Tranexamic acid for percutaneous nephrolithotomy: an abridged Cochrane review

Brent Cleveland, Brett Norling, Hill Wang, Vardhil Gandhi, Carrie L. Price, Michael Borofsky, Vernon Pais, Philipp Dahm

Research output: Contribution to journalReview articlepeer-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.

Original languageEnglish (US)
Pages (from-to)259-272
Number of pages14
JournalBJU International
Issue number3
StatePublished - Mar 2024

Bibliographical note

Publisher Copyright:
© 2023 The Authors. BJU International published by John Wiley & Sons Ltd on behalf of BJU International.


  • adverse events
  • blood loss
  • percutaneous nephrolithotomy
  • systematic reviews
  • tranexamic acid


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