EAU 2026 Testicular Cancer Guideline reflects key updates in diagnosis and management

The management of testicular cancer continues to evolve, with advances in diagnostics, risk stratification, and multimodal treatment shaping contemporary clinical practice. At the 41st Annual Congress of the European Association of Urology (EAU), updated testicular cancer guidelines were presented, reflecting the latest evidence and expert consensus across a range of clinical scenarios from early-stage disease to complex metastatic presentations.¹ These updates aim to refine decision-making, optimize patient outcomes, and address emerging technologies that have yet to be fully integrated into routine care.

For this second installment of our interview on the guidelines (you can read part 1 here), Professor Axel Heidenreich, guideline chairman and director of urology at the University Hospital Cologne, in Germany, discusses key updates and areas of continued uncertainty within the guidelines. Topics include the current limitations preventing routine adoption of circulating miRNA-371 as a diagnostic and surveillance tool, evolving recommendations on testicular prosthesis placement, and new guidance on the management of bone metastases using multimodal approaches. He also highlights important considerations in reducing venous thromboembolism (VTE) risk, as well as nuanced clinical decisions best managed in high-volume centers. Together, these insights provide a practical overview of how the latest EAU guidance may influence real-world urologic practice.

Urology Times: The panel stopped short of recommending routine use of miRNA-371. What unresolved issues must be addressed before this becomes a standard part of diagnostic or staging workup?

Heidenreich: One important thing is that miRNA is not standardized in all labs. We have multiple different assays, and we cannot compare the results of these different assays in terms of positivity or negativity. These need to be standardized, and they need to be certified. Then we know we can rely on the results, no matter if they are taken in the US, Germany, Egypt, or wherever.

The other thing is logistics. We use miRNA a lot. Within the past 3 years, we have evaluated more than 3000 patients with miRNA. But the logistics are extremely difficult. miRNA is very unstable, so you have to draw the blood specimen and work it up within 15 minutes to receive reliable, valid results. This is a problem if you work in a private office. If you don't work in a setting like ours, in a university hospital setting where you have specific nurses drawing the blood specimen and specific vectors to transport the blood specimen immediately to your molecular biology lab, you cannot perform miRNA testing because of false negative or false positive results. The next step is [to develop] a new method, at least, to stabilize the blood specimen and then to have more time to analyze it so that every urologist or oncologist could use it.

There are a couple of studies that have used miRNA in patients during follow-up procedures after they have finished their systemic chemotherapy or their orchiectomy. In a large study, we didn't find any benefit in predicting relapsing disease by the use of miRNA. Some other studies demonstrated that miRNA becomes positive a little bit earlier than metastasis could be detected on a CT scan. The time difference is only about 4 to 5 weeks. If you take into consideration that miRNA is still quite expensive, at least in Germany, miRNA isn't a marker that could be used everywhere, for every single patient. So, the main obstacles are standardization, stabilization, logistics, and the costs, and [these are the reasons] why we did not recommend using miRNA [routinely].

Urology Times: What does the guideline recommend regarding testicular prosthesis? How has the guideline’s view on the timing of insertion evolved to minimize infection risk?

Heidenreich: What we recommend is that every patient who is scheduled for a single orchiectomy should be informed about the possibility of placing a prosthesis at the time of surgery. There has been the fear that placing the prosthesis at the time of surgery might be associated with a significantly increased risk of infection, and then they need to take the prosthesis out in a second surgical procedure. However, we know from many studies that the risk of infection is not increased. You can put the prosthesis in the scrotum at the time of orchiectomy. You could do it as a second procedure, but you need to inform the patients that the prosthesis can be placed at the time of orchiectomy. There is no increased risk of toxicity. If the prosthesis is placed intrascrotally adequately by the surgeon, then it doesn't cause any harm, such as pain or discomfort. That's what we recommend: Inform the patient that a prosthesis can be placed without any increased toxicity.

Urology Times: The guideline includes a new section on the treatment of bone metastases. What are the current recommendations for standard cisplatin-based chemotherapy and other multimodal treatment options for these patients?

Heidenreich: Independent, if you just have a solitary bone metastasis or multiple bone metastases, it's always poor-risk disease. All patients who have metastases need to undergo at least 4 cycles of systemic chemotherapy. We also know that not all these osseous metastases can be cured or eliminated by chemotherapy alone. Depending on the localization of the metastatic deposits and the number of metastatic deposits, we have to combine it with either radiation therapy if you have solitary lesions or surgery if you have symptomatic lesions or pathologic factors. Whenever we see patients who have osseous metastases, we have to think about this multimodal treatment. Systemic chemotherapy is the cornerstone of treatment, and then you add in radiation treatment or surgery based on the best approach for your patient.

Urology Times: The panel emphasizes that patients with metastatic germ cell tumors are at a high risk for VTE. What were the recommendations regarding central venous access devices?

Heidenreich: We know that patients with testis cancer, as with many other patients with cancer, have an increased risk of [VTE]. Usually, patients are placed on some anticoagulant agents. It could be subcutaneous heparin injections, buffering, or new anticoagulated drugs. There are 2 risk factors that increase the risk of VTE significantly. This is a venous line or a port. We recommend not using an intravenous central line and not using a port to reduce the risk of [VTE]. That is the major message.

This finding has been validated in many retrospective studies. This is the only significant risk factor of developing [VTE], except for the extent of metastatic disease, if you have large retroperitoneal lymph node metastases compressing the inferior vena cava. But from all the external risk factors, we can say do not use a central venous line and do not use a port; just use a peripheral venous axis.

Urology Times: Is there anything else that you wanted to add?

Heidenreich: There are a few issues, which are not in the guidelines as recommendations with very high evidence, but should be considered in high-volume centers. One is when we have a seminoma with metastatic disease, and this patient has [favorable] risk disease; usually, they receive 3 cycles of chemotherapy. We know from our most recent IGCCCG [International Germ Cell Cancer Collaborative Group] analysis of patients with metastatic seminoma that those [favorable] risk patients who have significantly elevated LDH [lactate dehydrogenase] levels, which is more than 2.5 times above the upper limit, have a higher risk of relapsing disease after 3 cycles of chemotherapy. For most of those patients, we [suggest] delivering 4 cycles instead of 3 cycles.

The other issue is that when we see residual masses in nonseminomatous testicular germ cell tumors, and these masses are larger than 1 cm, then patients should undergo postchemotherapeutic resection of all visible residual masses. This should be done, as we already discussed, in [high-volume] centers only. If patients have started with intermediate-risk disease or poor-risk disease, then there is an indication for postchemotherapeutic RPLND [retroperitoneal lymph node dissection] already in patients who have visible residual masses less than 1 cm in diameter.

The next message would be for patients who have residual disease after chemotherapy for metastatic seminoma. We don't recommend the use of PET/CT scan anymore as the stratification marker for viable disease vs non-viable disease, taking into consideration that PET only has a positive predictive value of about 30% to 40%, so it doesn't help you in the decision-making process about who should undergo second-line treatment and who can be followed. Do not rely on the PET scan as the only imaging. These are additional aspects of the guidelines.

REFERENCE

1. Heidenreich A, Berney DM, Boormans JL, et al. EAU Guidelines on Testicular Cancer. Accessed April 16, 2026. https://uroweb.org/guidelines/testicular-cancer