Parthiv Mehta: Thank you for having me. I really appreciate being here. So I'm going to take the side of SpaceOAR. Here are my disclosures.

I think of radiation oncology as being pretty simple. We use radiation to kill cancer and unfortunately that involves a dose to the normal structure. So the secondary goal, which is also just as important, is to minimize damage to the normal tissues. So back in 2015 when SpaceOAR was first FDA approved, it was just kind of a no brainer. Clearly we're reducing the dose to a critical structure and we're allowing for further dose intensification hoping for improved cancer outcomes. Well, flash forward to 2022. We now have other options in this space. So the question becomes how do we evaluate what is a good perirectal spacer? I think the key is to figure out which one is more effective or are they all the same effectiveness? Which one is safer? What are the cost concerns and how easy are they to use? In terms of effectiveness, only SpaceOAR clearly being on the market for as long as it has been, has over 225 peer-reviewed articles published in peer review journals.

It has also been studied in all modalities of radiation, including SBRT, brachytherapy and IMRT. And the benefit of it has been shown in all of these different situations. Safety, clearly we're trying to use this in order to decrease the toxicity for our patients. So if we're causing unwanted side effects, then definitely this is not something we should be doing. Well, there have been over 220,000 SpaceOAR procedures done worldwide. The published complication rates are less than 0.1%. Major complications tend to happen with improper placement. So insertion into the rectal wall or insertion into a blood vessel. And I still think the key differentiator here is with SpaceOAR. So what happens, you can see that perirectal fat layer in the white, we put our needle in. How do we know that we're actually in the right spot? So the hydro dissection allows verification of the space prior to placement. Is the video working?

So clearly when you see that space open up, you can see fat both anteriorly and posteriorly. You know you're in the right spot. You don't have to worry that you're injecting into the rectum or into the prostatic capsule. In terms of cost, all of these products seem to be at a similar cost and they are being covered by most insurance. I think one advantage of the SpaceOAR view is that it really gives you great visualization. I have not had as much success with Barrigel as Dr. Mariados has, but when I use SpaceOAR view, it's very clear for our therapists when we're doing our cone beam CTs. In terms of ease of use, I think SpaceOAR allows the quickest perirectal placement. This is good for your patients, especially if you're doing it under local anesthesia. It's also good for the flow of your office. I like the visualization of the target area through the hydro dissection. There's no incision and no stitches and we can do this under local or MAC.

So in summary, I think when we look at the different factors we use to identify which perirectal spacer we should use, I think SpaceOAR meets or beats the competition for optimal perirectal spacer. Can we play this video? And I think I'm the only one here who can probably show a live case from pretty much start to finish in the midst of a five minute debate. So we verify our placement, we make sure we're not in a blood vessel by aspirating and then just insert the hydrogel. So this procedure can be done within a matter of two to three minutes. Thank you.