Editorial Comment on: Endoscopic Intravesical Fibrin Glue Application in the Treatment of Refractory Hemorrhagic Radiation Cystitis: A Single Cohort Pilot Study by Bove et al. (From: Bove P,Iacovelli V,Tirindelli MC,et al. J Endourol 2019;33:93–98;DOI: 10.1089/end.2018.0028)

Hemorrhagic cystitis, most commonly caused by pelvic radiation, has forever been a difficult management clinical scenario for urologists. The markedly increased treatment of prostate cancer with various forms of radiation, over the past 20 years, could certainly result in the expansion of this problem for urologists in the near future.

Our nonextirpative treatments, beginning with endoscopic clot evacuation and cauterization, can be marginally effective and provide only short-term benefit in the majority of those treated. For years, we have used alum, aminocaproic acid or prostaglandin irrigation, and repeat applications of formalin fixation. Hyperbaric oxygen therapy has also been used, although requiring up to 2 months for full course treatment, and not always effective, aside from not even being available to many based on the low number of treatment centers nationwide.

The authors present a single cohort prospective study in 20 patients using a fibrin glue spray to abnormal areas of the bladder mucosa with radiation cystitis refractory to conservative measures and endoscopic fulguration. The treatment is delivered under anesthesia using a pnemocystoscopy at 12 mm Hg intravesical pressure, and the glue is sprayed on the areas of concern. The fibrin glue sets fully within 5 minutes, and the procedure takes about 30 minutes in total. Their results were impressive. Inclusive of only a 20% retreatment rate, all within the first week, no additional treatments were necessary in the entire cohort, with a mean follow-up of >2 years. Some of these even had severe radiation changes at the outset. The formulation and delivery seem fairly easy, the cost is quite reasonable if the efficacy does hold true, it certainly appears to have less local toxicity or systemic effects, and requires far less time than any of the other treatments to date.

This novel approach should be expanded in a systematic manner through our urologic community to further assess the efficacy and reproducibility of the technique.