This Week in Urology — Sep 4, 2026

Welcome to This Week in Urology. This week we're covering 10 notable papers spanning bladder and prostate cancer management, the cardiometabolic care of men on androgen deprivation, and a cluster of stone and benign prostate papers that touch everything from stent size to climate. Let's dive in.

We start with the biggest document of the week. The Journal of Urology has published the 2026 update to the American Urological Association and Society of Urologic Oncology guideline on non-muscle invasive bladder cancer [1]. The panel ran a systematic search of Ovid MEDLINE and Embase for evidence published between May 2023 and December 2025, screening nearly three thousand studies down to 38 that formed the final evidence base, with the search strategy deliberately widened to capture the newly approved intravesical agents. The revisions touch risk stratification itself, along with statements on biomarkers, subtype histologies, transurethral resection technique, intravesical therapy, Bacillus Calmette-Guerin maintenance, and enhanced cystoscopy. The practical message is that if your bladder cancer practice is still running on the previous risk-stratified framework, the categories and the therapeutic options within them have both moved, particularly in the Bacillus Calmette-Guerin unresponsive space. This is a document to read in full rather than skim, because the changes are distributed across the whole pathway rather than concentrated in one recommendation.

Turning to prostate cancer, three papers this week describe how localised and metastatic disease are actually being treated. In Urology, a retrospective cohort using national commercial insurance claims looked at nearly thirty thousand men under 65 with localised prostate cancer diagnosed between 2004 and 2023 [2]. Active surveillance or observation rose from about one in ten men to just over a third across that period, while prostatectomy fell from roughly 56 percent to 43 percent. Among men who started on surveillance, close to seven in ten of them remained treatment free at five years. What is equally striking is how much more intensive surveillance has become: within the first two years, the proportion of men undergoing repeat biopsy rose from about 18 percent to nearly half, and magnetic resonance imaging went from essentially zero to just under two thirds. So surveillance in younger men is no longer a passive strategy, and the resource and counselling implications of that deserve to be discussed up front. Alongside that, Prostate Cancer and Prostatic Diseases reports a single institution series of 171 consecutive focal irreversible electroporation procedures for localised disease [3]. With a median follow-up of 35 months and a median treated lesion diameter of 11 millimetres, among the patients who underwent surveillance biopsy about 8 percent had significant in-field persistence while roughly 14 percent had significant out-of-field cancer. Continence was preserved in nearly 98 percent of men, and erectile function in about 84 percent of sexually active respondents. Notably, neither baseline grade group, tumour location, prostate-specific antigen density above 0.15, nor a prostate-specific membrane antigen PET maximum standardised uptake value of 10 or more predicted in-field failure. The authors are appropriately cautious: the functional results are good and in-field control looks reasonable, but out-of-field progression is the unresolved question and needs longer follow-up.

For metastatic hormone-sensitive disease, BJU International publishes a systematic review and meta-analysis of real-world comparative effectiveness across the androgen receptor pathway inhibitor doublets [4]. Valikovics and colleagues pooled 17 retrospective studies covering more than eighteen thousand patients treated with apalutamide, abiraterone, or enzalutamide added to androgen deprivation. Compared with abiraterone, apalutamide was associated with better overall survival, deeper prostate-specific antigen responses, and a longer time to castration resistance, and it also produced deeper prostate-specific antigen responses than enzalutamide. The trade-off ran the other way for tolerability, with discontinuation for adverse events roughly half as likely on abiraterone as on apalutamide. Abiraterone and enzalutamide looked broadly comparable to each other. Since all seventeen studies were retrospective and no head-to-head randomised trial exists, this is hypothesis-generating rather than definitive, but it supports individualising the choice around efficacy expectations versus tolerability and comorbidity.

That leads naturally into the most provocative trial of the week, published in JAMA Internal Medicine [5]. Leong and colleagues randomised 2,487 men with prostate cancer starting or recently started on androgen deprivation, across 55 sites in eight countries, to usual care alone or usual care plus routine referral to an internist or cardiologist who applied a protocol targeting a systolic blood pressure of 130 or lower and a statin regardless of baseline cholesterol, together with smoking cessation and lifestyle advice. Over a median follow-up of just under six years, the hierarchical composite favoured the intervention, with a win ratio of 1.60. But read the components carefully, because the benefit was driven almost entirely by better cholesterol control, with a mean total cholesterol difference of about 12 milligrams per decilitre from greater statin use. Blood pressure at close-out differed by under two millimetres of mercury between groups, and there was no difference between groups in time to cardiovascular death, myocardial infarction, stroke, or heart failure. So the honest interpretation is that systematic specialist referral improves risk factor control, mainly through getting men on statins, but this trial did not demonstrate a reduction in hard cardiovascular events. For most urologists the pragmatic takeaway is that starting androgen deprivation is a legitimate trigger to ensure a man is on a statin and has his blood pressure addressed, and you may not need a specialist referral pathway to achieve that.

On the benign side, Urology reports temporal and geographic trends in surgical management of benign prostatic hyperplasia across the United States Veterans Affairs system, covering more than 74,000 men operated on between 2000 and 2024 [6]. The average Charlson comorbidity index at the time of surgery doubled over that period, from 3.7 to 7.3, and that rise tracked more strongly with calendar year than with patient age, meaning we are operating on genuinely sicker men, not just older ones. Transurethral resection of the prostate remained the dominant procedure throughout. Prostatic urethral lift climbed steadily from 2015 to a peak of about 14 percent of procedures in 2021, overtaking photoselective vaporisation, but since 2021 prostatic urethral lift has declined while transurethral resection has risen again. That reversal is worth watching, and it suggests the durability data on minimally invasive therapies is starting to shape practice.

Finally, four stone papers. In World Journal of Urology, a patient- and assessor-blinded randomised trial compared 4.7 French with 6 French double-J stents left for three weeks after ureteroscopic lithotripsy in 124 patients [7]. International Prostate Symptom Scores were essentially identical between groups, but the smaller stent produced significantly better Ureteral Stent Symptom Questionnaire scores, a seven point advantage on the overall score. The counterweight was more frequent grade three complications, mainly stent dislodgement, in the thinner stent group, about 9 percent versus 3 percent, a difference that did not reach statistical significance in a trial this size. A second World Journal of Urology trial randomised 221 patients to no pre-stenting, two to four weeks, or four to six weeks before retrograde intrarenal surgery with a flexible and navigable ureteral access sheath [8]. Successful sheath placement rose from 80 percent without pre-stenting to around 93 and 95 percent in the two pre-stented arms, and pre-stenting was the only independent predictor of placement success, roughly tripling to quintupling the odds. Importantly, there was no advantage to the longer interval, and stone-free rates and serious complications did not differ across groups, so two to four weeks appears sufficient. Rounding out the stone theme, BJU International reports the KiSCAI study, developing machine learning models to predict dominant stone composition in 442 patients [9]. Clinical variables alone gave good discrimination, but adding standardised morphological descriptors pushed the ensemble models to near-excellent performance. The authors are candid that the morphological features are intraoperative or postoperative, so the combined model is decision support after the fact rather than a preoperative tool, and it needs external prospective validation. And in Urology, a Veterans Affairs cohort of more than 136,000 stone formers found that men living in the highest quartile of extreme heat exposure had about a 5 percent greater risk of recurrence than those in the lowest, with each additional ten extreme heat days per year associated with a 3 percent higher risk [10]. The effect is small at the individual level but supports building heat and hydration counselling into follow-up for high-risk stone formers.

If you only have time for one paper this week, make it the 2026 American Urological Association and Society of Urologic Oncology non-muscle invasive bladder cancer guideline update in The Journal of Urology [1]. It changes the risk framework and the therapeutic menu that most of us apply weekly in clinic, and unlike a single trial it will shape documentation, surveillance intervals, and referral decisions immediately.

Here are the key takeaways from this week in Urology. Re-read the non-muscle invasive bladder cancer guideline in full, because the revisions span risk stratification, biomarkers, intravesical therapy, and Bacillus Calmette-Guerin maintenance rather than one narrow area. Starting androgen deprivation is a good trigger for statin therapy and blood pressure review, but a formal cardiology referral pathway improved lipids without demonstrating fewer cardiovascular events. Real-world data suggest apalutamide-based doublets may offer efficacy advantages over abiraterone in metastatic hormone-sensitive disease, with abiraterone better tolerated, so individualise. Surveillance in younger men is both more common and far more resource-intensive than a decade ago, and patients should be counselled about the biopsies and imaging that come with it. And on the stone side, pre-stent for two to four weeks if you want reliable access sheath placement, consider a thinner stent for symptom burden while accepting a small dislodgement risk, and ask high-risk stone formers about heat exposure and hydration.

That's your roundup for This Week in Urology. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.