The recommendation to use β3 agonists for moderate-to-severe storage LUTS is now strong, up from weak in 2025.1,2
Aquablation also moves from weak to strong. It is recommended as an alternative to TURP for moderate-to-severe LUTS due to benign prostatic obstruction in prostates of 30–80 mL, particularly when preserving ejaculation is a priority.1,2 It is noted that Aquablation is feasible in prostates >80 mL; however, additional RCTs are needed.
Prostatic artery embolisation remains a weak recommendation and is still described as under investigation. Patients should accept less improvement than with TURP, and assessment and follow-up should involve urologists working with trained interventional radiologists.1
The weak recommendation to offer desmopressin for nocturia caused by nocturnal polyuria in men under 65 remains. The separate 2025 recommendation to offer low-dose treatment to men over 65 has been removed.1,2
This does not make age over 65 an absolute contraindication. The guideline still calls for discussion of benefits and risks, particularly in older men. Sodium monitoring remains essential: baseline, day 3, day 7, one month and periodically thereafter, with more frequent checks in patients at higher risk of hyponatraemia.1
In a young man with longstanding LUTS, consider primary bladder neck obstruction (PBNO) and dysfunctional voiding. The new section recommends video-urodynamics, either during initial assessment or after first-line treatment fails. If unavailable, standard urodynamics combined with a voiding cystourethrogram is an alternative; electromyography may also help.1
| Diagnosis | First-line treatment | If symptoms persist despite first-line treatment |
|---|---|---|
| PBNO | α-blocker | Consider bladder neck incision or intermittent catheterisation after counselling |
| Dysfunctional voiding | Behavioural measures with biofeedback | Consider intermittent catheterisation |
These recommendations are weak. For revision, the useful distinction is between treatment directed at the bladder neck and treatment aimed at relaxing the pelvic floor during voiding.1
Favourable and unfavourable intermediate-risk groups were already in the 2025 EAU table. The 2026 change is to the criteria, particularly the use of cT1–2 across the low- and intermediate-risk groups. cT2c alone no longer places a patient in the high-risk group.3,4
| Risk group | 2026 criteria |
|---|---|
| Low | ISUP grade group 1, PSA <10 ng/mL and cT1–2 |
| Favourable intermediate | ISUP 2 with PSA <10 ng/mL, or ISUP 1 with PSA 10–20 ng/mL; cT1–2 |
| Unfavourable intermediate | ISUP 2 with PSA 10–20 ng/mL, or ISUP 3 with PSA ≤20 ng/mL; cT1–2 |
| High, localised | ISUP 4–5 or PSA >20 ng/mL, with cT1–2 |
| Locally advanced | cT3–4 and/or cN+, regardless of PSA or ISUP grade group |
The localised rows assume N0M0 disease. A high-risk feature takes precedence over an intermediate-risk feature. For this classification, clinical T stage is based on DRE, with MRI findings reported separately.3
Low-risk and favourable intermediate-risk disease do not need additional staging imaging (strong). This does not remove the role of prebiopsy prostate MRI.5
For unfavourable intermediate-risk disease, use PSMA PET/CT if available, or at least cross-sectional abdominopelvic imaging and a bone scan (weak). The corresponding recommendation for high-risk and locally advanced disease is strong.5
The transperineal route remains strongly recommended. For 2026, there is a weak recommendation to omit perioperative antibiotic prophylaxis in patients without risk factors for infectious complications.5
Keep the patient selection in mind. This supports omission in lower-risk patients; antibiotics should still be considered in high-risk individuals.
The EAU now lists nitroxoline, alongside fosfomycin trometamol, pivmecillinam and nitrofurantoin, as a first-line treatment for cystitis in women (strong). The listed regimen is 250 mg three times daily for five days.6
This is an EAU recommendation; prescribing in UK practice should follow the relevant local antimicrobial guidance.
First distinguish symptomatic infection from asymptomatic candiduria. Asymptomatic funguria usually does not need antifungal treatment. Exceptions include neutropenia, very low birth weight infants and planned urological procedures that breach the mucosa.6
For localised infection caused by a fluconazole-susceptible organism, the oral regimen is fluconazole 200 mg daily for two weeks. A shorter course may be considered for cystitis without risk factors, although that is a weak recommendation.6
The important qualification for Candida glabrata is susceptibility. The EAU table lists 800 mg daily for susceptible isolates; it should not be prescribed automatically on the basis of the species name. Resistant organisms need an alternative regimen, and renal function also affects dosing.6
The urosepsis section is under review for 2027. The 2026 guideline directs readers to the Surviving Sepsis Campaign guidance in the meantime.6
The new frailty section recommends a validated frailty screen for older patients with a renal mass or RCC, followed by comprehensive geriatric assessment if screening identifies a risk of frailty. Both recommendations are weak.7
The recommendations on alternatives to surgery now distinguish three situations:8
| Clinical situation | EAU recommendation |
|---|---|
| Highly frail, comorbid patient with reduced life expectancy | Offer watchful waiting |
| cT1a tumour without an indication for immediate treatment, where delayed intervention may be appropriate | Offer active surveillance |
| cT1 tumour requiring treatment in a patient unfit for surgery | Offer tumour ablation or stereotactic ablative radiotherapy (SABR) |
All three are weak recommendations. The distinction between watchful waiting and active surveillance is important, as surveillance retains the option of delayed treatment.
After partial nephrectomy, a microscopic positive surgical margin should prompt closer follow-up rather than immediate re-resection or completion radical nephrectomy (weak).8
For follow-up after curative treatment, the guideline continues to recommend the 2003 Leibovich model for clear-cell RCC: 0–2 low risk, 3–5 intermediate and ≥6 high. UISS remains recommended for non-clear-cell follow-up risk assessment. Separately, the prognostic-factors chapter recommends VENUSS for localised and locally advanced papillary RCC.7,9
For FRCS(Urol), read these alongside NICE NG256, as the recommendations differ in places.
The recommended sampling window for fasting total testosterone is now 07:00–10:00, compared with 07:00–11:00 in 2025.10,11
The diagnostic threshold for late-onset hypogonadism remains 12 nmol/L, but diagnosis requires relevant symptoms or signs and consistently low results. A low result should be confirmed with repeat morning testing before treatment. Measure SHBG and calculate free testosterone when indicated; that recommendation was already present in 2025.10,11
For night-shift workers, the guideline advises fasting sampling after adequate sleep, rather than applying the clock times rigidly.10
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Single best answer questions with explanations and guideline references.