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Reducing Bleeding inAquablation: The Role of Tranexamic Acid
Daniel J. Pohl, MD, BA, Shannon McNall, MD, Rachael Gotlieb, MD, Arthur Mourtzinos, MD.
Lahey Clinic, Burlington, MA, USA.
BACKGROUND: Benign prostatic hyperplasia (BPH) commonly causes lower urinary tract symptoms that impair quality of life and surgery remains the standard for patients who fail medical therapy. While transurethral resection of the prostate is the gold standard, newer minimally invasive options, such as Aquablation, have emerged. Aquablation, a robotically controlled waterjet ablation, allows precise, image-guided resection with minimal risk of thermal injury. Despite these advances, perioperative bleeding remains a concern. Tranexamic acid (TXA), an antifibrinolytic agent, has not been well studied in Aquablation. This study aimed to evaluate whether intravenous TXA during Aquablation reduces the risk of clinically significant bleeding.
METHODS: We retrospectively reviewed 108 consecutive patients who underwent Aquablation by a single high-volume surgeon between April 2021 and July 2025. Patients receiving intraoperative intravenous TXA (1-2 g) were compared with those who did not. Pre- and postoperative hematocrits were analyzed, with clinically significant bleeding defined as a hematocrit drop ≥9 points. Patients with incomplete data were excluded. Multivariate analysis controlled for age, prostate size, PSA, medication use (alpha-blockers, 5-alpha reductase inhibitors, anticoagulants, antiplatelets), number of ablation passes, and time to hemostasis.
RESULTS: Overall, 11% (12/108) of patients experienced clinically significant bleeding. With administration of any amount of TXA, the odds ratio of having a clinically significant bleed was 0.15 (95% CI 0.03-0.73, p=0.019). The odds ratio of a clinically significant bleed per gram of TXA was 0.34 (95% CI 0.12-0.93, p=0.035), meaning that each 1g of TXA lowered the odds of a clinically significant bleed by roughly 66%. The use of preoperative anticoagulation or antiplatelet therapy was not independently associated with increased risk of significant bleeding.
CONCLUSIONS: Administration of TXA during Aquablation was associated with reduced odds of clinically significant bleeding. These findings suggest that TXA may represent a simple, cost-effective adjunct to improve the perioperative safety of Aquablation.
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