Refractory Radiation Proctitis Bleeding and Post-Renal AKI in Metastatic Prostate Cancer: Multidisciplinary Stabilisation with Sequential Endoscopic Therapy

Abstract

Background: Radiation proctitis is a recognised complication of pelvic radiotherapy for prostate cancer. When chronic rectal bleeding is refractory to first-line argon plasma coagulation (APC), limited evidence guides the selection of rescue endoscopic strategies. Concurrent malignant ureteric obstruction with post-renal acute kidney injury (AKI) and severe anaemia further complicate management by restricting oncological treatment eligibility. We present a case of multidisciplinary stabilisation of a frail elderly patient with progressive metastatic prostate cancer despite androgen receptor pathway inhibitor therapy, complicated by clinically documented radiation proctitis (ICD-10: K62.7), refractory lower gastrointestinal bleeding despite two prior APC sessions, left malignant ureteric obstruction with post-renal AKI, and severe dimorphic anaemia. Case Presentation: A 79-year-old man with metastatic prostate cancer (diagnosed 2020), prior pelvic radiotherapy, and 68 Ga-PSMA PET/CT-confirmed progressive nodal and skeletal metastases presented with persistent per rectal bleeding, severe anaemia (haemoglobin 7.7 g/dL), and left malignant ureteric obstruction with hydronephrosis and post-renal AKI (creatinine 230.5 μmol/L). Left antegrade double-J stenting was performed for malignant left ureteric obstruction with hydronephrosis and post-renal AKI, with subsequent renal recovery (creatinine 146 μmol/L; eGFR 42 mL/min/1.73 m 2 ) and avoidance of dialysis. Interventions: Two APC sessions were performed at Kenyatta University Teaching and Referral Hospital (KUTRH): APC #1 (28/03/2025, argon flow 2 L/min and 30 kV as documented) achieved initial haemostasis, and APC #2 (11/07/2025) treated recurrent sigmoid and rectal telangiectasia. Despite two sessions, bleeding recurred. A third colonoscopy at Mt Elgon Endoscopy Center (27/04/2026) using a water-assisted technique employed adrenaline injection and N-butyl-2-cyanoacrylate (Histoacryl) glue injection; APC was not performed during this third procedure. Rectal sucralfate suppositories were prescribed for 14 days. A clinician-supervised real-time colonoscopy mapping interface was used as a documentation and planning aid. Outcome: Per rectal bleeding was markedly reduced in the short term with no further immediate large-volume haemorrhage. Post-transfusion haemoglobin improved to 9.0 g/dL. The patient was clinically stabilised and optimised for oncology handover. Follow-up at reporting was 3 days post-procedure; long-term haemostasis durability is not established. Prognosis remained guarded. Conclusion: In this case, cyanoacrylate glue injection under water-assisted colonoscopy was associated with short-term bleeding control after recurrent bleeding following two APC sessions for clinically documented radiation proctitis. Concurrent double-J stenting improved post-renal AKI and avoided dialysis, while transfusion improved haemoglobin to 9.0 g/dL. Coordinated multidisciplinary management stabilised the patient for oncology handover. The durability and safety of cyanoacrylate glue for this indication require further study.