The MIBC chapter is arguably the most transformed of all the 2026 updates. The main development to be aware of is the arrival of perioperative immunotherapy.
The NIAGARA trial evaluated perioperative durvalumab plus neoadjuvant cisplatin/gemcitabine versus cisplatin/gemcitabine alone in cisplatin-eligible MIBC (cT2–T4a N0/1 M0). Crucially, a creatinine clearance of 40 mL/min or above was permitted. The results showed an EFS hazard ratio of 0.68, an OS hazard ratio of 0.75, and a pathological complete response rate of 37% versus 28%. The regimen received EMA approval in July 2025 and NICE approval in March 2026 (NICE TA1138).
The 2026 guideline now recommends: “Offer perioperative chemo-immunotherapy with cisplatin/gemcitabine and durvalumab to patients with MIBC who are eligible for cisplatin-based chemotherapy (GFR ≥40 mL/min allowed) and immunotherapy.”
Note the GFR threshold — 40 mL/min, not the traditional 60. This broadens eligibility considerably. For exam purposes, it is worth knowing the NIAGARA regimen structure: 4 cycles of neoadjuvant durvalumab plus cisplatin/gemcitabine, then cystectomy, then 8 cycles of adjuvant durvalumab.
In those ineligible for cisplatin-based chemotherapy, the guidance is to offer perioperative enfortumab vedotin plus pembrolizumab.
This important shift is definitely new, relevant exam knowledge that could easily be tested.
The 2026 NMIBC update is a complete rewrite incorporating 64 new studies. The most exam-relevant changes are below.
This is new territory. Sasanlimab plus BCG maintenance (CREST) and durvalumab plus BCG maintenance (POTOMAC) are now available options for selected BCG-naive high and very high-risk patients. Previously, checkpoint inhibitors in NMIBC were confined to BCG-unresponsive disease.
The EAU strong recommendation is to “discuss the benefits and harms of adding sasanlimab and durvalumab to BCG with maintenance in selected BCG-naïve patients with high- and very high-risk NMIBC.” Having an idea about these treatments ahead of the exam is therefore probably worthwhile.
Two new tables (7.3 and 7.4) now map treatment options for BCG-unresponsive papillary Ta/T1 and CIS respectively. These include pembrolizumab, nadofaragene firadenovec, TAR-200 (the gemcitabine-releasing intravesical device, FDA-approved September 2025), gemcitabine/docetaxel, and clinical trials.
Having an awareness of the latest treatments is sensible, though the minutiae are unlikely to be tested. Key concepts such as the distinction between BCG-refractory, BCG-relapsing and BCG-unresponsive disease remain essential knowledge.
Triplet therapy in metastatic hormone-sensitive prostate cancer is now a formal area of the guideline. Candidates should be comfortable with the principle of ADT plus docetaxel plus an androgen receptor pathway inhibitor in selected high-volume or fit patients.
The AMPLITUDE trial introduces the concept of PARP inhibition in hormone-sensitive disease. Niraparib added to abiraterone and ADT improved radiographic progression-free survival in HRR-mutated metastatic hormone-sensitive prostate cancer, particularly BRCA-mutated disease. At present, the important exam point is not “everyone gets a PARP inhibitor” — it is that molecular testing is increasingly relevant earlier in the prostate cancer pathway.
Biochemical recurrence has also become more nuanced. EAU high-risk biochemical recurrence after radical prostatectomy includes a PSA doubling time ≤1 year or pathological ISUP grade group 4–5. However, the EMBARK-based treatment recommendation is narrower.
The guidance offers a strong recommendation that enzalutamide with ADT should be offered to patients with high-risk M0 biochemical recurrence matching EMBARK-type criteria — including a PSA doubling time ≤9 months and appropriate PSA thresholds.
Awareness of both of these trials and the resultant guidance updates is useful.
MET with alpha-blockers is now a strong recommendation for distal ureteric stones 5–10 mm. The contradictory SUSPEND-versus-meta-analysis debate is effectively settled in the guideline wording, though the off-label counselling requirement remains.
The Zeng et al. 2026 RCT (Eur Urol 2026;89:45) showed that flexible URS with a navigable suction ureteral access sheath is non-inferior to mini-PCNL for 2–3 cm renal stones. This is incorporated into the revised URS section.
The suction UAS lowers intrarenal pressure (reducing sepsis risk) and is a plausible exam topic on stone surgery selection.
The 2026 EAU Guidelines have a number of relevant changes that candidates for upcoming FRCS(Urol) or FEBU examinations should be aware of. We have already made changes to reflect this within our questions to stay relevant and ensure candidates are best prepared.
Here's the uncomfortable truth about exam prep in 2026: a paid question bank that was excellent in 2024 may now contain dozens of questions with outdated answers. Guidelines change, technology appraisals publish, and trial data matures. When an updated guideline drops, the candidates who suffer are the ones whose resources haven't been touched since the last annual refresh.
At Urobank, every major guideline release triggers a structured review cycle:
For another example of Urobank staying up to date, read our blog on the NICE NG256 kidney cancer guideline. If you're using Urobank, you don't need to wonder whether your revision reflects the latest evidence — the work is done.
Every relevant question on Urobank is updated to reflect the 2026 EAU Guidelines — so you're never caught out by a guideline change in your FRCS(Urol) or FEBU exam.