AUA Lecture: 2025 Update of AUA and EAU NMIBC Guidelines

Jacob See-Tong PangTaiwan Moderator

Stephen A. BoorjianUnited States Speaker AUA Lecture: 2025 Update of AUA and EAU NMIBC GuidelinesBoth the American Urological Association (AUA) and European Association of Urology (EAU) have developed guidelines for the management of non-muscle invasive bladder cancer (NMIBC). While subtle differences in several aspects of these guidelines exist which merit mentioning, both guidelines emphasis the concept of risk stratification. In particular, understanding the criteria which classifies patients with NMIBC as high risk avoids undertreatment of the patients most likely to experience disease progress. Likewise, recognizing the indications for cystectomy among high risk NMIBC patients is critical to optimize survival. Meanwhile, continued options emerge for patients classified as having BCG unresponsive NMIBC, such that knowledge of that definition as well as current management strategies for these patients facilitates contemporary practice.From Bench to Bedside - A Comprehensive Overview of Kidney CancerEvaluation of patients with a newly identified renal mass includes dedicated cross-sectional imaging for appropriate characterization. Genetic syndromes which include renal cell carcinoma (RCC) are increasingly understood, and indeed knowledge of the intracellular pathways of these conditions has facilitate rationale drug development for kidney cancer. Managing patients with a small renal mass involves a critical assessment of competing risks inherent to the tumor, the patient (underlying comorbidity status), and the proposed treatment. Renal mass biopsy may play a role in select cases for additional information/risk stratification. The safety of active surveillance is being increasingly demonstrated as longer-term follow-up matures. Meanwhile, select patients with high risk disease now have the option of adjuvant immunotherapy following surgical resection. In the setting of metastatic RCC, again risk stratification plays a critical role in the decision for – and timing of – cytoreductive nephrectomy, particularly in the contemporary era of checkpoint inhibitor therapies.Real World Experience in the Management of Upper Tract Urothelial CarcinomaThe biggest challenging in managing upper tract urothelial carcionma (UTUC) remains accurate staging of tumors at diagnosis. Given the limited ability of contemporary staging methods, clinical risk stratification models have been developed to assist in providing risk-based treatment recommendations. For example, endoscopic management (e.g., ablation) represents the recommended first line approach for patients with low risk disease. Importantly, follow-up for these patients should include endoscopic re-evaluation. The value of testing patients with UTUC for Lynch syndrome is also critical to recognize. A role for neoadjuvant chemotherapy is being increasing explored for patients classified with high-risk UTUC, while several options exist for adjuvant chemotherapy and immunotherapy for patients with adverse pathology at surgical resection. Continued investigation into prevention of postoperative intravesical recurrences in patients with UTUC is warranted given the frequency of metachronous tumor development in the bladder among these patients.Updates on MIBC and Advanced Bladder Cancer: Where do We Stand in 2025While neoadjuvant chemotherapy prior to radical cystectomy has been demonstrated with randomized trial data to improve survival for patients undergoing radical cystectomy, nevertheless utilization is often restricted by misunderstandings regarding patient eligibility factors. As such, defining eligibility criteria will facilitate increased adoption. Likewise, new data indicates a role for adjust immunotherapy in select patients following surgery as well. Moreover, important recent evidence on the role of extended lymph node dissection and the opportunities for preserving sexual function after cystectomy by modifying surgical technique are critical to review in order to optimize future patient outcomes. Further, recent advancements in systemic therapy options for patients with metastatic urothelial carcinoma have led to unprecedented survival rates.Revisit on Testicular Tumors-What we Learned from past and Prepared for the FutureGerm cell tumor (GCT) progression typically occurs in a predictable sequence of disease spread to the retroperitoneum first and then distant metastases. Understanding the role of serum tumor markers at various disease stages is critical for guideline-concordant management and to optimize patient outcomes, avoiding both undertreatment and overtreatment. For patients with seminoma, retroperitoneal lymph node dissection now represents an option for patients with low volume retroperitoneal lymph node disease, with the goal of avoiding the long-term toxicities associated with chemotherapy and radiotherapy. For patients with residual postchemotherapy masses in seminoma, increasing evidence suggests that PET scans should be utilized/interpreted with caution, and that in the absence of mass growth continued follow-up may be the strategy for most patients. Similarly, for patients with nonseminomatous GCTs (NSGCT) and equivocal retroperitoneal lymph nodes at presentation, re-scanning after an interval of approximately 6-8 weeks may be preferable to initial treatment, as many of these nodes represent benign processes and as such will resolve. Nevertheless, postchemotherapy retroperitoneal lymph node dissection remains a critical component of the management of patients with NSCGT and a residual mass. Risk Stratification and Contemporary Management of Biochemical RecurrenceBiochemical recurrence (BCR) has been reported in up to 35% of patients following radical prostatectomy. Understanding the natural history and clinicopathologic risk factors associated with disease progression is critical to facilitate an individualized treatment approach. Likewise, recognizing the details of treatment delivery with salvage radiotherapy is necessary to optimize outcomes. Further, as data emerge on the utilization of systemic therapy for non-metastatic BCR, being able to contextualize reported outcomes with patient age, comorbidity status, and disease risk will enhance appropriate care delivery.