Haematuria from radiation cystitis is often difficult to manage resulting in recurrent hospital admissions, blood transfusions and surgical intervention. RADA16 self-assembling peptide (Purastat®) is a synthetic peptide which forms a protein matrix for haemostasis and has been used in many surgical specialities. It has been shown to cause regression of radiation induced telangiectasia in cases of radiation proctitis. A single case report has described its use for radiation cystitis. We aim to provide a step-by-step description of cystoscopic application of Purastat® for patients with intractable haematuria from radiation cystitis.

Patients were taken to the operating theatre under general/spinal anaesthesia where a standard cystoscopy using water/normal saline was performed to assess the lower urinary tract. Active bleeding was controlled with either diathermy or laser ablation. Fluid was evacuated from the bladder and the bladder insufflated with CO2 to a pressure of 8-15mmH2O. CO2 insufflation is very helpful as the constant pressure tamponades bleeding resulting in clearer views for the application of Purastat®. We prefer using a 22Fr rigid cystoscope or 26Fr resectoscope as this allowed attachment of suction tubing to help evacuate any residual fluid in the trigone after CO2 insufflation. In cases with very tight vesicourethral anastomotic strictures we dilated the patients to 18Fr and used a 16Fr flexible cystoscope though application of Purastat® is more challenging. Purastat® was then applied to the affected regions via a ureteric catheter. The Purastat was left for 5 minutes after which the CO2 case was emptied from the bladder. A catheter was left at the discretion of the operating surgeon.

A total of 17 Purastat® treatments were administered to 15 patients between Feb to Oct 2024. Median age was 75 (Range 54-91years) and time from radiotherapy 7 years (1.5-17). All patients were male and had radiation therapy for prostate cancer (47% primary and 53% adjuvant/salvage treatment). 7 (47%) had previous surgical intervention for haematuria. 14 (93%) patients had significant reduction in their haematuria at 6 weeks. Clavien-Dindo 90-day complications were 1 (7%) - Grade 1 retention, 3 (20%) – Grade 2 blood transfusions, 4 (27%)- Grade 3 Surgical intervention under general anaesthetic.

Conclusion: We describe a step-by-step technique for the cystoscopic application of Purastat® for radiation cystitis. This is a promising treatment for patients with refractory haematuria and offers another potential treatment option for this difficult to manage condition.