Intraoperative Tranexamic Acid in Radical Cystectomy: Impact on Bleeding, Thromboembolism, and Survival Outcomes

Purpose: Perioperative blood transfusion has been reported in > 50% of patients undergoing radical cystectomy (RC). Unfortunately, perioperative blood transfusion (PBT) in patients undergoing RC has been associated with poor oncological outcomes. Tranexamic acid (TXA) use has been proposed to decrease the need for PBT. Here, we seek to investigate the impact of intraoperative TXA on the risk of perioperative bleeding and venous thromboembolism (VTE) in patients undergoing RC. We also investigate its long-term impact on overall survival (OS) and cancer-specific survival (CSS) outcomes.

Materials and methods: We queried the prospectively maintained Mayo Clinic Radical Cystectomy registry and identified all RC performed for bladder cancer between 1990 and 2021. Primary outcomes assessed include the risk of perioperative bleeding, the need for blood transfusion, and the risk of VTE. Secondary outcomes include the impact of using TXA on OS and CSS.

Results: Of 2862 patients with complete available data, 468 received TXA (TXA recipient) and were matched 1:1 for age, neoadjuvant chemotherapy, pathologic staging, and preoperative hemoglobin with a group who did not receive TXA (TXA nonrecipient). TXA recipients experienced less estimated blood loss intraoperatively (median of 600 vs 650) cc and were less likely to need PBT (31% vs 50%, P value < .001) compared with TXA nonrecipients. There was no difference between groups in deep venous thrombosis and pulmonary embolism rates within 90 days of RC. In the adjusted survival model, use of TXA was not independently associated with significant impact on OS or CSS. However, perioperative blood transfusion was associated with poor OS and CSS (P value < .001).

Conclusions: TXA use was associated with a significant reduction in estimated blood loss and PBT without increased risk of VTE. In univariable analyses, we observed an association between TXA use and improved OS as well as CSS. However, in multivariable analyses, TXA itself was not independently associated with improved OS or CSS; instead, PBT was. Further studies are warranted to explore strategies for minimizing PBTs and their impact on survival outcomes.