Efficacy and Safety of Intraoperative Tranexamic Acid Infusion for Reducing Blood Transfusion During Open Radical Cystectomy

Tranexamic acid reduces perioperative blood transfusions following open radical cystectomy - a propensity-score matched analysis

PURPOSE

Radical cystectomy is associated with bleeding and high transfusion rates, presenting challenges in patient management. This study investigated the prophylactic use of tranexamic acid during radical cystectomy.

METHODS

All consecutive patients treated with radical cystectomy at a tertiary care university center were included from a prospectively maintained database. After an institutional change in the cystectomy protocol patients received 1 g of intravenous bolus of tranexamic acid as prophylaxis. To prevent bias, propensity score matching was applied, accounting for differences in preoperative hemoglobin, neoadjuvant chemotherapy, tumor stage, and surgeon experience. Key outcomes included transfusion rates, complications, and occurrence of venous thromboembolism.

RESULTS

In total, 420 patients were included in the analysis, of whom 35 received tranexamic acid. After propensity score matching, 32 patients and 32 controls were matched with regard to clinicopathologic characteristics. Tranexamic acid significantly reduced the number of patients who received transfusions compared to controls (19% [95%-Confidence interval = 8.3; 37.1] vs. 47% [29.8; 64.8]; p = 0.033). Intraoperative and postoperative transfusion rates were lower with tranexamic acid, though not statistically significant (6% [1.5; 23.2] vs. 19% [8.3; 37.1], and 16% [6.3; 33.7] vs. 38% [21.9; 56.1]; p = 0.257 and p = 0.089, respectively). The occurrence of venous thromboembolism did not differ significantly between the groups (9% [2.9; 26.7] vs. 3% [0.4; 20.9]; p = 0.606).

CONCLUSION

Prophylactic tranexamic administration, using a simplified preoperative dosing regimen of 1 g as a bolus, significantly lowered the rate of blood transfusion after cystectomy. This exploratory study indicates the potential of tranexamic acid in enhancing outcomes of open radical cystectomy.

Reduction of red blood cell transfusion with a patient blood management protocol in urological and visceral surgery: a before-after study

BACKGROUND

Although Patient Blood Management (PBM) is recommended by international guidelines, little evidence of its effectiveness exists in abdominal surgery. The aim of this study was to evaluate the benefits of the implementation of a PBM protocol on transfusion incidence and anaemia-related outcomes in major urological and visceral surgery.

METHODS

In this before-after study, a three-pillar PBM protocol was implemented in 2020-2021 in a tertiary care centre, including preoperative correction of iron-deficiency anaemia, intraoperative tranexamic acid administration, and postoperative restrictive transfusion. A historical cohort (2019) was compared to a prospective cohort (2022) after the implementation of the PBM protocol. The primary outcome was the incidence of red blood cell transfusion intraoperatively or within 7 days after surgery.

RESULTS

Data from 488 patients in the historical cohort were compared to 499 patients in the prospective cohort. Between 2019 and 2022, screening for iron deficiency increased from 13.9% to 69.8% (p < 0.01), tranexamic acid administration increased from 9.5% to 84.6% (p < 0.01), and median haemoglobin concentration before transfusion decreased from 77 g.L-1 to 71 g.L-1 (p = 0.02). The incidence of red blood cell transfusion decreased from 11.5% in 2019 to 6.6% in 2022 (relative risk 0.58, 95% CI 0.38-0.87, p = 0.01). The incidence of haemoglobin concentration lower than 100 g.L-1 at discharge was 24.2% in 2019 and 21.8% in 2022 (p =  0.41). The incidence of medical complications was comparable between the groups.

CONCLUSION

The implementation of a PBM protocol over a two-year period was associated with a reduction of transfusion in major urological and visceral surgery.

The effect of the use of tranexamic acid in percutaneous nephrolithotomy on blood loss and surgical visual clarity: a prospective, randomized, controlled and double-blind study

Tranexamic acid, once a randomly used antifibrinolytic agent, has been in standard protocols for many specific surgeries. Studies are still needed to standardize the dose and route of tranexamic acid administration, examine its possible contributions in urological surgery, and establish a protocol for its use. To contribute to this goal, we designed a prospective, randomized, double-blind study on 75 patients with 1 control and 2 study groups (n = 25) who underwent percutaneous nephrolithotomy. Group Tranexamic acid received 10 mg/kg intravenous tranexamic acid preoperatively. And Group Irrigation received the same amount in the initial irrigation fluid. Primarily, we observed the total amount of blood transfusion and the changes in hemoglobin and hematocrit values during 2 postoperative days. Distinctively, we intraoperatively monitored hemoglobin continuously as a saturation hemoglobin value to assess the timing of the effect of tranexamic acid. Secondarily, we questioned surgical visual clarity with a standard visual score to reveal its contribution to surgical practicality, operative time, and residual fragment quantity. Our results revealed a significant difference in the reduction of hemoglobin and hematocrit change and blood transfusion in both tranexamic acid groups concerning control, especially on the second day (p = 0.003, p = 0.002, p = 0.001). Likewise, surgical visual scores were significantly better in both tranexamic acid groups (p = 0.018). In conclusion, intravenous or local administration of tranexamic acid at a dose of 10 mg/kg will be sufficient to maintain perioperative stability in hemoglobin values, use fewer blood products and provide a better visual advantage for the surgeon intraoperatively.The trial registration number is NCT05947435, and the date of registration is 07/07/2023, retrospectively registered.

Tranexamic acid for percutaneous nephrolithotomy

BACKGROUND

Percutaneous nephrolithotomy (PCNL) is the gold standard for the treatment of large kidney stones but comes with an increased risk of bleeding compared to other treatments, such as ureteroscopy and shock wave lithotripsy. Tranexamic acid (TXA) is an antifibrinolytic agent that has been used to reduce bleeding complications in other settings.

OBJECTIVES

To assess the effects of TXA in individuals with kidney stones undergoing PCNL.

SEARCH METHODS

We performed a comprehensive literature search of the Cochrane Library, PubMed (including MEDLINE), Embase, Scopus, Global Index Medicus, trials registries, other sources of the grey literature, and conference proceedings. We applied no restrictions on the language of publication nor publication status. The latest search date was 11 May 2023.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared treatment with PCNL with administration of TXA to placebo (or no TXA) for patients ≥ 18 years old.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified studies and abstracted data. Primary outcomes were: blood transfusion, stone-free rate (SFR), and thromboembolic events (TEEs). Secondary outcomes were: adverse events (AEs), secondary interventions, major surgical complications, minor surgical complications, unplanned hospitalizations or readmissions, and hospital length of stay (LOS). We performed statistical analyzes using a random-effects model. We rated the certainty of evidence (CoE) according to the GRADE approach using a minimally contextualized approach with predefined thresholds for minimally clinically important differences (MCIDs).

MAIN RESULTS

We analyzed 10 RCTs assessing the effect of systemic TXA in PCNL versus placebo (or no TXA) with 1883 randomized participants. Eight studies were published as full text. One was published in abstract proceedings, but it was separated into two separate studies for the purpose of our analyzes. Average stone surface area ranged 3.45 to 6.62 cm2. We also found a single RCT published in full text assessing the effects of topical TXA in PCNL versus placebo (or no TXA) with 400 randomized participants, the results of which are further described in the review. Here we focus only on the results of TXA used systemically. Blood transfusion - Based on a representative baseline risk of 5.7% for blood transfusions taken from a large presentative observational studies, systemic TXA may reduce blood transfusions (risk ratio (RR) 0.45, 95% confidence interval (CI) 0.27 to 0.76; I2 = 28%; 9 studies, 1353 participants; low CoE). We assumed an MCID of ≥ 2%. Based on 57 participants per 1000 with placebo (or no TXA) being transfused, this corresponds to 31 fewer (from 42 fewer to 14 fewer) participants being transfused per 1000. Stone-free rate - Based on a representative baseline risk of 75.7% for SFR, systemic TXA may increase SFRs (RR 1.11, 95% CI 0.98 to 1.27; I2 = 62%; 4 studies, 603 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 757 participants per 1000 being stone free with placebo (or no TXA), this corresponds to 83 more (from 15 fewer to 204 more) stone-free participants per 1000. Thromboembolic events - There is probably no difference in TEEs (risk difference (RD) 0.00, 95% CI -0.01 to 0.01; I2 = 0%; 6 studies, 841 participants; moderate CoE). We assumed an MCID of ≥ 2%. Since there were no thromboembolic events in intervention and/or control groups in 5 out of6 studies, we opted to assess a risk difference with systemic TXA for this outcome. Adverse events - Systemic TXA may increase AEs (RR 5.22, 95% CI 0.52 to 52.72; I2 = 75%; 4 studies, 602 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 23 participants per 1000 with placebo (or no TXA) having an adverse event, this corresponds to 98 more (from 11 fewer to 1000 more) participants with adverse events per 1000. Secondary interventions - Systemic TXA may have little to no effect on secondary interventions (RR 1.15, 95% CI 0.84 to 1.57; I2 = 0%; 2 studies, 319 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 278 participants per 1000 with placebo (or no TXA) having a secondary intervention, this corresponds to 42 more (from 44 fewer to 158 more) participants with secondary interventions per 1000. Major surgical complications - Based on a representative baseline risk for major surgical complications of 4.1%, systemic TXA may reduce major surgical complications (RR 0.36, 95% CI 0.21 to 0.62; I2 = 0%; 5 studies, 733 participants; moderate CoE). We assumed an MCID of ≥ 2%. Based on 41 participants per 1000 with placebo (or no TXA) having a major surgical complication, this corresponds to 26 fewer (from 32 fewer to 16 fewer) participants with major surgical complications per 1000. Minor surgical complications - Systemic TXA may reduce minor surgical complications (RR 0.71, 95% CI 0.45 to 1.10; I2 = 76%; 5 studies, 733 participants; low CoE). We assumed an MCID of ≥ 5%. Based on 396 participants per 1000 with placebo (or no TXA) having a minor surgical complication, this corresponds to 115 fewer (from 218 fewer to 40 more) participants with minor surgical complications per 1000. Unplanned hospitalizations or readmissions - We are very uncertain how unplanned hospitalizations or readmissions are affected (RR 1.55, 95% CI 0.45 to 5.31; I2 = not applicable; 1 study, 189 participants; very low CoE). We assumed an MCID of ≥ 2%. Hospital length of stay - Systemic TXA may reduce hospital LOS (mean difference 0.52 days lower, 95% CI 0.93 lower to 0.11 lower; I2 = 98%; 7 studies, 1151 participants; low CoE). We assumed an MCID of ≥ 0.5 days.

AUTHORS' CONCLUSIONS

Based on 10 RCTs with substantial methodological limitations that lowered all CoE of effect, we found that systemic TXA in PCNL may reduce blood transfusions, major and minor surgical complications, and hospital LOS, as well as improve SFRs; however, it may increase AEs. We are uncertain about the effects of systemic TXA on other outcomes. Findings of this review should assist urologists and their patients in making informed decisions about the use of TXA in the setting of PCNL.

Bloodless surgery in urologic oncology: A review of hematologic, anesthetic, and surgical considerations

The urologic oncology patient who refuses blood transfusion can present unique challenges in perioperative blood management. Since blood loss and associated transfusion can be expected in many complex urologic oncology surgeries, a multidisciplinary approach may be required for optimal outcomes. Through collaboration with the hematologist, anesthesiologist, and urologist, various techniques can be employed in the perioperative phases to minimize blood loss and the need for transfusion. We review the risks and benefits of these techniques and offer recommendations specific to the urologic oncology patient.

Effect Analysis of Preoperative Intravenous Tranexamic Acid Combined With Intraoperative Immersion in Reducing Perioperative Blood Loss of One Stage Posterior Thoracolumbar Tuberculosis

Background

To investigate the efficacy and safety of preoperative intravenous tranexamic acid (TXA) combined with intraoperative immersion in reducing perioperative blood loss in one-stage posterior thoracolumbar tuberculosis.

Methods

All patients were divided into four groups: Group A received an intravenous drip of TXA before surgery, group B received multiple local immersions during the operation, group C received an intravenous drip combined with multiple local immersions, and the control group (group CG) were not treated with TXA during the same period. The total blood loss (TBL), intraoperative blood loss (IBL), hidden blood loss (HBL), postoperative drainage volume, maximum hemoglobin drop value (max Hb drop), liver and kidney function, coagulation indexes, blood transfusion rate, hospital stay and incidence of complications were compared among the four groups.

Results

TBL, IBL, HBL, max Hb drop, POD1 drainage, and POD2 drainage in group A, group B, and group C were significantly lower than those in group CG. TBL, IBL, HBL and max Hb drop were group C < group A < group B < group CG. The drainage volume of group C was significantly lower than that of the other groups. There was no significant difference in blood coagulation index (PT, D-D) or liver and kidney function (ALT, Cr) among the four groups. There was no difference in postoperative hospital stay between group A and group B, but it was significantly lower in group C than in the other three groups. All patients achieved satisfactory bone graft fusion at the last follow-up.

Conclusion

Preoperative intravenous drip of TXA combined with intraoperative multiple immersion can effectively reduce perioperative blood loss while not increasing the risk of thrombosis without affecting liver and kidney function, coagulation function or tuberculosis prognosis.

Can the prophylactic administration of tranexamic acid reduce the blood loss after robotic-assisted radical prostatectomy? Robotic Assisted Radical Prostatectomy with tranEXamic acid (RARPEX): study protocol for a randomized controlled trial

Background

The prophylactic administration of tranexamic acid reduces blood loss during procedures at high risk of perioperative bleeding. Several studies in cardiac surgery and orthopedics confirmed this finding. The aim of this prospective, double-blind, randomized study is to evaluate the effect of tranexamic acid on peri-and postoperative blood loss and on the incidence and severity of complications.

Methods/design

Based on the results of our pilot study, we decided to conduct this prospective, double-blind, randomized trial to confirm the preliminary data. The primary endpoint is to analyze the effect of tranexamic acid on perioperative and postoperative blood loss (decrease in hemoglobin levels) in robotic-assisted radical prostatectomy. The additional endpoint is to analyze the effect of tranexamic acid on postoperative complications and confirm the safety of tranexamic acid in robotic-assisted radical prostatectomy.

Discussion

No study to date has tested the prophylactic administration of tranexamic acid at the beginning of robotic-assisted radical prostatectomy. This study is designed to answer the question of whether the administration of tranexamic acid might lower the blood loss after the procedure or increase the rate and severity of complications.

Trial registration

ClinicalTrials.gov NCT04319614. Registered on 25 March 2020

Impact on blood loss and transfusion rates following administration of tranexamic acid in major oncological abdominal and pelvic surgery: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Major bleeding and receiving blood products in cancer surgery are associated with increased postoperative complications and worse outcomes. Tranexamic acid (TXA) reduces blood loss and improves outcomes in various surgical specialities. We performed a systematic review and meta-analysis to investigate TXA use on blood loss in elective abdominal and pelvic cancer surgery.

METHODS

A literature search was performed for studies comparing intravenous TXA versus placebo/no TXA in patients undergoing major elective abdominal or pelvic cancer surgery.

RESULTS

Twelve articles met the inclusion criteria, consisting of 723 patients who received TXA and 659 controls. Patients receiving TXA were less likely to receive a red blood cell (RBC) transfusion (p < 0.001, OR 0.4 95% CI [0.25, 0.63]) and experienced less blood loss (p < 0.001, MD -197.8 ml, 95% CI [-275.69, -119.84]). The TXA group experienced a smaller reduction in haemoglobin (p = 0.001, MD -0.45 mmol/L, 95% CI [-0.73, -0.18]). There was no difference in venous thromboembolism (VTE) rates (p = 0.95, OR 0.98, 95% CI [0.46, 2.08]).

CONCLUSIONS

TXA use reduced blood loss and RBC transfusion requirements perioperatively, with no significant increased risk of VTE. However, further studies are required to assess its benefit for cancer surgery in some sub-specialities.

The Efficacy and Safety of Tranexamic Acid in the Management of Perioperative Bleeding After Percutaneous Nephrolithotomy: A Systematic Review and Meta-Analysis of Comparative Studies

Introduction: We performed a systematic review and meta-analysis of the current literature to assess the efficacy and safety of tranexamic acid (TXA) in the management of postoperative bleeding after percutaneous nephrolithotomy (PCNL). Methods: A systematic literature review was performed in March 2021. Two reviewers independently screened, identified, and evaluated comparative studies assessing the effectiveness of TXA in preventing bleeding after PCNL when compared with placebo or no intervention. The incidence of transfusion, complete stone clearance, and complications were extracted among TXA and control groups to generate the risk ratio (RR) and corresponding 95% confidence interval (CI). Blood loss, hemoglobin (Hb) drop, length of hospital stays, and operative (OR) time were analyzed using standard mean difference (SMD) with corresponding 95% CI. Effect estimates were pooled using the inverse-variance approach with a random-effect model. Results: A total of 11 studies (8 randomized controlled trial, 1 prospective cohort, and 2 retrospective cohort studies; total 1842 patients) of low-to-moderate-quality were included in the meta-analysis. Overall pooled effect estimates demonstrated a decreased transfusion rate (RR 0.36; 95% CI 0.25 to 0.51), blood loss (SMD -0.74; 95% CI -1.14 to -0.34), and Hb drop (SMD -0.95; 95% CI -1.51 to -0.39) among patients in the TXA group when compared with those in the control. The number needed to treat was 11 to prevent one transfusion. Patients who received TXA also had improved stone clearance (RR 1.08; 95% CI 1.02 to 1.14), lower minor (RR 0.72; 95% CI 0.58 to 0.89) and major (RR 0.38; 95% CI 0.21 to 0.69) complications, shorter hospital stays (SMD -0.52; 95% CI -1.01 to -0.04) and decreased OR time (SMD -0.89; 95% CI -1.46 to -0.31). Conclusions: TXA can effectively reduce postoperative bleeding after PCNL. Future studies should identify a subset of patients who may benefit from preoperative TXA administration for PCNL.

Safety and Efficacy of Using Tranexamic Acid at the Beginning of Robotic-Assisted Radical Prostatectomy in a Double-Blind Prospective Randomized Pilot Study

BACKGROUND

The prophylactic administration of tranexamic acid has been shown to be appropriate for procedures with a high risk of perioperative bleeding in cardiac surgery and orthopaedics. In urology the ambiguous results have been reported. Our goal was to evaluate the effect of tranexamic acid administration in robotic-assisted radical prostatectomy (RARP). A pilot, prospective, double-blind, randomized study was conducted to evaluate this effect.

METHODS

The study included 100 patients who received RARP in the period from April 2017 to January 2018. The patients were randomly assigned to study and control groups of 50 patients each.

RESULTS

The median follow-up was 6 months. Lower haemoglobin level drop weighted for gram of operated prostate was observed in the study group when treating the dorsal vein complex (DVC) at the beginning of the procedure (p = 0.004 after 3 hours and p < 0.001 after 24 hours). There was no evidence of any serious side effect of tranexamic acid.

CONCLUSION

We demonstrated the safety of tranexamic acid at RARP. In addition, we showed that administration of tranexamic acid at the beginning of RARP significantly reduces the decrease in haemoglobin after the procedure when treating the DVC at the beginning of the procedure.

The Use of Tranexamic Acid in Hip and Pelvic Fracture Surgeries

Tranexamic acid (TXA) use has expanded across many surgical specialties. It has been shown to reduce blood loss, decrease transfusion rates, and, in some cases, improve mortality. Within orthopaedic surgery, its popularity has primarily grown within arthroplasty and spinal surgery. It has only recently gained traction within the field of orthopaedic trauma and fracture care. At this time, most literature focuses on hip fracture and pelvic trauma surgery. For hip fractures, the results are encouraging and generally support the claim that TXA may lower overall blood loss and decrease transfusions. Conversely, less support exists for TXA use in fractures of the acetabulum or pelvic ring. Based on the current fracture-related studies, TXA does not seem to carry an increased risk of thromboembolism or other complications. In addition, few studies have been noted discussing the route of administration, timing, or dosage. This article reviews the most current literature regarding TXA use in fracture care and expands on the need for further research to evaluate the role of TXA in orthopaedic trauma populations who carry a high risk for transfusion.

The efficacy and safety of multiple-dose intravenous tranexamic acid in reducing perioperative blood loss in patients with thoracolumbar burst fracture

OBJECTIVE

To evaluate the efficacy and safety of tranexamic acid (TXA) for single-segment thoracolumbar burst fracture without neurologic injury underwent pedicle screw fixation via Wiltse approach.

PATIENTS AND METHODS

We identified 264 patients with single-segment thoracolumbar burst fracture without neurologic injury underwent pedicle screw fixation via Wiltse approach (January 2016-June 2019) at a single center. The cohort was separated into three groups. Group A received 20 mg/kg TXA at 5 min before skin incision and 16 h after first dose; Group B received 20 mg/kg TXA at 5 min before skin incision; Group C received NS at each same time point. The outcomes were evaluated by hidden blood loss (HBL), total blood loss (TBL), intraoperative blood loss (IBL), transfusion rate, maximum hemoglobin (Hb) drop, prethrombotic state molecular markers, liver and renal function, coagulation function, inflammatory factor and adverse events.

RESULTS

The HBL, TBL and maximum Hb drop were significantly lower in Group A than those of Group B and Group C, while the difference between Group B and Group C was statistically significant. The IBL was significantly lower in Group A and Group B than that of Group C. However, there was no significantly difference among the three groups in live and renal function, coagulation function, prethrombotic state molecular markers, transfusion rate and complications during the perioperative period. There was significantly lower level of interleukin-6 (IL-6) in Group A than Group C at the day after surgery, and lower level of C-reactive protein (CRP) at the third day after surgery.

CONCLUSIONS

Intravenous TXA used in the treatment of thoracolumbar burst fracture underwent pedicle screw fixation via Wiltse approach is effective and safe in decreasing perioperative blood loss. The two-dose TXA regimen can further reduce blood loss and alleviate post-operative inflammation response, without affecting prethrombotic state molecular marks and without increasing the risk of complications.

Efficacy and safety of antifibrinolytics in oncological surgery: a systematic review and meta-analysis

Background and objectives

Contents

Conclusions

[Efficacy and safety of antifibrinolytics in oncological surgery: a systematic review and meta-analysis]

BACKGROUND AND OBJECTIVES

The administration of antifibrinolytics has been shown to be effective in reducing blood loss and the need for transfusions in surgeries. However, few studies have evaluated these drugs in cancer surgery. The objective was to review the efficacy and safety of the treatment with antifibrinolytics in patients who underwent oncologic surgeries.

CONTENTS

An electronic bibliographic research was conducted in PubMed, OVID, MEDLINE, EMBASE, EBSCO and in the Cochrane Library data basis in order to identify randomized clinical trials performed in any type of oncologic surgery. The data evaluated were blood loss, need for transfusion and incidence of arteriovenous thromboembolism. Five randomized controlled trials evaluating 838 patients met the inclusion requirements. In the analysis of the incidence of thromboembolic events in the five RCTs, there was no statistically significant difference between the administration of tranexamic acid when compared with the placebo (OR=0.36, 95% IC: 0.11-1.19, p=0.09, I2=0%). However, when total estimated blood loss and need for blood transfusion are analyzed, the use of tranexamic acid was associated with a significant reduction over placebo (MD=-135.79, 95% CI: -179.50 to -92.08, p<0.00001, I2=68%) and (OR=0.45, 95% CI: 0.32-0.65, p<0.00001, I2=60%), respectively.

CONCLUSIONS

This meta-analysis found no evidence that the administration of antifibrinolytics increases the risk of thromboembolic complications in patients submitted to oncologic surgery, and has shown evidence that it is effective in reducing total perioperative blood loss and the need for blood transfusion.

Tranexamic Acid Use in Open Reduction and Internal Fixation of Fractures of the Pelvis, Acetabulum, and Proximal Femur: A Randomized Controlled Trial

OBJECTIVE

To assess the safety and efficacy of tranexamic acid (TXA) use in fractures of the pelvic ring, acetabulum, and proximal femur.

DESIGN

Prospective, randomized controlled trial.

SETTING

Single Level 1 trauma center.

PATIENTS

Forty-seven patients were randomized to the study group, and 46 patients comprised the control group.

INTERVENTION

The study group received 15 mg/kg IV TXA before incision and a second identical dose 3 hours after the initial dose.

MAIN OUTCOME MEASUREMENTS

Transfusion rates and total blood loss (TBL) [via hemoglobin-dilution method and rates of venous thromboembolic events (VTEs)].

RESULTS

TBL was significantly higher in the control group (TXA = 952 mL, no TXA = 1325 mL, P = 0.028). The total transfusion rates between the TXA and control groups were not significantly different (TXA 1.51, no TXA = 1.17, P = 0.41). There were no significant differences between the TXA and control groups in inpatient VTE events (P = 0.57).

CONCLUSION

The use of TXA in high-energy fractures of the pelvis, acetabulum, and femur significantly decreased calculated TBL but did not decrease overall transfusion rates. TXA did not increase the rate of VTE. Further study is warranted before making broad recommendations for the use of TXA in these fractures.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Intraprostatic injection of tranexamic acid to control refractory bleeding while maintaining therapeutic anticoagulation

Tranexamic acid (TXA) has been used to manage menstrual bleeding and reduce bleeding during orthopedic procedures, but has not been widely used in urology. We present a patient with refractory gross hematuria with required therapeutic anticoagulation who failed multiple other measures to control prostatic bleeding. This patient's hematuria abated with endoscopic localized injection of tranexamic acid into the prostate. The effects were durable with no bleeding recurrence reported while maintaining therapeutic anticoagulation.

The latest treatment options for bladder cancer

INTRODUCTION

Bladder cancer carries a high healthcare burden and a poor prognosis once distant metastatic spread has occurred.

SOURCES OF DATA

We utilised a PubMed/MEDLINE literature search using the terms bladder cancer, chemotherapy, immunotherapy, intra-vesical therapy, surgery and radiotherapy, and current clinical management guidelines (Association of Cancer Physicians, British Association of Urological Surgeons, National Institute for Health and Care Excellence, European Association of Urology).

AREAS OF AGREEMENT

Optimal bladder cancer management requires a multi-modal approach incorporating surgery, radiotherapy, chemotherapy and immunotherapy.

AREAS OF CONTROVERSY

Selection criteria for radical surgery, or radiotherapy as a bladder sparing option, and their relative efficacy, remains poorly defined.

GROWING POINTS

Palliative immunotherapy has been recently established for advanced bladder cancer after prior chemotherapy. Earlier use is under investigation.

AREAS TIMELY FOR DEVELOPING RESEARCH

Validated predictive biomarkers, potentially from easily repeatable sites ('liquid biopsies'), will be required to optimise use of molecularly targeted treatment options.

Re-evaluation of the efficacy of tranexamic acid in reducing blood loss in percutaneous nephrolithotomy: a randomized clinical trial

BACKGROUND

Tranexamic acid was reported to reduce bleeding in patients undergoing percutaneous nephrolithotomy (PCNL). The current study was performed to re-evaluate the efficacy and safety of tranexamic acid in reducing PCNL-related blood loss.

METHODS

A total of 132 consecutive patients were randomized into two groups; the case group received 1 g of intravenous tranexamic acid before induction, followed by IV infusion of a fixed dose of 1 gr tranexamic acid at 8-hour intervals for the first 48 hours after the procedure, while the control group received normal saline as placebo. Demographic and clinical characteristics of patients were recorded. The collected data were then analyzed using χ2, t-test, and multivariate regression analysis with IBM SPSS Statistics software.

RESULTS

There was no significant difference in demographic characteristics of the two groups. Mean hemoglobin drop was 2.2±1.5 g/dL in tranexamic acid group and 2.4±1.5 g/dL in controls (P=0.312). The blood loss did not show significant difference between tranexamic acid and control groups (751±523 mL vs. 826±525 mL, P=0.416). Multivariate analysis has revealed that multiple access tracts is a risk factor for increased blood loss (P=0.014).

CONCLUSIONS

Tranexamic acid administration is not associated with significant reduction of PCNL-related blood loss. Our findings are unlike the results of few recent studies, thus warranting further investigations and new trials before the widespread use of this drug is considered safe in patients undergoing PCNL.

Laparoscopic versus open radical cystectomy for patients with bladder cancer over 75-year-old: a prospective randomized controlled trial

The aim of this study was to compare the morbidity, mortality, oncological results and quality of life between laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC) in the elderly patients over 75 years old. Between January 2012 and January 2015, 60 patients were recruited into this study, who were randomly assigned in a 1:1 ratio to either LRC or ORC group. Baseline patient characteristics, pathological factors, operative and postoperative characteristics, postoperative complications and survival data were retrospectively collected, analyzed and compared between the two groups. Patients in LRC group and ORC group had comparable baseline characteristics and pathological factors (all P > 0.05). LRC group required longer operative time (408.2 ± 76.9 vs. 311.7 ± 65.3 min, P = 0.000) and had less EBL (621.6 ± 100.7 vs. 1088.5 ± 109.4 ml, P = 0.000) compared with ORC group. The incidence of infection and ileus within 90 days after surgery in ORC group was significantly higher than LRC group(6.9% vs. 28.6%, P = 0.041; 3.4% vs. 25%, P = 0.025). At a median follow-up of 28 months (range 12–48 months), the survival analysis showed that there were no significant differences between the LRC and ORC groups in overall survival (log-rank χ² = 0.122; P = 0.726), or progress-free survival (log-rank χ² = 0.153; P = 0.696). In conclusion, this study confirmed that LRC could achieve similar tumor treatment efficacy compared to ORC, with fewer perioperative complications and less blood loss. We suggest that LRC should be considered as the primary intervention for patients aged over 75 years old with muscle invasive bladder cancer or non-muscle invasive bladder cancer with high risk factors.

[Prophylactic use of tranexamic acid in noncardiac surgery : Update 2017]

BACKGROUND

Minimising perioperative bleeding is a key goal of "patient blood management" programs. One component of respective strategies includes preventive inhibition of fibrinolysis using protease inhibitors, such as tranexamic acid (TXA). TXA inhibits plasminogen activation and plasmin-induced fibrin degradation.

OBJECTIVES

The present article provides an overview of the existing literature and TXA applications in the prophylaxis of perioperative bleeding.

METHODS

Literature search in PubMed/MEDLINE (U.S. National Library of Medicine®, Bethesda, MD, USA).

RESULTS

TXA reduces perioperative blood loss and transfusion requirements in several randomized controlled trials (RCTs) and meta-analyses in the field of hip and knee arthroplasty for both intravenous and topical use. Moreover, evidence favours use of TXA in complex spine surgery and reconstructive surgery (e. g. craniosynostosis in children). Single RCTs showed benefits of TXA in abdominal hysterectomy, open prostatectomy, liver surgery and actively bleeding trauma patients. For prophylaxis of peripartum haemorrhage (PPH) following vaginal delivery or Caesarean section, TXA cannot be routinely recommended, although evidence points to benefits in actively bleeding patients. A recommendation exists for the treatment of (active) PPH. For prophylactic perioperative administration, different dosage regimens exist for adults. Most often an initial i. v. bolus of 1 g or 10-15 mg/kg body weight with/without repetition after 6 h or continuous infusions over 8 h is administered. Increased rates of thromboembolic events were not noted.

CONCLUSION

Protease inhibitors such as TXA reduce perioperative blood loss and transfusion requirements in selected surgical fields.

[Safety and efficacy of intravenous tranexamic acid in endoscopic transurethral resections in urology: Prospective randomized trial]

BACKGROUND

Endoscopic urological procedures (transurethral resection of the prostate TURP/transurethral resection of bladder tumor TURBT) are not without risk of significant bleeding. This risk is due to the vascular nature of the tissues and their high levels of fibrinolytic enzymes in the tissues and urine. This study was conducted to evaluate the safety and efficacy of the antifibrinolytic agent tranexamic acid (TXA) in reducing blood loss in patients undergoing TURP/TURBT and transfusion requirement.

METHODS

This study was a prospective, randomized, double-blind, placebo controlled clinical trial. One hundred and thirty-one patients of ASA physical status I or II, undergoing TURP (60 patients) or TURBT (71 patients) were randomly allocated to receive IV TXA: bolus of 10mg/kg at the induction of anesthesia followed by infusion of 1mg/kg/h intraoperatively and for 24h postoperatively or an equal volume of saline (control group). Blood loss was evaluated in terms of reduction in the serum hemoglobin level (delta Hb=Hb H24-Hb H0).

RESULTS

There was no difference between two groups in terms of transfusion requirements and episodes of retention. TXA did not significantly reduce mean blood loss compared with placebo during TURP (1.37±0.69 vs. 1.72±1.23g/dL respectively, P=0.256) or TURBT (1.15±0.95 vs. 1.07±0.88g/dL; P=0.532). No thrombotic complications were noted in any patient.

CONCLUSION

Tranexamic acid did not reduce transfusion requirements or perioperative blood loss in transurethral resection of the prostate or bladder tumor.

LEVEL OF EVIDENCE

4.

Impact of Intra- and Postoperative Blood Transfusion on the Incidence, Timing, and Pattern of Disease Recurrence After Radical Cystectomy

BACKGROUND

The administration of blood transfusion (BT) has been associated with a decrease in survival expectancies in patients treated with radical cystectomy (RC), as a consequence of the immunosuppressive effect mediated by BT. We sought therefore to evaluate if the usage of BT may influence the risk and pattern location of distant recurrences after RC, which may be influenced by this effect.

METHODS

Data from 2 independent cohorts of consecutive patients with bladder cancer treated with RC were analyzed. Distant recurrence included all recurrence locations outside of the true pelvis, such as lung, liver, bone, extra pelvic lymph nodes, peritoneal, or brain recurrences. Cox regression analyses evaluating the risk of developing distant recurrence after RC were built.

RESULTS

In the testing cohort, composed of 1081 patients, 41.2% received a perioperative BT. Within a median follow-up of 52 months (interquartile range, 44-61 months), 277 (25.6%) patients experienced a distant recurrence. In the validation cohort, composed of 433 patients, 42.3% received perioperative BT within a median follow-up of 83 months, and 127 (28.3%) patients experienced distant recurrence. On multivariable analyses predicting distant recurrences, BT was not associated with the risk of distant recurrence stratified by location and time (within first year or later after RC; all P ≥ .2) in both cohorts.

CONCLUSIONS

BT administration was not associated with a different pattern, timing, or rate of distant recurrences in patients when compared with those who did not receive BT. New data are needed to investigate the mechanisms behind the association between BT and survival in RC patients.