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Study Supports Use of Tranexamic Acid During Percutaneous Nephrolithotomy

Key findings

  • The goal of this systematic review and meta-analysis (n=1,201 patients) was to determine how adding tranexamic acid during percutaneous nephrolithotomy affected complications and outcomes
  • Compared with placebo, tranexamic acid was associated with significant improvement in stone-free rate and significant decreases in operative time, minor and major complications, transfusions, and length of stay
  • Only two cases of thrombotic complications were noted, in a single study, for a global incidence of 0.5%
  • Decreased intraoperative bleeding may allow for better visualization, decreasing operative time and improving stone free-rates
  • While these results are promising, research is needed in appropriate candidates for tranexamic acid in percutaneous nephrolithotomy, potential drug interactions and proper dosing for patients with comorbidities

Percutaneous nephrolithotomy (PCNL) is the gold standard for treating large and/or complex kidney stones. Modernization of techniques has decreased complication rates, but bleeding is still a concern.

Tranexamic acid (TXA), which promotes blood clotting, has been used for various medical indications for over 50 years. Now it's also being studied for the prevention of bleeding after PCNL.

David E. Hinojosa-González, MD, a research fellow in the Department of Urology at Massachusetts General Hospital, Brian H. Eisner, MD, co-director of the Kidney Stone Program in the department, and colleagues recently conducted a systematic review and meta-analysis of TXA in this setting. In the Central European Journal of Urologytheir analysis concludes that compared with placebo, TXA was associated with significant improvements in operative time, change in hemoglobin, transfusion rate, complication rates, length of stay, and stone-free rates.


In August 2021, the researchers identified eight trials that involved 1,201 patients (TXA, n=598; placebo, n=603). They considered only randomized, controlled trials published in English or Spanish.

TXA Superior to Placebo

The meta-analysis determined intraoperative use of TXA was superior to placebo for:

  • Operative time—Mean difference between groups, −11.51 minutes, favoring TXA (P=0.00001)
  • Change in hemoglobin from preoperatively to 24–48 hours postoperatively—Mean difference between groups, −0.87 g/dL, favoring TXA (P<0.00001)
  • Transfusion—3.8% of patients with TXA vs. 11.4% with placebo (OR, 0.31; P<0.0001)
  • Minor postoperative complications—31% vs. 41% (OR, 0.59; P=0.005)
  • Major postoperative complications—4.5% vs. 13% (OR, 0.31; P=0.0001)
  • Length of stay—Mean difference between groups, −0.74 days, favoring TXA (P=0.0001)
  • Stone-free rate—78% vs. 73% (OR, 1.78; P=0.003)

TXA Comparable to Placebo

The incidence of thrombotic complications in the TXA group was 0.5%. There was one case of deep vein thrombosis and one case of pulmonary embolism, both in the same report. Its authors thought these complications were more likely attributable to patient risk factors for thrombosis undisclosed to investigators prior to enrollment than to TXA.

There were also very low numbers of embolization procedures and urinary blood clot obstructions after PCNL, with no significant differences between the TXA and placebo groups.

Continued Scrutiny Needed

Even minor intraoperative bleeding may impair the nephroscope's visual field, which may explain why stone-free rates and operative time were better with TXA. Decreased bleeding may also be related to decreased operative time.

While these findings support the adoption of TXA for PCNL, more research is needed to define its role in the procedure. Unknowns include which patients are appropriate candidates for this additional intervention, how TXA interacts with other medications, and how the dose may need to be adjusted in patients with comorbidities.

greater odds, vs. placebo, of becoming stone-free when tranexamic acid was used during percutaneous nephrolithotomy

lower odds, vs. placebo, of major complications when tranexamic acid was used during percutaneous nephrolithotomy

incidence of thrombotic complications when tranexamic acid was used during percutaneous nephrolithotomy

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