March 2026 JUOP Editorial: Highlights from the 2026 EAU in London—Part I—Prostate Cancer

For this month and likely two to follow, Professor Rocco from Italy worked with several colleagues from the Italian Society of Urology to give some useful updates on their annual 2026 meeting, staring with prostate cancer. Prostate Cancer Prostate cancer remained one of the congress's clearest examples of how the field is shifting from broad treatment algorithms toward more selective, risk-adapted decision making. Across screening, imaging, oligometastatic disease, and systemic therapy, the recurring theme was not simply escalation but better discrimination of who is most likely to benefit from a given intervention. IMPACT OF 68GaGa-PSMA-11 PET/CT IN THE DIAGNOSIS OF PROSTATE CANCER IN MEN WITH EQUIVOCAL OR NON-SUSPICIOUS FINDINGS ON MULTI-PARAMETRIC MRI (PRIMARY2): A MULTI-CENTRE, PHASE III, RANDOMISED TRIAL Dr. James Buteau presented PRIMARY2 at EAU26 as one of the most practice-relevant studies in prostate cancer diagnostics. The trial tackled a common and difficult scenario: biopsy-naïve men with persistent clinical suspicion of prostate cancer, despite negative or equivocal mpMRI findings. The key message was clear: PSMA PET/CT nearly halved the number of men undergoing biopsy, with 49% biopsy avoidance in the experimental arm. This was achieved without an important reduction in the detection of clinically significant prostate cancer, while substantially lowering the diagnosis of clinically insignificant disease. Clinically significant cancer was detected in 12% of men in the PSMA arm vs 16% in the control group, whereas insignificant cancer fell from 32% to 14%. Beyond efficacy, the study underscored the value of the standardized PRIMARY score, which showed high reproducibility between readers. At the same time, the discussion was appropriately cautious, raising questions about the clinical acceptability of the noninferiority margin, the low event rate in this population, and the costs of introducing PSMA PET/CT into an already MRI-based diagnostic pathway. Overall, PRIMARY2 suggests that PSMA PET/CT may help refine biopsy selection and reduce overdiagnosis, although implementation will ultimately depend on cost-effectiveness and access to imaging resources. Gothenburg 1: A Randomized Population-Based Prostate Cancer Screening Study with a 30 Years of Follow-Up At the Game Changer session, Prof. Jonas Hugosson presented the Gothenburg 1 trial, a major prostate cancer screening program with 30 years of follow-up. Since December 1994, 20,000 men aged 50 to 64 years have been randomized either to biennial PSA screening or to usual opportunistic PSA testing. If PSA was ≥ 3 ng/mL, patients underwent systematic biopsy. The results showed a benefit in terms of prostate cancer mortality: the absolute reduction in mortality increased from 0.33% at 15 years to 0.61% at 30 years; the number needed to invite decreased from 311 at 15 years to 161 at 30 years; and the number needed to diagnose decreased from 13 to 6 over the same period. Of particular interest is the number needed to diagnose, as it is comparable with that reported in breast cancer, although a longer follow-up is required to reach this threshold. However, the historical PSA-to-systematic-biopsy pathway came at the cost of excess detection and overdiagnosis. Prof. Hugosson's take-home message is therefore not a return to PSA-only screening, but rather a stronger rationale for organized, risk-adapted screening strategies that integrate MRI and more selective biopsy pathways. PRAISE-U The PRAISE-U session, chaired by Prof. Peter Albers, Dr. Erik Briers, and Prof. Hein Van Poppel, featured presentations from Dr. Katharina Beyer and Prof. Monique Roobol and offered one of the clearest views of how prostate cancer screening is moving from theory to implementation across Europe. What stood out was the pragmatic nature of the proposed pathway. Screening was presented not as a simple PSA-based cascade, but as a layered strategy combining PSA testing, local risk calculators or PSA density, selective MRI, additional triage of equivocal PI-RADS 3 lesions, and biopsy only when justified. Early pilot data suggest that this model can substantially reduce referrals for MRI and biopsy, while maintaining good compliance among those who participate. At the same time, participation rates varied considerably across pilot sites, underlining that implementation depends as much on invitation strategy, organization, public awareness, and local healthcare infrastructure as on the diagnostic algorithm itself. A particularly important message was that a fully uniform European screening protocol is unlikely to be feasible. Instead, the field seems to be converging on a shared risk-based philosophy with necessary national and regional adaptations. Overall, the session conveyed cautious optimism: Prostate cancer screening in Europe is no longer primarily an efficacy question, but an implementation, quality assurance, and sustainability challenge. The real progress shown at EAU26 was that this challenge is now being addressed in a structured and collaborative way. Management of Oligometastatic Prostate Cancer Presentations from Dr. Renu Eapen and Prof. Amar U. Kishan made clear that the field has moved beyond the reassuring simplicity of lesion counting and into a more complex phase in which imaging, biology, and treatment intent must be interpreted together. Across the session, oligometastatic prostate cancer emerged not as a fixed entity, but as a heterogeneous clinical state that may reflect either truly limited metastatic potential or an early manifestation of systemic disease. What stood out was the central role of disease definition. Oligometastatic prostate cancer was repeatedly presented as a condition shaped not only by tumor biology but also by the sensitivity of the imaging used to detect it. In this context, PSMA PET/CT appeared less as a technical refinement than as a tool capable of fundamentally altering staging and management, reclassifying patients initially considered oligometastatic on conventional imaging. At the same time, early biological data suggest that some oligometastatic phenotypes may indeed represent a more attenuated prometastatic state, raising the possibility of more rational integration of systemic and local therapies. A particularly important message was that treatment decisions remain more complex than the label itself suggests. Radiotherapy to the primary currently appears to have the most solid evidence base, surgery may be considered in selected patients, and metastasis-directed therapy remains promising but insufficient as a substitute for systemic treatment. Overall, the session conveyed cautious realism: oligometastatic prostate cancer is not a single therapeutic category, but a disease state that demands better biological stratification, modern imaging, and careful patient selection. The real progress shown at EAU26 was that the field now seems more willing to embrace this complexity rather than oversimplify it. News in the mHSPC Setting, PARP Inhibitors, and More Prof. Karim Fizazi's mHSPC update highlighted how the discussion is moving beyond a one-size-fits-all intensification strategy toward a more selective model driven by timing of metastatic presentation, patient age, molecular features, and depth of response. The session focused less on whether combination treatment works, which is already well established, and more on how emerging data may refine who should receive which combination. The most relevant advances presented at EAU26 concerned the progressive shift from volume-based to biology-informed treatment selection. Emerging data suggested that age may influence ARPI choice, with signals raising caution around abiraterone in men older than 75 years, whereas biomarker-driven intensification is becoming increasingly plausible. In particular, PARP inhibitors appear likely to move earlier in the disease course for BRCA-altered mCSPC, while PTEN-deficient disease may open the way to AKT inhibition strategies. PSMA-targeted radioligand therapy also remains an important area of development, although its exact role in mHSPC is still being defined. Taken together, these data suggest that the next major step in mHSPC will not simply be further intensification but better selection of who should be intensified, with what, and for how long. The most important update from EAU26 was therefore not just the arrival of new agents, but the emergence of a more refined framework in which de novo and metachronous disease should not be managed as biologically equivalent states, and treatment decisions may increasingly be guided by age, molecular features, and early treatment response rather than metastatic burden alone. When to Use ctDNA in Prostate Cancer? Dr. Alexander Wyatt presented ctDNA not as a future concept, but as a test that is starting to find a real place in prostate cancer care. Across the session, the main message was that ctDNA already seems useful in selected clinical situations, particularly when tumor burden is high enough to make plasma genotyping informative, but that its value still depends heavily on timing, assay context, and careful interpretation. What stood out was the difference between being able to detect ctDNA and being able to use it correctly. Speakers showed that ctDNA can match tumor tissue quite well for important genomic alterations, particularly in active metastatic disease, making it a practical option when tissue is unavailable or inadequate. At the same time, the limitations were made equally clear: false-negative results may occur when ctDNA levels are low, copy-number losses may be missed by current assays, and false positives can arise from clonal hematopoiesis if testing is not interpreted carefully. In practical terms, ctDNA appears most informative when tumor burden is higher, especially at disease progression rather than during a strong treatment response. Another key message was that ctDNA may become useful not only for genotyping but also for monitoring disease over time. Early drops in ctDNA after treatment initiation were presented as a possible sign of response, while rising ctDNA levels and the emergence of BRCA2 reversion mutations may help explain resistance during PARP inhibitor treatment. Overall, the session conveyed cautious optimism. The real advance highlighted at EAU26 was that ctDNA in prostate cancer is beginning to move from promise to practice, with the clearest role currently in selected patients, at selected time points, and for specific clinical questions. Overall, the prostate cancer program at EAU26 pointed in a clear direction: the field is becoming more selective, more imaging-informed, and more biologically driven. Across screening, oligometastatic disease, mHSPC, and ctDNA, the common message was not simply to do more, but to choose better, identifying which patients truly need escalation, which diagnostic steps add real value, and where modern biomarkers and molecular imaging can meaningfully refine care (Figures 1-5).Figure 1.: People: The 2026 EAU featured a Prostate Cancer Run for fundraising and early morning fun and exercise.Figure 2.: People. The 2026 EAU Friendship dinner emphasize recognition for hard work and international relations.Figure 3.: People: Professor Rocco presents on challenges in salvage prostatectomy.Figure 4.: Places: The iconic scenes from a London meeting venue. (A) Tower Bridge at Sunset/Blue hour cover pic. (B) The iconic buses and taxis. (C) The Tower of London with a little sunshine and rainbow.Figure 5.: Things: EAU participants viewing multiple surgeries with headphones to choose which narration and discussion.March JUOP Articles First off, in March 2026, we posted the JUOP top reviewers for 2025,1 and we thank the many reviews from the board and ad hoc reviewers who took the time and expertise. How do we find reviewers? Every way possible, including personal networks, AUA author/reviewer databases, department web listings, and even Chat GPT. At times, we are short on reviewers and a paper has been in cycle for a while, and I usually then write to the board email list with a “rescue review” request, asking for members to step up and review with quick turnaround. This has worked well also, and I appreciate the team efforts. A few follow-up questions of interest you may have: 1) Do author suggested reviewers help? 2) are author suggestions for reviewers not to invite honored? and 3) are additional reviewer suggestions given by initial reviewer invitees (usually in the circumstance of them declining to review) helpful? The answer to all 3, at least for this journal and likely others, is yes. We may not use all author suggested reviewers but likely some and it helps if they are described as experts in the field with no specific connection (i.e., former trainee or mentee) to the authors. It may help if you let the suggested reviewers know and see if they would agree to review—you may be surprised how often suggested reviewers decline. If authors object to a reviewer (s) we likely honor that—might have some curiosity as to the potential conflict but realize there can be competing interests. Finally, it is extremely helpful for reviewers to suggest new experts to review when they are not available. Health Services Research In a study using the National Cancer Database, Puente et al2 looked at utilization pattern of robot-assisted partial nephrectomy. With over 120 thousand patients, they several racial and ethnic differences across cT1-cT2 stages and rates of radical vs partial nephrectomy and with robotic assisted techniques. The authors discuss related issues in access to technologies and barriers to modern care. As with many health disparities research, the results are clear but causality more difficult to explain. Editorials from Bhattu and Lierz/Singer3,4 explore these topics further. Retrospective Study Yusim et al5 performed a single institution study aimed to add more MRI data to MRI-targeted biopsy risk classifications. With a primary end point of adverse pathology after radical prostatectomy, they found that 2 parameters that were predictive in univariate and multivariate analyses—the number of cancer-involved regions (> 3), and maximum cancer core length (> 10 mm). This model required prebiopsy MRI and targeting when appropriate so may not apply to systemic only biopsies with postbiopsy MRI staging (still happens in practice despite clear evidence in favor or prebiopsy MRI). Triaging grade group 2 between treatment and surveillance has become the highest volume activity in my clinic and these studies can aid in making such distinctions. It is a small study, and our board member has additional editorial comments.6 People, Places, and Things Figures 1-5 show scenes from the London venue of the 2026 annual meeting of the European Association of Urology.