Benign prostatic hyperplasia (BPH) affects up to 80% of men over 70 and commonly requires surgical management via transurethral resection of the prostate (TURP), the gold-standard intervention. While advances in surgical techniques have improved safety, peri-operative bleeding remains a frequent complication, increasing risks such as transfusion, prolonged hospital stay, and TUR syndrome. Tranexamic acid (TXA), an antifibrinolytic agent, has shown efficacy in reducing surgical bleeding across various specialties. Topical TXA, administered through irrigation fluid during TURP, may offer localized hemostatic benefit with minimal systemic absorption. This systematic review assesses the effectiveness and safety of topical TXA in TURP on outcomes including blood loss, transfusion requirement, irrigation fluid usage, operative time, length of stay (LOS), and complications.

This review was conducted per PRISMA guidelines. A comprehensive literature search of Ovid Medline, Embase, and PubMed was performed in September 2024 to identify RCTs involving topical TXA in TURP. Studies using only IV or oral TXA, non-TURP procedures, or non-English publications were excluded. Two reviewers independently screened titles, abstracts, and full texts. Data extracted included patient demographics, TXA administration methods, and clinical outcomes. Meta-analyses were conducted where appropriate using a random-effects model.

Five RCTs involving TURP and topical TXA were included. All reported reduced intraoperative blood loss in TXA groups compared to controls, although variations in measurement methods prevented pooling of these data. Meta-analysis of hemoglobin drop demonstrated a statistically significant reduction with topical TXA (WMD -0.455 g/dL; p = 0.017). Irrigation fluid usage was also significantly lower in the TXA group in pooled analysis (WMD -0.111 L; p = 0.002). Meta-analysis of operative time did not show statistical significance (WMD -3.964 minutes; p = 0.270). Length of stay showed no significant difference between groups (WMD -0.354 days; p = 0.391). Transfusion rates were generally lower in TXA groups, but inconsistent reporting and transfusion thresholds precluded pooled analysis. No thromboembolic or major adverse events were reported.

Topical TXA appears to be a safe and effective strategy for reducing intraoperative blood loss and hemoglobin decline during TURP. Its effect on transfusion rates, operative duration, and hospital stay remains inconclusive due to heterogeneity and limited sample sizes. Given the small number of studies and methodological variation, further large-scale trials are needed to determine optimal use and establish standardized protocols. In the interim, topical TXA may be considered on a case-by-case basis, especially in resource-limited settings.