The efficacy and safety of tranexamic acid use during radical cystectomy

Introduction: Radical cystectomy (RC) is the standard treatment for muscle-invasive bladder cancer (MIBC), but it is associated with substantial perioperative blood loss and high transfusion rates. Tranexamic acid (TXA), an antifibrinolytic agent, has demonstrated efficacy in reducing surgical blood loss across various specialties; however, due to a paucity of randomized controlled trials in the RC setting, its role remains uncertain. We conducted a systematic review and meta-analyses to synthesize the current evidence and provide a critical assessment of TXA use during RC. Methods: Studies evaluating TXA during RC were identified through a comprehensive search of multiple databases up to November 2024. Primary outcomes included intraoperative and perioperative blood transfusion rates and estimated blood loss. The secondary outcome assessed was thromboembolic events. Results: Five studies comprising 1736 patients were included. TXA did not significantly reduce estimated blood loss (MD: -85.56 mL; 95% confidence interval CI -191.13–20.02, p>0.05) or intraoperative transfusion rates (odds ratio OR 0.73, 95% CI 0.40–1.33, p>0.05); however, TXA was associated with a lower likelihood of perioperative transfusions (OR 0.56, 95% CI 0.32–0.97, p<0.05). Notably, TXA increased the risk of thromboembolic events (OR 2.05, 95% CI 1.15–4.65, p<0.05). Heterogeneity varied across analyses, with robotic-assisted RC underrepresented in the included studies. Conclusions: This systematic review and meta-analysis revealed that, in patients undergoing RC, the use of TXA does not significantly reduce estimated blood loss or intraoperative transfusion rates. Moreover, TXA appears to be associated with an increased incidence of thromboembolic events, suggesting a potential pro-thrombotic effect. Based on these findings, its routine use in this context cannot be recommended, particularly when intended to reduce thromboembolic risk.