What are the recommendations of the European Association of Urology (EAU) guidelines 2026 for managing urological diseases, such as prostate cancer, bladder cancer, kidney stones, and urinary tract infections?

EAU Guidelines 2026: Key Recommendations for Urological Diseases

The European Association of Urology has released comprehensive updated guidelines through 2025 covering upper urinary tract urothelial carcinoma, muscle-invasive and metastatic bladder cancer, and urological infections, with significant changes in diagnostic approaches, treatment algorithms, and follow-up protocols. Note that "2026 guidelines" are not yet available; the most recent updates are from 2024-2025.

Upper Urinary Tract Urothelial Carcinoma (UTUC) - 2025 Update

Epidemiology and Risk Stratification

• UTUC accounts for 5-10% of all urothelial carcinomas with approximately two cases per 100,000 inhabitants annually in Western countries 1
• Two-thirds of patients present with muscle-invasive disease at diagnosis, compared to only 15-25% in bladder cancer 1
• Approximately 9% present with metastases at initial diagnosis 1
• Tobacco exposure increases the relative risk of developing UTUC by 2.5- to 7.0-fold 1

Lynch Syndrome Screening

• Patients with UTUC diagnosed before age 60, bilateral/multifocal UTUC at diagnosis, or personal history of Lynch-related malignancy should undergo germline DNA sequencing and family counseling 1
• More than 20% of UTUC patients may have suspicion of Lynch-related disease using simplified screening tools 1

Key 2025 Updates

The 2025 guidelines include 1:

• Significant changes to diagnostic recommendations
• Complete revision of risk stratification, ureteroscopy, and surgical approach for radical nephroureterectomy
• Four new recommendations: two for kidney-sparing management of localized low-risk UTUC and two for high-risk non-metastatic UTUC management
• Updated follow-up protocols
• New section on quality indicators for UTUC management

Muscle-Invasive and Metastatic Bladder Cancer (MIBC) - 2025 Update

Novel Targeted Therapies

• Use FGFR3 alteration testing to select patients with unresectable or metastatic urothelial carcinoma for erdafitinib treatment 1
• Administer trastuzumab deruxtecan for metastatic disease with HER2 overexpression 1

Surgical Management

• Perform radical cystectomy with extended lymph node dissection based on SWOG trial results 1
• Sexual organ-preserving techniques in women have been significantly updated 1
• Hospital volume considerations now included in recommendations 1

Adjuvant Therapy

• Offer adjuvant nivolumab to patients with pT3/4 and/or pN+ disease who are not eligible for or declined adjuvant cisplatin-based chemotherapy 1

Trimodality Therapy

• Manage all candidates for trimodality bladder-preserving treatment in a multidisciplinary team using shared decision-making 1
• New recommendations for salvage cystectomy after trimodality therapy 1

Radiotherapy Updates

• Pre- and postoperative radiotherapy recommendations significantly adapted 1

Urological Infections - 2024 Guidelines

Uncomplicated Cystitis in Women

First-line treatments 1:

• Fosfomycin trometamol 3g single dose (1 day) - recommended only in women
• Nitrofurantoin macrocrystals 50-100mg four times daily for 5 days
• Nitrofurantoin monohydrate/macrocrystals 100mg twice daily for 5 days
• Pivmecillinam 400mg three times daily for 3-5 days

Alternative treatments 1:

• Cephalosporins (e.g., cefadroxil) 500mg twice daily for 3 days if local E. coli resistance <20%
• Trimethoprim 200mg twice daily for 5 days (not in first trimester pregnancy)
• Trimethoprim-sulfamethoxazole 160/800mg twice daily for 3 days (not in last trimester pregnancy)

Uncomplicated Cystitis in Men

• Prescribe trimethoprim-sulfamethoxazole 160/800mg twice daily for 7 days 1
• Fluoroquinolones can be used according to local susceptibility testing 1

Recurrent UTI Prevention

Strong recommendations 1:

• Diagnose recurrent UTI via urine culture
• Use vaginal estrogen replacement in postmenopausal women
• Use immunoactive prophylaxis to reduce recurrent UTI in all age groups
• Use methenamine hippurate in women without urinary tract abnormalities
• Use continuous or postcoital antimicrobial prophylaxis when non-antimicrobial interventions fail
• Consider self-administered short-term antimicrobial therapy for patients with good compliance

Weak recommendations 1:

• Do not perform extensive routine workup (cystoscopy, full abdominal ultrasound) in women <40 years with recurrent UTI and no risk factors
• Advise premenopausal women to increase fluid intake
• Advise on local or oral probiotics with proven efficacy strains
• Advise on cranberry products (low quality evidence with contradictory findings)
• Use D-mannose (weak and contradictory evidence)
• Use endovesical instillations of hyaluronic acid or hyaluronic acid/chondroitin sulfate when less invasive approaches fail

Uncomplicated Pyelonephritis

• Perform urinalysis including white/red blood cells and nitrite for routine diagnosis 1
• Obtain urine culture and antimicrobial susceptibility testing in all cases 1
• Perform upper urinary tract ultrasound to rule out obstruction or renal stones in high-risk patients 1

Urosepsis Management

Critical first-hour interventions 2:

• Initiate antimicrobial therapy within the first hour after diagnosis
• Obtain two sets of blood cultures and urine culture before antibiotics
• Perform urgent imaging to identify obstruction or abscess
• Relieve any urinary tract obstruction immediately

First-line empirical IV regimens 2:

• Piperacillin/tazobactam 2.5-4.5g IV every 8 hours
• Ceftriaxone 1-2g IV daily (use 2g for sepsis)
• Cefepime 2g IV every 12 hours
• Ciprofloxacin 400mg IV every 12 hours (only if local resistance <10%)
• Levofloxacin 750mg IV daily (only if local resistance <10%)

Combination therapy 2:

• Add gentamicin 5mg/kg IV daily to cephalosporins for initial empirical therapy in septic patients, then de-escalate to monotherapy after 48-72 hours based on culture results

Reserved agents for multidrug-resistant organisms 2:

• Meropenem 1g IV every 8 hours
• Imipenem/cilastatin 0.5g IV every 8 hours
• Ceftazidime/avibactam 2.5g IV every 8 hours
• Ceftolozane/tazobactam 1.5g IV every 8 hours
• Meropenem-vaborbactam 2g IV every 8 hours
• Plazomicin 15mg/kg IV daily

De-escalation strategy 2:

• Narrow antibiotic therapy to the most specific effective agent within 48-72 hours based on culture and susceptibility results
• Treatment duration of 7-10 days is adequate for most cases with effective source control

Critical pitfalls to avoid 2:

• Do not use fluoroquinolones empirically if local resistance exceeds 10%
• Do not use nitrofurantoin, oral fosfomycin, or pivmecillinam for pyelonephritis or urosepsis
• Do not delay source control; perform imaging immediately if clinical deterioration occurs

Catheter-Associated UTI (CA-UTI)

Strong recommendations 1:

• Treat symptomatic CA-UTI according to complicated UTI recommendations
• Take urine culture before initiating antimicrobial therapy in catheterized patients whose catheter has been removed
• Do not treat catheter-associated asymptomatic bacteriuria in general
• Treat catheter-associated asymptomatic bacteriuria before traumatic urinary tract interventions (e.g., TURP)
• Replace or remove the indwelling catheter before starting antimicrobial therapy
• Do not apply topical antiseptics or antimicrobials to the catheter, urethra, or meatus
• Do not use prophylactic antimicrobials to prevent CA-UTI
• Minimize catheterization duration
• Use hydrophilic coated catheters to reduce CA-UTI

Urethritis

Diagnostic approach 1:

• Perform Gram stain of urethral discharge or urethral smear for preliminary diagnosis of gonococcal urethritis
• Perform validated NAAT on first-void urine sample or urethral smear before empirical treatment to diagnose chlamydial and gonococcal infections
• Delay treatment until NAAT results are available in patients with mild symptoms
• Perform urethral swab culture before treatment in patients with positive NAAT for gonorrhea to assess antimicrobial resistance

Treatment regimens 1:

Gonococcal infection:

• Ceftriaxone 1g IM or IV single dose PLUS azithromycin 1g PO single dose
• Alternative: Cefixime 400mg PO single dose plus azithromycin 1g PO single dose

Chlamydia trachomatis:

• Azithromycin 1.0-1.5g PO single dose OR
• Doxycycline 100mg twice daily PO for 7 days

Mycoplasma genitalium:

• Azithromycin 500mg PO on day 1
• If macrolide resistance: Moxifloxacin 400mg daily for 7-14 days

Trichomonas vaginalis:

• Metronidazole/Tinidazole 2g PO single dose

• Treat sexual partners while maintaining patient confidentiality 1

Bacterial Prostatitis

• Enterobacterales are the primary pathogens in acute bacterial prostatitis 1
• Chronic bacterial prostatitis encompasses a broader spectrum including atypical microorganisms 1
• Use the National Institute of Diabetes, Digestive, and Kidney Diseases classification to distinguish bacterial prostatitis from chronic pelvic pain syndrome 1

Prostate Abscess Management

Drainage approach 3:

• Perform percutaneous drainage under transrectal ultrasound guidance as first-line intervention due to lower complication rates and shorter hospital stays
• Transrectal needle aspiration or small-bore pigtail catheter placement is viable alternative to transurethral drainage

Antimicrobial therapy for E. coli prostate abscess 3:

• First-line: Piperacillin-tazobactam 4.5g every 6-8 hours IV
• For multidrug-resistant E. coli: Ertapenem 1g once daily, Meropenem 1g every 8 hours IV, or Imipenem-cilastatin 1g every 6-8 hours IV

Critical pitfalls 3:

• Do not rely on antibiotics alone; abscesses require drainage for source control
• Do not attempt prostatic massage in suspected abscess as this risks bacteremia and sepsis

Common Pitfalls Across All Urological Infections

• Avoid fluoroquinolones if local resistance exceeds 10% or patient used them in last 6 months 1, 2
• Do not delay source control in complicated infections or urosepsis 2
• Always obtain cultures before initiating antibiotics to guide targeted therapy 1, 2, 3
• Adjust antibiotic dosing in patients with renal impairment 2