April 2026 JUOP Editorial: Highlights from the 2026 EAU in London—Part 2

For this month's feature, we continue the excellent review comments from the group from the Italian Society of Urology, led by Bernandro Rocco. Renal Cell Carcinoma Renal cell carcinoma updates centered on 2 themes that are increasingly shaping kidney cancer care: better selection of patients for perioperative intensification and more refined noninvasive characterization of renal masses. The session suggested a field that is not changing its foundations overnight but is beginning to add clinically meaningful layers of precision. LITESPARK-022: Adjuvant pembrolizumab plus belzutifan for clear cell renal cell carcinoma (ccRCC): primary and exploratory efficacy outcomes from the phase 3 study At the EAU26 Game Changer session, Prof. Thomas Powles presented the phase 3 LITESPARK-022 trial in patients with clear cell RCC at increased risk of recurrence after surgery. A total of 1841 patients were enrolled and randomly assigned, after nephrectomy, to pembrolizumab plus belzutifan or pembrolizumab plus placebo in a double-blind design. Belzutifan, a HIF-2α inhibitor, combined with pembrolizumab significantly improved disease-free survival, with a 28% reduction in the risk of recurrence or death (HR 0.72, 95% CI 0.59-0.87; P = .0003). The benefit was consistent across the studied subgroups, including patients with sarcomatoid features. Distant metastasis-free survival, one of the exploratory end points, was 81.6% vs 75.1% at 24 months in the combination and control arms, respectively. This efficacy came at the cost of increased toxicity, with grade ≥ 3 treatment-emergent adverse events occurring in 52.1% of patients receiving the combination vs 30.2% with pembrolizumab alone, including anemia, hypoxia, and elevated hepatic enzymes. Overall, LITESPARK-022 positioned pembrolizumab plus belzutifan as a potentially practice-changing adjuvant strategy in selected high-risk ccRCC patients. First-In-Human Phase I Evaluation of [68Ga]Ga-OncoCAIX PET/CT in Clear Cell Renal Cell Carcinoma: Preliminary Diagnostic Performance, Safety, and Biodistribution Renal imaging also featured prominently. Dr. Fabrizia Gelardi presented a first-in-human, prospective, multicenter phase I study evaluating [68Ga]Ga-OncoCAIX PET/CT in patients with suspected clear cell renal cell carcinoma. The aim was to assess the safety, biodistribution, and preliminary diagnostic performance of this CAIX-targeting radiotracer. A total of 20 adults with suspected ccRCC on conventional imaging, ECOG performance status ≤ 1, and no active concomitant disease were enrolled. No treatment-related adverse events were observed, supporting the tolerability of this novel tracer. From an imaging standpoint, CAIX PET/CT demonstrated rapid and selective tumor uptake together with fast clearance from healthy organs, including the kidneys, a feature that may enhance its utility in the noninvasive characterization of renal masses. Histopathological confirmation was available for 5 patients, and all 5 showed concordance with the PET findings: 1 PET-positive ccRCC, 3 PET-negative oncocytomas, and 1 PET-negative chromophobe RCC. Although the true diagnostic accuracy of the tracer remains to be established, these early findings identify [68Ga]Ga-OncoCAIX as a promising diagnostic tool and suggest that, if confirmed in larger series, this approach could refine the work-up of indeterminate renal lesions. Managing Advanced Disease in Renal Cancer Another theme that stood out in the RCC program was how to manage the primary tumor in patients who already have metastatic disease. The plenary session on managing advanced renal cancer underscored that this question is becoming more clinically relevant as modern combination therapy extends survival and, in some patients, produces meaningful responses in the kidney primary. Rather than supporting a single local strategy, the discussion framed management of the intact primary as a dynamic decision that may need to be revisited over the course of treatment. What emerged most clearly was the breadth of local options now entering the conversation. Surveillance, radiotherapy, ablation, and surgery were all discussed as possible components of care to be weighed in a multidisciplinary setting according to symptoms, metastatic burden, response to systemic therapy, technical feasibility, and overall patient goals. In that sense, the message from EAU26 was less about replacing one standard with another and more about recognizing that advanced RCC increasingly requires adaptive decision making. As outcomes improve with systemic therapy, local treatment of the primary tumor is becoming a more relevant part of personalized care in selected patients. Overall, the RCC highlights from EAU26 suggested a field that is refining rather than reinventing care. In high-risk clear cell disease, perioperative treatment is expanding beyond pembrolizumab alone; in diagnostics, molecular imaging is beginning to sharpen the characterization of indeterminate renal masses; and in advanced disease, the role of local treatment of the primary tumor is being reconsidered within a more multidisciplinary and patient-centered framework. Together, these developments point toward a more personalized model of kidney cancer care, in which systemic therapy, imaging, surgery, and local control strategies are integrated more deliberately over time. Urothelial Carcinoma During the EAU26 Congress, it became clear that the management of urothelial carcinoma is evolving towards a more stratified, risk-adapted approach across all stages of disease. The overarching concept is the optimization of treatment in both quantitative and qualitative terms: while treatment deintensification is being pursued in low-risk non–muscle-invasive disease, intensification—particularly in the perioperative setting—is being proposed for muscle-invasive disease. NMIBC: Intensification in High-Risk Disease vs Deintensification in Low-Risk Disease The session dedicated to NMIBC clearly highlighted a dual strategic direction: intensification for high-risk patients and deintensification for selected low-risk cases. The discussion opened with Professor Evanguelos Xylinas, who presented data from the randomized CREST, ALBAN, and POTOMAC trials, underscoring that therapeutic intensification strategies with immunotherapy have shown a significant benefit in event-free survival (EFS) and disease-free survival (DFS) in BCG-naïve patients with high-risk NMIBC. However, he also highlighted several important unresolved issues: Immune-related toxicity. The need for careful patient selection. An as yet unclear role in very-high-risk patients. Dr Roberto Contieri emphasized that deintensification is already a clinical reality, capable of ensuring excellent long-term oncological outcomes, although it is not yet widely or standardly implemented. At present, the main available treatment strategies include: Office-based electrofulguration or laser ablation of selected lesions. Active surveillance. Chemoablation in recurrent low-grade Ta disease. One of the most relevant discussions focused on the growing awareness of overtreatment risk during the follow-up of low-risk and intermediate-risk NMIBC. Limited Oncological Burden Although Ta low-grade tumors have a high propensity for recurrence, they retain a very low risk of progression and therefore negligible cancer-specific mortality. In addition, urologists are able to identify low-grade recurrences with a clinical accuracy of approximately 85%, even in the absence of urinary cytology. Limitations of TURBT Up to 20% of small lesions identified during follow-up may be benign, and TURBT, although endoscopic, is not free from risk, with approximately 5.1% 30-day complications, particularly anesthetic and infectious complications in elderly, multimorbid, and frail patients. Economic Burden of NMIBC. The healthcare-related economic burden of NMIBC remains a well-recognized issue. Urinary Biomarkers—DaBlaCa-15 Already awarded among the best oncology abstracts of the congress in 2025, the randomized DaBlaCa-15 trial showed that, in a selected subgroup of patients with high-grade NMIBC, the use of urinary biomarkers during follow-up may provide clinical safety comparable with cystoscopy, while significantly reducing the number of cystoscopic procedures. Summary Deintensification appears feasible in selected patients with NMIBC, while also highlighting the current limitations of urinary biomarkers in low-grade disease and the need for further validation studies to demonstrate true patient benefit. Cystoscopy cannot be indiscriminately replaced, but management may become increasingly tailored and rational. BCG-Unresponsive NMIBC: Bladder-Sparing Strategies vs Radical Cystectomy The debate between radical cystectomy and bladder-sparing strategies placed patient perception and decision-making complexity at the center of discussion. In the setting of high-risk BCG-unresponsive disease, the congress reinforced a key principle: Gold standard: radical cystectomy remains the treatment of reference, supported by strong evidence in the EAU Guidelines. Bladder-sparing strategies: these options are expanding, but they are supported by weaker evidence and remain reserved for selected patients. The CISTO study showed that, at 12 months, overall quality of life—including anxiety, depression, and financial well-being—was better in patients undergoing radical cystectomy than in those managed with conservative strategies, contrary to the widespread assumption that bladder preservation necessarily translates into better quality of life. According to Dr Sarah Psutka, the therapeutic armamentarium available in 2026 is rapidly expanding, but still characterized by major uncertainties: The optimal number of cycles of bladder-sparing therapy (BST) required to balance oncological control with bladder function preservation. The lack of biomarkers to guide patient selection, treatment sequencing, and treatment intensification or deintensification, particularly with respect to their applicability in real-world practice. Patient-Centered Care In decision making, the patient's central role clearly emerged, together with the need for clinicians to assess treatment burden, costs, and the real impact on quality of life. Summary Organ preservation does not necessarily equate to better quality of life, and radical cystectomy remains the gold standard in BCG-unresponsive NMIBC. Therapeutic decisions must become increasingly shared and individualized, aligning clinical goals with patient priorities. MIBC: Bladder-Sparing Strategies and Perioperative Intensification Bladder preservation after neoadjuvant therapy was one of the most debated topics of the congress, although radical cystectomy continues to represent the main treatment strategy at present. Multimodal Bladder-Sparing Approach This strategy relies on integration of clinical assessment, imaging, and biomarkers such as ctDNA and utDNA to identify pathological complete response (pCR) and select suitable candidates. Current Limitations Standardized and validated criteria for safely selecting patients are still lacking. In this context, bladder preservation emerges as a promising but complex strategy. Jeremy Teoh proposed a structured approach based on 4 fundamental pillars: Multiparametric Assessment Pretreatment and post-treatment MRI. Maximal TURBT/ERBT. Biomarkers including PD-L1, DDR/RB1, and ctDNA. Patient Selection Ideal candidates: pCR/pT0/minimal residual disease. Significant residual disease: neoadjuvant therapy followed by cystectomy. Therapeutic Strategy Radiotherapy vs systemic treatment. Immunotherapy or antibody–drug conjugates (ADCs). Definition of treatment duration. Intensive Follow-Up Cystoscopy. Imaging. Longitudinal ctDNA monitoring. In MIBC, EAU26 marked a major evolution towards more aggressive perioperative strategies aimed at achieving high pCR rates. Limits of Response Prediction Alexandre Zlotta emphasized that the NIAGARA trial demonstrated increased pCR rates with the addition of durvalumab to neoadjuvant cisplatin–gemcitabine chemotherapy. Enfortumab Vedotin (EV) plus Pembrolizumab KEYNOTE-905/EV-303: in cisplatin-ineligible patients or those refusing cisplatin, pCR was 57.1% vs 8.6% in the control arm, with an associated overall survival benefit. KEYNOTE-B15: in cisplatin-fit patients, pCR was 55.8% vs 32.5% with standard chemotherapy. Summary Intensification of perioperative treatment, associated with an increased proportion of complete responders, is defining a new phase in MIBC management. Bladder sparing is a promising strategy for the future, but at present, it should remain confined to experimental settings or highly specialized centers. Dynamic Biomarkers: The Emerging Role of ctDNA Biomarkers may represent a major frontier in urothelial cancer management, reopening and expanding several previous investigative pathways. Presurgical Setting Risk stratification: precystectomy ctDNA correlates with risk of recurrence, meaning that ctDNA burden may serve as a prognostic biomarker and as an indicator for treatment intensification. A ctDNA volume-related approach was proposed: High ctDNA → possible treatment intensification. Negative ctDNA → favorable biological profile. Postneoadjuvant setting: Management is increasingly moving toward biomarker-guided, response-adapted strategies. According to Alexandre Zlotta, ctDNA may play a role in: Early identification of residual disease. Guidance of therapeutic decisions. Support for dynamic and personalized strategies. A possible stratification model was outlined: Clinical CR + VI-RADS <1 + negative ctDNA/utDNA → possible observation. Clinical CR + VI-RADS 2 → radiotherapy. No clinical CR → radiotherapy or cystectomy. Positive ctDNA → systemic therapy. Summary ctDNA is evolving from an exploratory biomarker into a concrete clinical decision-making tool. First-Line Treatment of Advanced/Metastatic Urothelial Disease The congress established a major change in the first-line treatment of advanced/metastatic urothelial carcinoma with enfortumab vedotin plus pembrolizumab. Prof. Thomas Powles, in the context of the EV-302 trial, presented the concept of going “beyond platinum.” Overall survival: 33.8 months with EV plus pembrolizumab vs 15.9 months with platinum-based chemotherapy. EV plus pembrolizumab has therefore become the new absolute first-line standard in advanced/metastatic urothelial disease. Nevertheless, a critical perspective is still needed regarding toxicity management, treatment duration, and clearly defined protocols for subsequent lines of therapy. Real-World Data (UNITE Study) Despite the benefits observed with this new first-line therapy in 387 treated patients—response rates approaching 57.2%, median progression-free survival of 12.2 months, and median overall survival of 22.8 months—13.4% of patients still experienced early progression. Negative Prognostic Factors ECOG performance status ≥ 2. Anemia. Elevated neutrophil-to-lymphocyte ratio (NLR). Presence of variant histology. Summary The role of EV plus pembrolizumab as first-line treatment in advanced/metastatic urothelial carcinoma is not in question given its compelling results. What still needs to be strengthened is treatment optimization in patients with a biologically aggressive disease phenotype. UTUC: Toward New Biological Targets and Personalized Therapies In upper tract urothelial carcinoma, EAU26 brought the following developments into focus: Impact UTUC Project An international Delphi consensus aimed at reducing management heterogeneity in a disease still characterized by limited level I evidence. New Adjuvant Therapeutic Strategies in HER2-Expressing UTUC Preliminary data on disitamab vedotin plus tislelizumab as adjuvant treatment after radical surgery showed encouraging 12-month disease-free survival compared with standard platinum-based chemotherapy. Summary Targeted therapies and new treatment strategies are also gaining ground in upper tract urothelial carcinoma, driven by the need to move beyond current treatment stratification models and improve heterogeneous clinical outcomes. Conclusions: Personalization as the New Paradigm EAU26 made it clear that the management of urothelial carcinoma is entering a new era based on 3 pillars: Deintensification in low-risk patients to avoid overtreatment. Intensification and innovation in high-risk patients to improve clinical efficacy and disease targeting. Tailored medicine applied across the entire urothelial disease pathway. More specifically: NMIBC: moving toward more selective surveillance. BCG-unresponsive disease: radical cystectomy remains the gold standard. MIBC: evolution of perioperative strategies, without omission of subsequent surgery. Advanced urothelial disease: EV plus pembrolizumab is the new first-line standard of care. The future of urothelial carcinoma will increasingly move toward precision medicine, capable of adapting treatment intensity and sequencing to the biological profile of the individual patient. April 2026 JUOP New Articles Review Choudhary et al1 performed a narrative review of the most common urinary diversions with a focus on strategies to reduce gut-related complications, including some future concepts in tissue engineering. Divya Ajay2 provides a nice editorial comment and continuation of the discussion. Clinical Trials Haney-Aubert et al3 performed a pilot study to build and artificial intelligence (AI) program to analyze microultrasound prostate images. They trained with 100 cancer and 100 image sets and describe a combination of expert reader, novice reader, and AI training pathways to improve training. The article shows promise for future study and is well illustrated and with a summary video on our website. Retrospective Study Palencia et al4 performed a retrospective, single institution study on dorsal venous complex control methods during robotic prostatectomy. The bulk of the series had a stapled technique (224) and a smaller cohort oversewn (43). With multiple surgeons involved, the main metrics in positive surgical margins and outcomes were not statistically different. The authors present cost and OR time differences surgeons can review to determine if they want to consider any technique changes. There are other studies feasible in this space as “hood” and “retzius sparing” approaches will carry the dissection mostly under the dorsal vein and only require a short oversew post resection. People, Places, Things Figures 1-6 continue our theme of London Highlights, host of the 2026 EAU Congress.Figure 1.: Soaring gothic arches and vaulting inside Westminster Abbey.Figure 2.: The high alter of Westminster Abbey with choir stalls and stained glass.Figure 3.: The dramatic view down the nave of Westminster Abbye, with gilded details and candlelight.Figure 4.: Big Ben at night with the long-exposure streaks from cars and double decker buses.Figure 5.: Around the town—The Churchill Arms in Kensington—a traditional pub for after the meeting.Figure 6.: For a day trip…Stonehenge beneath the overcast sky. Amazing to think of a preserved structure from over 2000 years BC.