Testicular Cancer Awareness Month: EAU Guideline FAQs for Urologists

April is Testicular Cancer Awareness Month, offering an important opportunity to spotlight advances in the diagnosis, treatment, and survivorship care of one of the most curable solid malignancies affecting young men. Although long-term outcomes remain excellent, evolving evidence continues to refine how clinicians balance cure rates with treatment-related toxicity, fertility preservation, and quality-of-life considerations.

The 2026 European Association of Urology (EAU) Guidelines on Testicular Cancer reflect that shift, with notable updates in de-escalation strategies for stage II seminoma, stronger recommendations for patient counseling around testicular prosthesis, and expanded guidance on metastatic disease management. The updated recommendations also reinforce the importance of risk-adapted care, multidisciplinary decision-making, and referral of complex surgical cases to experienced high-volume centers.¹

Urology Times® spoke with guideline chair Prof Axel Heidenreich to discuss the most clinically relevant updates included in the 2026 recommendations and how they may influence day-to-day practice. In the following FAQ roundup, Heidenreich offers perspective on topics such as nerve-sparing retroperitoneal lymph node dissection, the preference for single-cycle BEP in selected stage I nonseminoma, the evolving role of miRNA-371, and practical strategies to optimize survivorship-focused care.

For additional insights, check out part 1 and part 2 of our full interview with Prof Heidenreich.

1. What are the most important updates in the 2026 EAU testicular cancer guidelines?

Key changes include:

• New recommendations regarding testicular prosthesis
• Restructured management of stage IIA/B seminoma, including nerve-sparing retroperitoneal lymph node dissection (RPLND) and radio-chemotherapy
• Updated recommendations on de-escalation strategies
• A new dedicated section on treatment of bone metastases
• Expanded content on rare para- and testicular tumors

Prof Heidenreich said the update also focuses on “clinical situations in which you could de-intensify treatment…without impairing the oncological efficacy.”

2. Why is treatment de-intensification becoming more important in testicular cancer?

Since cure rates are already high, minimizing long-term toxicity has become increasingly important. Prof Heidenreich noted that patients receiving 3 or 4 cycles of chemotherapy may later develop cardiovascular disease, cerebrovascular events, or secondary malignancies.

He added, “More patients die, not because of testicular cancer, they die because of the [adverse] effects of the intensified systemic treatment.”

3. When should nerve-sparing RPLND be considered for stage IIA/B seminoma?

The updated guidelines incorporate RPLND as an option for highly selected patients with marker-negative clinical stage IIA/B seminoma. Ideal candidates are those with low-volume metastatic lymph nodes 3cm or less in diameter.

4. Who should perform primary RPLND for seminoma?

The guidelines emphasize centralization.

Prof Heidenreich was direct, “All urologists who see such patients should not do the surgery by themselves.” He added that this is “expert surgery” and should be performed only in “centers of excellence” with expertise in minimally invasive surgery.

5. What is the alternative de-escalation option besides surgery for stage IIA/B seminoma?

The guidelines also discuss focused radiotherapy plus 1 cycle of carboplatin as a de-escalated approach for selected patients.

Prof Heidenreich said this strategy reduces radiation exposure and offers “similar oncological outcomes as surgery,” making it a reasonable alternative when surgery is not preferred.

6. What is now recommended for clinical stage I nonseminoma when adjuvant chemotherapy is chosen?

The guidelines strongly support 1 cycle of BEP rather than the historical 2-cycle approach when adjuvant chemotherapy is selected. Evidence shows single-cycle BEP reduces relapse rates to approximately 3% while improving the risk-benefit ratio compared with 2 cycles.

Prof Heidenreich stated: “1 cycle of BEP is equally oncologically efficacious as 2 cycles, but it reduces the treatment associated toxicity.”

7. Which patients with stage I nonseminoma are best suited for adjuvant BEP?

Risk-adapted decision-making remains central. The strongest and most reproducible predictive factor for relapse is lymphovascular invasion (LVI). The guidelines recommend discussing surveillance or single-cycle BEP with LVI-positive patients, while surveillance is generally preferred for patients without LVI.

Prof Heidenreich added that embryonal carcinoma burden may refine risk assessment, noting that patients with LVI plus a high percentage of embryonal carcinoma may be especially appropriate candidates for adjuvant therapy.

8. Are there exceptions where primary RPLND should be considered in stage I disease?

Yes. In selected stage I NSGCT cases—particularly post-pubertal teratoma with somatic malignant component—primary RPLND remains relevant. Prof Heidenreich said these patients may harbor occult nodal disease that is “chemo-refractory, so patients can only be cured by primary RPLND.”

9. What are the recommendations surrounding miRNA-371?

The guideline notes promising diagnostic performance for miR-371a-3p, but routine use is not yet recommended because of unresolved barriers including:

• Lack of assay standardization
• Limited availability of the test
• Need for prognostic validation
• Logistical challenges with specimen handling

Prof Heidenreich summarized the obstacles as “standardization, stabilization, logistics, and the costs.”

10. What changed regarding testicular prosthesis counseling?

The 2026 guideline now strongly states that prosthesis should be offered to all patients undergoing unilateral or bilateral orchidectomy. These may be inserted at the time of orchidectomy or subsequently without adverse effects.

Prof Heidenreich said prior concerns about infection have not been supported by available data: “You can put the prosthesis in the scrotum at time of orchiectomy…There is no increased risk of toxicity.”

11. How should clinicians manage bone metastases in germ cell tumors?

Bone metastases are an independent predictor of poor outcomes. The guideline recommends cisplatin-based chemotherapy as the backbone of treatment, as the evidence on additional multimodal treatments is limited to small, retrospective studies.

Prof Heidenreich emphasized, “Systemic chemotherapy is the cornerstone of treatment.”

12. What are the updated recommendations regarding venous thromboembolism (VTE) prevention during chemotherapy?

Patients with metastatic germ cell tumors undergoing cisplatin-based chemotherapy are at increased risk of VTE. The guideline includes a dedicated prevention section. While panel members were split on who should receive thromboprophylaxis (all males vs those with certain risk factors), Prof Heidenreich highlighted one actionable message shared by the majority of the guideline panel: avoid central venous access devices when possible.

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