The effect of tranexamic acid in perioperative bleeding transfusion in radical cystectomy: a systematic review and meta-analysis

INTRODUCTION: Tranexamic acid (TXA) is an antifibrinolytic agent with demonstrated benefits in various surgical procedures, including urological surgeries. However, its effect on radical cystectomy (RC) remains uncertain, largely due to limited data from an earlier meta-analysis that combined RC with substantially different urological procedures, as well as conflicting results from two recently published meta-analyses specifically evaluating the impact of TXA on RC. METHODS: This systematic review and meta-analysis was registered in PROSPERO (CRD42024628394) and conducted following PRISMA and Cochrane guidelines. Randomized controlled trials (RCTs) and observational studies comparing TXA versus no TXA in patients undergoing RC. Primary endpoints included perioperative blood transfusion (PBT) and venous thromboembolism (VTE). Random-effects models with Hartung-Knapp-Sidik-Jonkman (HKSJ) adjustment were used to calculate pooled risk ratios (RR) and 95% confidence intervals (CI). RESULTS: Three studies (one RCT and two propensity-score matched observational studies) involving 1,344 patients (673 TXA; 671 control) were included. The pooled analysis for PBT showed a non-significant reduction in risk (RR 0.69; 95% CI 0.25-1.86; p = 0.25; I2 = 81%). Similarly, the risk of VTE was not significantly different between groups, although a potential trend toward increased risk was noted (RR 1.60; 95% CI 0.80-3.17; p = 0.10; I2 = 0%). CONCLUSIONS: Current evidence is underpowered to confirm the efficacy or safety of TXA during radical cystectomy. While no significant benefit or harm was identified, the wide confidence intervals necessitate further large-scale randomized trials to provide definitive clinical guidance.