

Most bowel symptoms following modern radiation therapy are mild and temporary, but occasionally they can persist or become troublesome.

The basic idea behind a rectal spacer is delightfully simple:

Prostate → spacer → rectum

Instead of asking radiation technology to perform an anatomical magic trick, we physically move the rectum a little farther away.

Even approximately 1 cm of additional separation can substantially reduce the radiation dose received by the anterior rectal wall.

What is Barrigel?

Barrigel is a sterile, biodegradable gel made from stabilised, non-animal-derived hyaluronic acid.

Hyaluronic acid occurs naturally in many tissues within the human body and is widely used in medical applications.

Barrigel is injected into the tissue plane between the prostate and anterior rectal wall before prostate radiation therapy.

The gel creates a temporary cushion that pushes the rectum away from the prostate.

Importantly, Barrigel does not treat the prostate cancer itself.

Its purpose is to protect surrounding normal tissue while radiation treats the cancer.

How is Barrigel inserted?

Barrigel is usually inserted before radiation planning.

The procedure is performed using ultrasound guidance.

A needle is passed through the skin of the perineum, the area between the scrotum and anus, rather than through the rectum.

The needle is carefully positioned between the back of the prostate and the front wall of the rectum.

Barrigel is then slowly injected while the position of the gel is continuously monitored with ultrasound.

Typically several millilitres of gel are used to create the required separation.

The procedure may be performed using:

• local anaesthetic
• sedation
• or another form of anaesthesia depending upon the patient and treating centre.

Fiducial markers used for radiation targeting may sometimes be inserted during the same procedure.

Antibiotic prophylaxis and strict sterile technique are important.

Who may benefit from Barrigel?

Barrigel may be considered for men undergoing radiation therapy for localised prostate cancer where reducing radiation exposure to the rectum is desirable.

This may include men undergoing:

Conventional external-beam radiation therapy

A spacer may reduce the amount of radiation reaching the rectum during a multi-week course of treatment.

Hypofractionated radiation therapy

Modern prostate radiation is increasingly delivered using larger doses over fewer treatment sessions.

A randomised clinical trial involving 201 men demonstrated that a hyaluronic-acid spacer significantly reduced rectal radiation exposure during hypofractionated prostate radiotherapy.

Acute grade 2 or greater gastrointestinal side effects occurred in approximately 2.9% of spacer-treated patients compared with 13.8% without a spacer.

Stereotactic body radiation therapy – SBRT

SBRT delivers relatively high radiation doses over only a few treatments. Precise protection of surrounding structures therefore becomes particularly important.

Selected salvage radiation situations

Spacer placement may occasionally be considered in more complex circumstances, although previous prostate or pelvic treatment can alter the normal tissue planes and make insertion more difficult.

These cases require individual assessment by the radiation oncologist and urologist.

When should Barrigel not be used?

Barrigel is contraindicated in patients with clinical T4 prostate cancer.

It should also be approached cautiously in men with conditions that may make insertion difficult or increase the risk of complications.

These include:

• active infection or inflammation near the injection site
• bleeding disorders
• anticoagulant or thrombolytic therapy
• significant antiplatelet medication
• known allergy to hyaluronic-acid products
• significant anorectal stenosis or anatomical abnormalities
• previous surgery causing extensive scarring around the prostate or rectum
• significant haemorrhoidal disease
• immunodeficiency or significant immunosuppressive therapy.

Anticoagulant and antiplatelet medications should not simply be stopped without medical advice. Their management needs to be individualised according to the reason they are being taken.

What are the potential side effects?

Most patients tolerate spacer insertion well.

Temporary symptoms may include:

• discomfort in the perineum
• minor bleeding or bruising
• a sensation of rectal fullness
• temporary discomfort when opening the bowels
• urinary frequency or discomfort
• weak urinary stream
• temporary constipation.

The feeling that there is “something there” behind the prostate can occur initially and generally settles.

What are the uncommon but important complications?

Although rectal spacer insertion is generally considered a low-risk procedure, it is still an invasive procedure.

Possible complications include:

• infection
• prostatitis
• bleeding or haematoma
• urinary retention
• significant rectal pain
• difficult or painful defaecation
• incorrect positioning of the spacer
• injection into the prostate
• injury to the urethra or bladder
• rectal-wall injury
• rectal ulceration or tissue necrosis
• vascular injection or embolisation
• very rarely, fistula formation or severe pelvic infection.

This is why spacer insertion should be performed by clinicians experienced in transperineal ultrasound-guided procedures.

Correct placement matters just as much as the choice of spacer.

What happens to Barrigel afterwards?

Barrigel is biodegradable.

It remains between the prostate and rectum during the period when radiation treatment is being delivered and is subsequently broken down and absorbed by the body.

No second operation is normally required to remove it.

Barrigel versus SpaceOAR®

Barrigel and SpaceOAR are designed to solve the same anatomical problem, but they use different materials.

	Barrigel	SpaceOAR
Material	Stabilised hyaluronic acid	Polyethylene glycol hydrogel
Main purpose	Separate prostate and rectum	Separate prostate and rectum
Placement	Transperineal injection	Transperineal injection
Imaging guidance	Ultrasound	Ultrasound
Biodegradable	Yes	Yes
Remains permanently	No	No
Material characteristics	Hyaluronic-acid gel that can be progressively shaped during injection	PEG hydrogel formed after injection
Radiopaque version	No equivalent to SpaceOAR Vue	SpaceOAR Vue contains iodine for CT visibility
Evidence	Randomised evidence demonstrating improved rectal dosimetry and reduced acute GI toxicity	Extensive clinical experience and randomised/prospective evidence supporting rectal dose reduction

Both therefore create a temporary physical separation between the prostate and rectum.

Is Barrigel better than SpaceOAR?

At present it would be too simplistic to say that one spacer is universally “better”.

Both can substantially reduce radiation exposure to the rectum when correctly placed.

There are, however, some practical differences.

Barrigel can be shaped during insertion

Barrigel is injected as hyaluronic-acid gel. The operator can progressively deposit and shape the material while watching the developing space with ultrasound.

This can be useful when trying to achieve an appropriate distribution behind the prostate.

SpaceOAR has a long clinical track record

SpaceOAR has been extensively studied and is widely used internationally.

SpaceOAR Vue also contains iodine, making the spacer readily visible on CT. This may be helpful when MRI is unsuitable or when CT-based radiation planning is required.

Placement may matter more than the label on the syringe

An important point is that the quality, volume and position of the spacer can significantly influence the radiation dose received by the rectum.

A 2025 real-world comparative study found differences in dosimetry between Barrigel and SpaceOAR that were strongly influenced by the amount of spacer inserted. At comparable volumes, Barrigel performed favourably for some dosimetric measurements.

Interestingly, rectal-wall infiltration occurred in 7 of 287 SpaceOAR procedures (2.44%) and none of the Barrigel procedures in that particular study.

This does not prove that Barrigel is universally safer, but it highlights the importance of spacer material, injection technique and careful positioning.

What if Barrigel is not perfectly positioned?

One potentially useful characteristic of hyaluronic acid is that it can potentially be treated with hyaluronidase, an enzyme that breaks down hyaluronic acid.

This provides a theoretical and practical advantage if significant malposition is recognised.

The Queensland Clinical Excellence guidance specifically notes Barrigel’s potential to be hydrolysed in situations of spacer misplacement.

This does not make incorrect placement harmless, however. Prevention through meticulous ultrasound-guided insertion remains far preferable to correction afterwards.

Do all men having prostate radiation need a spacer?

No.

Modern radiation techniques such as IMRT, VMAT and image-guided radiotherapy already provide highly sophisticated targeting.

Whether a spacer provides meaningful additional benefit depends upon:

• prostate anatomy and size
• distance between prostate and rectum
• radiation technique
• radiation dose and fractionation
• previous prostate or pelvic treatment
• bowel disease
• anticoagulation
• individual risk of radiation toxicity
• and the experience of the treating radiation team.

Some patients may gain considerable benefit while others may gain relatively little.

The decision should therefore be made jointly between the patient, radiation oncologist and urologist.

What does the evidence tell us?

The European Association of Urology recognises biodegradable rectal spacers as a method of increasing the distance between the prostate and rectum and reducing rectal radiation exposure.

Evidence across rectal spacer studies suggests reductions in both acute and late grade 2 or greater rectal toxicity.

For Barrigel specifically, a multicentre randomised trial demonstrated impressive dosimetric results during hypofractionated radiotherapy.

98.5% of patients receiving the hyaluronic-acid spacer achieved at least a 25% reduction in the volume of rectum receiving 54 Gy.

The average reduction was approximately 85%.

The same study demonstrated substantially fewer acute grade 2 or greater gastrointestinal side effects in patients receiving the spacer.

These findings support rectal spacing as a useful tool for appropriately selected men receiving prostate radiation therapy.

The bottom line

Barrigel is a temporary hyaluronic-acid rectal spacer used to create additional distance between the prostate and rectum before prostate cancer radiation therapy.

It does not improve the radiation by attacking the cancer. Instead, it gives the radiation oncologist a little more anatomical breathing room.

For appropriately selected patients it can:

increase prostate-to-rectum separation → reduce rectal radiation dose → reduce the risk of bowel toxicity.

Barrigel and SpaceOAR both achieve this objective using different biomaterials. Neither should automatically be regarded as the best option for every patient.

The choice should take into account the planned radiation technique, individual anatomy, previous treatment, medical history and the experience of the treating team.

Most importantly, a rectal spacer is an additional protective tool, not a guarantee against radiation-related bowel complications.

When should I discuss a rectal spacer?

If you are considering external-beam radiation therapy or SBRT for prostate cancer, it is reasonable to ask your radiation oncologist or urologist:

“Would I benefit from a rectal spacer, and would Barrigel or SpaceOAR be more appropriate for me?”

That conversation should occur before radiation planning begins.

This information is intended for patient education and does not replace individual assessment by your urologist or radiation oncologist.

So, if you have discussed this with your radiation oncologist and you would like the benefit of protecting your rectum against the effects of radiation, come see your local Brisbane urologist, Dr Jo, to discuss this option.

Removing the prostate while putting cancer control first

Robotic-assisted radical prostatectomy is a well-established surgical treatment for localised and selected locally advanced prostate cancer. During the operation, the prostate gland and seminal vesicles are removed, and the bladder is reconnected to the urethra. In selected patients, pelvic lymph nodes may also be removed.

One of the important decisions made before and during prostate cancer surgery is whether the nerves responsible for erections can safely be preserved.

This is known as nerve-sparing prostatectomy.

Unfortunately, nerve preservation is not always appropriate. When prostate cancer is close to, involves, or is suspected of extending beyond the outer edge of the prostate near these nerves, attempting to preserve them may compromise the completeness of cancer removal.

In this situation, a partial or complete non-nerve-sparing robotic prostatectomy may be recommended.

The guiding principle is simple:

Preserve the nerves when it is oncologically safe to do so, but do not preserve them at the expense of adequately treating the prostate cancer.

What are the nerves that are being “spared”?

Running immediately alongside the prostate are delicate bundles of nerves and blood vessels known collectively as the neurovascular bundles.

These structures contain nerves that play an important role in producing erections.

They sit extremely close to the outer surface, or capsule, of the prostate. This anatomical relationship creates a challenge during prostate cancer surgery.

If the cancer is safely contained within the prostate and sufficiently distant from the neurovascular bundle, the surgeon may be able to carefully dissect the prostate away while preserving the nerves.

This is a nerve-sparing radical prostatectomy.

If cancer is suspected to extend towards or through the prostate capsule in this area, the surgeon may need to remove some or all of the neurovascular tissue together with the prostate.

This is a non-nerve-sparing prostatectomy.

Why would a surgeon deliberately remove the erectile nerves?

It may initially seem counterintuitive to remove structures that are so important for sexual function.

The reason is cancer control.

The primary purpose of radical prostatectomy is to completely remove the prostate cancer.

If a tumour is growing very close to the edge of the prostate, particularly next to a neurovascular bundle, dissecting too close to the prostate in an attempt to preserve the nerves could potentially leave cancer cells behind.

This is called a positive surgical margin.

In appropriately selected patients, taking a wider margin around the prostate may therefore provide a safer cancer operation.

The decision represents a balance between:

Cancer control

and

preservation of erectile function.

When these two goals conflict, cancer control generally takes priority.

When may a non-nerve-sparing prostatectomy be recommended?

Non-nerve-sparing surgery may be considered when there is a significant risk that prostate cancer has extended towards or into the tissues surrounding the prostate.

Examples include:

Locally advanced prostate cancer

A tumour suspected of extending through the prostate capsule, particularly clinical T3 disease, may require a wider surgical excision.

Cancer close to the neurovascular bundle on MRI

Modern multiparametric prostate MRI can provide valuable information about the location of the tumour and its relationship to the prostate capsule and neurovascular bundles.

Features suggesting extraprostatic extension may influence the decision not to preserve the nerve bundle on that side.

High-grade prostate cancer

Higher-grade cancers, including cancers with an unfavourable Gleason score or ISUP Grade Group, may have a greater likelihood of extending outside the prostate.

The biopsy result alone does not automatically determine whether the nerves can be preserved, but it forms part of the overall assessment.

Extensive cancer on prostate biopsy

Large-volume disease, particularly when concentrated along the outer portion of the prostate near a neurovascular bundle, may make nerve preservation less appropriate.

Very high PSA or other high-risk features

PSA level, PSA density, biopsy findings, MRI appearance and clinical examination are considered together when estimating the likelihood of disease extending beyond the prostate.

Cancer involving one particular side of the prostate

Importantly, nerve sparing does not necessarily have to be “all or nothing.”

If the cancer is predominantly on one side, it may sometimes be possible to preserve the neurovascular bundle on the opposite side.

This is known as unilateral nerve sparing.

Nerve sparing is not simply YES or NO

Modern robotic prostate surgery is more nuanced than dividing operations into completely nerve-sparing and completely non-nerve-sparing procedures.

Depending on the location and extent of the cancer, surgery may involve:

• Bilateral nerve sparing
• Unilateral nerve sparing
• Partial nerve sparing
• Wider excision on one side and nerve preservation on the other
• Complete bilateral non-nerve-sparing surgery

The surgical plan can therefore be tailored to the individual patient and, importantly, to the cancer on each side of the prostate.

How does nerve-sparing surgery differ from non-nerve-sparing surgery?

During nerve-sparing surgery, the surgeon carefully separates the neurovascular bundle from the surface of the prostate while attempting to minimise traction, heat and other potential injury to these delicate nerves.

During non-nerve-sparing surgery, the dissection is deliberately performed further away from the prostate.

The neurovascular tissue is removed together with the prostate where necessary to obtain a wider cancer margin.

The robotic platform provides magnified three-dimensional vision and highly controlled instrument movement. This allows the surgeon to identify tissue planes with considerable precision.

However, robotic technology cannot make an unsafe nerve-sparing operation safe.

The biology and location of the cancer ultimately determine how close to the prostate the surgeon can safely operate.

What happens to erections after non-nerve-sparing prostatectomy?

This is one of the most important issues to discuss before surgery.

The nerves surrounding the prostate are responsible for signalling increased blood flow into the penis to produce a natural erection.

If both neurovascular bundles are completely removed, the likelihood of recovering spontaneous erections adequate for sexual intercourse is very low.

This is different from nerve-sparing surgery, where the nerves remain anatomically intact but may temporarily function poorly following surgery.

After nerve-sparing prostatectomy, erectile recovery can occur gradually over many months and sometimes over 18–24 months or longer.

After complete bilateral non-nerve-sparing surgery, however, the nerves themselves have been removed rather than temporarily stunned.

The expectations for recovery are therefore very different.

Does non-nerve-sparing surgery affect sensation or orgasm?

This is an important distinction.

The nerves responsible for penile sensation are different from the neurovascular nerves primarily responsible for erections.

Many men can therefore continue to experience penile sensation and sexual pleasure following radical prostatectomy.

Orgasm may also remain possible.

However, radical prostatectomy removes the prostate and seminal vesicles and disconnects the reproductive pathway. Consequently, there is no ejaculation of semen after surgery.

This is sometimes described as a dry orgasm.

The sensation of orgasm can also feel different after prostate surgery.

Does non-nerve-sparing prostatectomy cause infertility?

Yes.

Radical prostatectomy results in permanent infertility because the prostate and seminal vesicles are removed and sperm can no longer enter the ejaculate.

Men who may wish to father children in the future should discuss sperm banking before surgery.

This applies whether the operation is nerve sparing or non-nerve sparing.

Is a non-nerve-sparing procedure reversible?

No.

Once a neurovascular bundle has been surgically removed, it cannot simply be reattached at a later date.

This is an important difference between temporary nerve dysfunction and actual nerve removal.

After nerve-sparing surgery, the nerves may be anatomically preserved but temporarily injured or “stunned”. Recovery may therefore occur with time.

After complete non-nerve-sparing surgery, the erectile nerves have been physically removed as part of the cancer operation.

The procedure itself is therefore not reversible.

However, this does not mean that erections or sexual activity are impossible.

There are several effective treatments available for erectile dysfunction following prostatectomy.

Can erections still be achieved after non-nerve-sparing surgery?

Rarely yes, but they will usually require assistance.

Treatment options include:

PDE5 inhibitor tablets

Medications such as sildenafil or tadalafil are commonly used after prostate surgery.

They rely substantially on functioning nerve pathways and are therefore generally more effective following nerve-sparing surgery.

Their effectiveness following complete bilateral non-nerve-sparing surgery is considerably more limited.

Vacuum erection device

A vacuum erection device creates negative pressure around the penis, drawing blood into the erectile tissues.

A constriction ring can then be placed around the base of the penis to maintain the erection.

Because this technique does not depend on intact erectile nerves, it can be useful after non-nerve-sparing surgery.

Penile injection therapy

Medication can be injected directly into the erectile tissue of the penis.

These medications act directly on penile blood vessels and therefore do not require normal prostate-associated nerve signalling.

For this reason, penile injections can be highly effective even after bilateral non-nerve-sparing prostatectomy.

Penile prosthesis

For men with persistent erectile dysfunction who wish to restore reliable erections, a penile prosthesis can provide an effective long-term solution.

An inflatable penile prosthesis allows an erection to be mechanically produced when desired.

For appropriately selected men, satisfaction rates following penile prosthesis surgery are generally high.

What about penile rehabilitation?

Penile rehabilitation may be discussed following radical prostatectomy.

The objectives can include maintaining penile tissue health, encouraging regular oxygenation of the erectile tissues, minimising shortening and fibrosis, and assisting the return to sexual activity.

A rehabilitation program may involve:

• PDE5 inhibitor medication where appropriate
• Vacuum erection therapy
• Penile injection therapy
• Regular sexual stimulation
• Early assessment and management of erectile dysfunction

The appropriate program depends heavily on whether surgery was bilateral nerve sparing, unilateral nerve sparing or completely non-nerve sparing.

It is therefore important that expectations are realistic.

After complete bilateral nerve removal, rehabilitation cannot make the removed nerves grow back. Instead, treatment focuses on maintaining penile health and providing alternative ways of achieving an erection.

Can the surgeon decide during the operation whether to spare the nerves?

Sometimes.

The intended degree of nerve sparing is usually planned before surgery using information from:

• Prostate MRI
• Prostate biopsy
• PSA
• Clinical examination
• Location and volume of cancer
• Gleason score and ISUP Grade Group
• Estimated risk of extraprostatic extension
• The patient’s existing erectile function
• The patient’s priorities regarding cancer control and sexual function

However, the final surgical approach may occasionally need to be modified according to findings encountered during the operation.

The most important objective remains adequate removal of the cancer.

Does non-nerve-sparing surgery improve cancer cure rates?

Not every patient benefits from wider surgery.

For men with cancer safely confined within the prostate, unnecessary removal of the neurovascular bundles may produce significant functional consequences without providing additional cancer benefit.

Conversely, when cancer is suspected of extending close to or beyond the prostate capsule adjacent to a neurovascular bundle, wider excision may reduce the risk of leaving tumour at the surgical margin.

This is why the decision must be individualised.

The best operation is not automatically the operation that preserves the most nerves. It is the operation that provides appropriate cancer clearance while preserving as much normal function as can safely be preserved.

What about urinary continence?

Nerve sparing primarily relates to erectile function, rather than the urinary sphincter responsible for continence.

Urinary control after radical prostatectomy depends on several factors including:

• Age
• Pre-operative urinary function
• Pelvic floor strength
• Urethral length
• Bladder function
• Surgical anatomy and technique
• Previous prostate treatments
• Individual healing

Pelvic floor rehabilitation before and after surgery can be an important part of recovery.

Non-nerve-sparing surgery does not automatically mean that a patient will remain incontinent.

Questions worth asking before surgery

If a non-nerve-sparing robotic prostatectomy has been recommended, useful questions to discuss with your urologist include:

Why is nerve preservation considered unsafe in my particular cancer?

Is the concern on one side or both sides of the prostate?

Could unilateral or partial nerve sparing be considered?

What does my MRI show about the relationship between the cancer and neurovascular bundles?

What is my estimated chance of erectile recovery with the proposed operation?

What erectile rehabilitation options will be available after surgery?

Should I consider sperm banking before treatment?

These conversations are particularly important because the decision to remove a neurovascular bundle is generally irreversible.

The important message

A non-nerve-sparing robotic-assisted radical prostatectomy is not an inferior version of nerve-sparing surgery.

In the right patient, it is a deliberate cancer-control strategy.

When prostate cancer is close to or suspected of involving the tissues surrounding the prostate, preserving the erectile nerves too aggressively may risk leaving cancer behind.

Modern robotic surgery allows the operation to be tailored to the individual patient. Some men can undergo bilateral nerve preservation, others may benefit from preservation on only one side, while patients with more extensive disease may require a wider non-nerve-sparing excision.

The consequences for erectile function are important and should be understood before surgery.

Once the neurovascular nerves have been removed, the procedure cannot be reversed.

However, loss of spontaneous erections does not mean the end of sexual intimacy. Vacuum devices, penile injection therapy and penile prostheses can provide effective options when natural erections are no longer possible.

Ultimately, the aim is to achieve the best possible balance between two important goals:

Effective treatment of the prostate cancer and preservation of quality of life.

A note for patients

Every prostate cancer is different. MRI findings, biopsy results, PSA, cancer grade, age, general health, pre-existing erectile function and personal priorities all influence the appropriate surgical approach.

A detailed discussion with your urologist before robotic prostatectomy is essential so that you understand whether nerve sparing is appropriate, what degree of nerve preservation may be possible and what this means for cancer control, continence and sexual function.

This information is intended for general patient education and does not replace individual medical advice. Treatment recommendations should be based on your individual prostate cancer characteristics, imaging, pathology, general health and discussion with your treating urologist.

So., come chat to your Brisbane based urologist, Jo to discuss this option with you.