Effect of Tranexamic Acid on Bleeding Outcomes After Percutaneous Nephrolithotomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Tranexamic acid for percutaneous nephrolithotomy: an abridged Cochrane review

OBJECTIVE

To assess the effects of tranexamic acid (TXA) in individuals with kidney stones undergoing percutaneous nephrolithotomy (PCNL).

PATIENTS AND METHODS

We performed a literature search of Cochrane Library, PubMed (including MEDLINE), Embase, Scopus, Global Index Medicus, trials registries, grey literature, and conference proceedings. We included randomised controlled trials (RCTs) that compared treatment with PCNL with administration of TXA to placebo (or no TXA) for patients aged ≥18 years. Two review authors independently classified studies and abstracted data. Primary outcomes were blood transfusion, stone-free rate (SFR), thromboembolic events (TEE). We rated the certainty of evidence (CoE) according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach using a minimally contextualised approach with pre-defined thresholds for minimally clinically important differences (MCID).

RESULTS

We included 10 RCTs assessing the effect of systemic TXA in PCNL vs placebo (or no TXA). Eight studies were published as full text. Based on an adjusted baseline risk of blood transfusion of 5.7%, systemic TXA may reduce blood transfusions (risk ratio [RR] 0.45, 95% confidence interval [CI] 0.27-0.76). Based on an adjusted baseline SFR of 75.7%, systemic TXA may increase SFR (RR 1.11, 95% CI 0.98-1.27). There is probably no difference in TEEs (risk difference 0.001, 95% CI -0.01 to 0.01). Systemic TXA may increase adverse events (AEs) (RR 5.22, 95% CI 0.52-52.72). Systemic TXA may have little to no effect on secondary interventions (RR 1.15, 95% CI 0.84-1.57). The CoE for most outcomes was assessed as low or very low.

CONCLUSIONS

Based on a body of evidence of 10 RCTs, we found that systemic TXA in PCNL may reduce blood transfusions, major surgical complications, and hospital length of stay, as well as improve the SFR; however, it may increase AEs. These findings should inform urologists and their patients in making informed decisions about the use of TXA in the setting of PCNL.

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.

Percutaneous management of upper tract stones: from mini to maxi percutaneous nephrolithotomy

PURPOSE OF REVIEW

Percutaneous nephrolithotomy (PCNL) continues as the gold standard for the surgical management of large renal stones. This short review is intended to highlight recent publications on PCNL of all tract sizes, from mini to standard.

RECENT FINDINGS

Literature on PCNL in the last 2 years has focused on several main themes - decreasing complications, improving postoperative pain control, and new technology to improve outcomes. Mini-PCNL continues to prove effective and safe, with a new vacuum sheath showing promise of improving stone-free rates and decreasing infections. In terms of infections, preoperative midstream urine culture continues to be a poor indicator of postoperative infection. One of the biggest changes to PCNL practice is the reintroduction of tranexamic acid, which has shown to significantly decrease bleeding and improve outcomes. In terms of postoperative pain control, local blocks are effective and low risk.

SUMMARY

There are many options for surgeons when it comes to PCNL from sheath size to pain management to preoperative medication to decrease bleeding. Future research will continue to highlight, which advances are the most beneficial.

The role of tranexamic acid in reducing bleeding during transurethral resection of the prostate: An updated systematic review and meta-analysis of randomized controlled trials

Introduction

Transurethral resection of the prostate (TURP) is regarded as the current gold standard surgical intervention for benign prostatic hyperplasia (BPH). However, this procedure is associated with significant chances of intraoperative and postoperative bleeding. Several studies have reported the role of tranexamic acid in prostatic surgeries, but, its role in TURP is still unclear. This review aims to evaluate the role of tranexamic acid in reducing the blood loss during TURP.

Materials and Methods

A systematic search was performed on Medline, Scopus, Embase, and Cochrane, up to December 2021. Relevant randomized controlled trials (RCTs) evaluating the role of tranexamic acid in TURP were screened using our predefined eligibility criteria. Data were expressed as odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CIs). All analyses were performed using RevMan 5.4 (Cochrane Collaboration, UK).

Results

Six trials were included in this meta-analysis, comprising of 582 patients with BPH who underwent TURP. The meta-analysis revealed an insignificant difference in the rate of blood transfusion (OR 0.68, 95% CI 0.34, 1.34, P = 0.27) but, a significantly lower amount of blood loss and a lower reduction in the hemoglobin (Hb) levels in the patients receiving tranexamic acid as compared to the control group (MD - 127.03, 95% CI - 233.11, -20.95, P = 0.02; MD - 0.53, 95% CI - 0.84, -0.22, P < 0.01; respectively). Also, the operative time (P = 0.12) and the length of hospitalization (P = 0.59) were similar between the two groups.

Conclusion

The administration of tranexamic acid was not found to be effective in reducing the need for blood transfusion, the operative time, and the length of hospitalization during the TURP. However, it could reduce the amount of blood loss and the fall in the Hb levels.