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The impact of tranexamic acid on perioperative outcomes in urological surgeries: A systematic review and meta-analysis
Kim J, Alrumaih A, Donnelly C, Uy M, Hoogenes J, Matsumoto ED
Canadian Urological Association journal = Journal de l'Association des urologues du Canada. 2023
Abstract
INTRODUCTION Tranexamic acid (TXA) is an antifibrinolytic agent widely used in surgery to decrease bleeding and reduce the need for blood product transfusion. The role of TXA in urology is not well summarized. We conducted a systematic review of studies reporting outcomes of TXA use in urological surgery. METHODS A comprehensive search was conducted from the following databases: PubMed, Embase, Cochrane Library, and Web of Science. Two reviewers performed title and abstract screening, full text review, and data collection. Primary outcomes included estimated blood loss (EBL), decrease in hemoglobin, decrease in hematocrit, and blood transfusion rates. Secondary outcomes included TXA administration characteristics, length of stay, operative time, and postoperative thromboembolic events. RESULTS A total of 26 studies consisting of 3201 patients were included in the final analysis. These included 11 studies on percutaneous nephrolithotomy, 10 on transurethral resection of the prostate, three on prostatectomy, and one on cystectomy. Estimated blood loss (EBL), transfusion rate, hemoglobin drop, operative time, and length of stay were significantly improved with TXA administration. In addition, the use of TXA was not associated with an increased risk of venous thromboembolism (VTE). The route, dosage, and timing of TXA administration varied considerably between included studies. CONCLUSIONS TXA use may improve blood loss, transfusion rates, and perioperative parameters in urological procedures. In addition, there is no increased risk of VTE associated with TXA use in urological surgery; however, there is still a need to determine the most effective TXA administration route and dose. This review provides evidence-based data for decision-making in urological surgery.
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Efficacy and safety of intravenous tranexamic acid in urologic surgery: A systematic review and meta-analysis of randomized controlled trials
Lin, Y. H., Lee, K. C., Hsu, C. C., Chen, K. T.
Medicine. 2023;102(25):e34146
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Abstract
BACKGROUND This meta-analysis compared the effects of intravenous Tranexamic acid (TXA) and a placebo on hemostasis, hospital course, and complications in adult patients undergoing various urologic surgeries. METHODS The literature was extensively searched using various databases. The primary outcomes were standardized mean differences (SMDs) of intraoperative blood loss and odds ratios (ORs) of necessary blood product transfusion. The secondary outcomes included SMDs of operative time, SMDs of decreased hemoglobulin levels at 24 hours after surgery, and ORs of thromboembolic events. RESULTS The meta-analysis included 13 randomized controlled trials (RCT) comprising 1814 participants in total. The SMD of intraoperative blood loss for TXA versus placebo was -0.705 (95% confidence interval [CI]: -1.113 to -0.297). The pooled ORs of transfusion in the TXA group compared with the placebo group was 0.426 (95% CI: 0.290-0.625). These findings indicated a significantly lower intraoperative blood loss and a reduced need for transfusion following intravenous TXA. The pooled ORs of thromboembolic events in the TXA group compared with the placebo group was 0.664 (95% CI: 0.146-3.024). CONCLUSIONS Intravenous TXA can reduce intraoperative blood loss, decrease the need for transfusion, and shorten operative time, and it does not increase the risk of thromboembolic events.
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Clinical outcomes of low-pressure pneumoperitoneum in minimally invasive urological surgery
West A, Hayes J, Bernstein DE, Krishnamoorthy M, Lathers S, Tegan G, Teoh J, Dasgupta P, Decaestecker K, Vasdev N
Journal of robotic surgery. 2022;:1-10
Abstract
The adoption of minimally invasive laparoscopic techniques has revolutionised urological practice. This necessitates a pneumoperitoneum (PNP) and the impact the PNP pressure has on post-operative outcomes is uncertain. During the current COVID-19 era guidance has suggested the utilisation of lower PNP pressures to mitigate the risk of intra-operative viral transmission. Review the current literature regarding the impact of pneumoperitoneum pressure, within the field of urology, on post-operative outcomes. A search of the PubMed, Medline and EMBASE databases was undertaken to identify studies that met the inclusion criteria. The Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines were adhered to. Ten studies, that included both randomised controlled trials and retrospective case series reviews, were identified that met the inclusion criteria. The effect of PNP pressure on outcomes following prostatectomy, live donor nephrectomy, partial nephrectomy and a variety of benign upper tract procedures were discussed. Low pressure PNP appears safe when compared to high pressure PNP, potentially reducing post-operative pain and rates of ileus. When compared to general surgery, there is a lack of quality evidence investigating the impact of PNP pressures on outcomes within urology. Low pressure PNP appears non-inferior to high pressure PNP. More research is required to validate this finding, particularly post-cystectomy and nephrectomy.
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Comparison of the efficacy and safety of transurethral laser versus open prostatectomy for patients with large-sized benign prostatic hyperplasia: A meta-analysis of comparative trials
Wei, H. B., Guo, B. Y., Tu, Y. F., Hu, X. H., Zheng, W., Zhang, D. H., Zhuo, J.
Investigative and Clinical Urology. 2022;63(3):262-272
Abstract
PURPOSE The selection of open prostatectomy (OP) over transurethral laser surgery is controversial for large volume prostates. Thus, we aim to compare the efficacy and safety of transurethral laser versus OP, and provide the latest evidence of clinical practice for large-sized benign prostatic hyperplasia (BPH). MATERIALS AND METHODS This meta-analysis used Review Manager V5.3 software and the systematic literature search of Cochrane Library, Embase, PubMed, and Web of Science datasets was performed for citations published from 2000 to 2020 that compared transurethral laser with OP for the treatment of large BPH. Variables of interest assessing the two techniques included clinical characteristics, and the perioperation-, effectiveness-, and complication-related outcomes. RESULTS The meta-analysis included twelve studies containing 1,514 patients, with 792 laser and 722 OP. The transurethral laser group was associated with shorter hospital stay and catheterization duration, and less hemoglobin decreased in the perioperative variables. There was no significant difference in the international prostate symptom score, post-void residual urine volume, maximum flow rate, and quality of life score. Transurethral laser group had a significantly lower incidence of blood transfusion than OP group (odds ratio, 0.10; 95% confidence interval, 0.05 to 0.19; p<0.001; I²=8%), and no statistical differences were found with respect to the other complications. CONCLUSIONS Both OP and transurethral laser prostatectomy are effective and safe treatments for large prostate adenomas. With these advantages of less blood loss and transfusion, and shorter catheterization time and hospital stay, laser may be a better choice for large BPH.
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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
Pranata FH, Kloping YP, Hidayatullah F, Rahman ZA, Yogiswara N, Rahman IA, Febriansyah NA, Soebadi DM
Indian journal of urology : IJU : journal of the Urological Society of India. 2022;38(4):258-267
Abstract
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.
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The role of preoperative dutasteride in reducing bleeding during transurethral resection of the prostate: A systematic review and meta-analysis of randomized controlled trials
Kloping YP, Yogiswara N, Azmi Y
Asian journal of urology. 2022;9(1):18-26
Abstract
OBJECTIVE Bleeding is one of the most common complications of transurethral resection of the prostate (TURP). Several previous studies reported that administering dutasteride before surgery could reduce perioperative bleeding. We aimed to evaluate the efficacy of preoperative dutasteride treatment in benign prostatic hyperplasia patients undergoing TURP by performing a meta-analysis of relevant randomized controlled trials (RCTs). METHODS A comprehensive literature search was performed through the electronic databases including Medline, Cochrane Library, Google Scholar, and ClinicalTrial.gov in October 2020. RCTs evaluating the role of dutasteride for TURP were screened using the eligibility criteria and the quality of RCTs was assessed using the Cochrane Risk of Bias Tool. The heterogeneity was assessed using I (2) statistic. The measured outcomes were hemoglobin (Hb) levels, perioperative blood loss, blood transfusion, microvessel density (MVD), and operation time. Data were pooled as mean difference (MD) and odds ratio (OR). RESULTS A total of 11 RCTs consisting of 627 samples from the treatment group and 615 samples from the placebo group were analyzed. Patients that received dutasteride had less reduction in Hb levels (MD -1.10, 95% confidence interval [CI] -1.39 to -0.81, p<0.00001). Dutasteride also significantly reduced the operation time (MD -1.79, 95% CI -2.97 to -0.61, p=0.003) and transfusion rate after surgery (OR 0.34, 95% CI 0.15 to 0.77, p=0.009) compared to the control group. However, the MVD (MD -3.60, 95% CI -8.04 to 0.84, p=0.11) and perioperative blood loss in dutasteride administration for less than 4 weeks (MD 46.90, 95% CI -144.60 to 238.41, p=0.63) and more than 4 weeks (MD -190.13, 95% CI -378.05 to -2.21, p=0.05) differences were insignificant. CONCLUSION Preoperative administration of dutasteride is able to reduce bleeding during TURP, as indicated by less reduction in Hb level, lower transfusion rate, and less operation time.
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Endoscopic Therapy in the Management of Patients With Severe Rectal Bleeding Following Transrectal Ultrasound-Guided Prostate Biopsy: A Case-Based Systematic Review
Malik A, Ishtiaq R, Goraya MHN, Inayat F, Gaduputi VV
Journal of investigative medicine high impact case reports. 2021;9:23247096211013206
Abstract
Rectal bleeding is a known complication of transrectal ultrasound-guided prostate biopsy. It is usually mild and resolves spontaneously. However, massive life-threatening hemorrhage can also rarely occur in this setting, potentially presenting a therapeutic conundrum. We hereby delineate the case of a patient who experienced severe intermittent lower gastrointestinal bleeding following a transrectal ultrasound-guided prostate biopsy. Traditional tamponade methods failed to control the hemorrhage. Subsequently, an urgent flexible sigmoidoscopy revealed an anterior rectal wall prominence with biopsy punctures as the possible source of bleeding. Endoclip was successfully applied at the bleeding site, achieving permanent hemostasis. The patient had an uneventful recovery and was discharged from the hospital. While the use of endoclipping has been widely reported in gastrointestinal endoscopy, its application remains exceedingly rare in this group of patients. To our knowledge, this case represents only the third report of endoclipping alone to treat massive rectal bleeding follwing a prostate biopsy procedure. In addition, we systematically review published medical literature to evaluate endoscopic techniques aimed at managing this important complication. This article illustrates that endoscopic therapy may present an efficient, noninvasive method to deal with severe post-biopsy rectal hemorrhage. Therefore, prompt consultation with the gastroenterology service should be advocated.
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Percutaneous nephrolithotomy versus flexible ureteroscopic lithotripsy in the treatment of upper urinary tract stones: a meta-analysis comparing clinical efficacy and safety
Chen, Y., Wen, Y., Yu, Q., Duan, X., Wu, W., Zeng, G.
BMC Urology. 2020;20(1):109
Abstract
BACKGROUND Upper urinary tract stones is the most common diseases in urology. Percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (fURL) are common treatment, but both their efficacy and safety are controversial. Thus we aim to evaluate the efficacy and safety of PCNL and fURL in the treatment of upper urinary tract stones, providing a reference for clinical work. METHODS PubMed, Web of Science, Embase and CNKI were searched through Apr. 1, 2019 to identify eligible studies. Data were analyzed by using RevMan 5.3 and Stata 12.0 software. Pooled relative risks (RRs) or weighted mean difference (WMD) with 95% confidence intervals (CIs) were calculated using fixed or random effects methods. Publication bias and sensitivity analysis were performed. RESULTS Four randomized controlled trials (RCTs), fifteen cohort studies involving 1822 patients were included. Stone-free rate of PCNL was significantly high than that of fURL (RR: 1.07; 95% CI: 1.03, 1.12; P = 0.0004). The decline of hemoglobin in PCNL was significantly high than that of fURL (WMD: 1.07; 95% CI: 0.54, 1.61; P < 0.0001). The number of blood transfusion was significantly greater in the PCNL compared to the fURL (RR: 5.04; 95% CI: 1.78, 14.24; P = 0.002). The incidence of postoperative bleeding or hematuria showed greater significantly difference in the PCNL compared to the fURL (RR: 2.72; 95% CI: 1.55, 4.75; P = 0.0005). Operation time, fever, infection, perforation, requiring drug analgesia was not significantly different between two surgical procedures. CONCLUSIONS In the treatment of upper urinary tract stones, the stones clearance rate of PCNL is higher than fURL, and the safety of fURL is higher than PCNL.
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Can tranexamic acid reduce the blood transfusion rate in patients undergoing percutaneous nephrolithotomy? A systematic review and meta-analysis
Wang Z, He X, Bai Y, Wang J
J Int Med Res. 2020;48(4):300060520917563
Abstract
OBJECTIVE A systematic review and meta-analysis was conducted to explore the efficacy of tranexamic acid (TXA) in reducing transfusion events in patients undergoing percutaneous nephrolithotomy (PCNL). METHODS PubMed, Web of Science, Embase, EBSCO, and Cochrane library databases from January 1980 to October 2019 were searched for randomized controlled trials (RCTs) that assessed TXA efficacy in reducing transfusion events during PCNL. Intervention treatments include using TXA compared with placebo (or no intervention) for patients who underwent PCNL. The search strategy and study selection process were managed in accordance with the PRISMA statement. RESULTS Six RCTs are included in the meta-analysis. Overall, TXA intervention groups showed a significant reduction in blood transfusion events (RR = 0.34; 95% confidence interval [CI] = 0.19 to 0.62), hemoglobin decrease (MD = -0.80; 95% CI = -1.32 to -0.28), operative time (MD = -12.62; 95% CI = -15.62 to -9.61), and length of hospital stay (MD = -0.73; 95% CI = -1.36 to -0.10) compared with control groups after PCNL. However, TXA had no substantial impact on the rate of stone clearance (RR = 1.10; 95% CI = 1.00 to 1.21). CONCLUSIONS TXA can effectively reduce the transfusion rate and blood loss during PCNL.
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Intra-operative cell salvage in urological surgery: a systematic review and meta-analysis of comparative studies
Kinnear, N., O'Callaghan, M., Hennessey, D., Liddell, H., Newell, B., Bolt, J., Lawrentschuk, N.
Bju International. 2019;123(2):210-219
Abstract
OBJECTIVE To evaluate systematically the safety and efficacy of intra-operative cell salvage (ICS) in urology. METHODS A search of Medline, Embase and Cochrane Library to August 2017 was performed using methods pre-published on PROSPERO. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Eligible titles were comparative studies published in English that used ICS in urology. Primary outcomes were allogeneic transfusion rates (ATRs) and tumour recurrence. Secondary outcomes were complications and cost. RESULTS Fourteen observational studies were identified, with a total of 4 536 patients. ICS was compared with no the blood conservation technique (seven studies), preoperative autologous donation (PAD; five studies) or both (two studies). Cohorts underwent open prostatectomy (11 studies), open cystectomy (two studies) or open partial nephrectomy (one study). Meta-analysis was possible only for ATRs within prostatectomy studies. In this setting, ICS reduced ATR compared with no the blood conservation technique (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.15-0.76) but not PAD (OR 0.76, 95% CI 0.39-1.31). In the non-prostatectomy setting, ATRs amongst patients who underwent ICS were significantly higher or similar in one and two studies, respectively. Tumour recurrence was found to be significantly less common (two studies), similar (eight studies) or not measured (four studies). All six studies reporting complications found no difference in their ICS cohorts. Regarding cost, one study from 1995 found ICS more expensive than PAD, while two more recent studies found ICS to be cheaper than no blood conservation technique. As a result of inter-study heterogeneity, meta-analyses were not possible for recurrence, complications or cost. CONCLUSION Low-level evidence exists that, compared with other blood conservation techniques, ICS reduces ATR and cost while not affecting complications. It does not appear to increase tumour recurrence post-prostatectomy, although follow-up durations were short. Small study sizes and short follow-ups mean conclusions cannot be drawn with regard to recurrence after nephrectomy or cystectomy. Randomized trials with long-term follow-up evaluating ICS in urology are required.