Tranexamic acid in radical cystectomy: a systematic review and meta-analysis of efficacy and safety

Radical cystectomy (RC) is a high-risk procedure, associated with significant bleeding and high risk of perioperative blood transfusion (PBT), which may limit clinical and oncological outcomes. Tranexamic acid (TXA), an antifibrinolytic agent, effectively reduces bleeding in various surgical settings; however, its role in RC remains understudied. This systematic review and meta-analysis evaluates the efficacy and safety of TXA in RC patients. A systematic search of CENTRAL, PubMed, Embase, and Web-of-Science was conducted, including studies published between January 2013 and January 2025. Four studies (one randomised controlled trial (RCT) and three retrospective cohort studies) met inclusion criteria. Data were pooled using random-effects meta-analysis. Risk of bias was assessed using ROBINS-I and RoB-2, and certainty of evidence was evaluated using GRADE. TXA was associated with a significant reduction in overall PBT (odds ratio (OR) 0.48, 95%-confidence interval (CI) 0.27–0.82; p = 0.008), though the only RCT included failed to identify this trend. Estimated blood loss was numerically reduced in the TXA group, but did not reach statistical significance (mean difference − 36.8 mL; 95%-CI -78.1-4.6; p = 0.08). Notably, TXA did not increase the incidence of venous thromboembolism (OR 1.49, 95%-CI 0.86–2.57; p = 0.16). Key limitations include substantial heterogeneity between studies (I² = 78% for PBT outcome), varying TXA dosing protocols, and the predominance of retrospective studies. TXA may reduce PBT requirements in RC without increasing thromboembolic risk. Further research is needed to confirm these findings, refine dosing protocols, and assess efficacy in minimally invasive RC.