Guidelines

Non-muscle-invasive Bladder Cancer

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1. INTRODUCTION

1.1. Aim and scope

This overview represents the updated European Association of Urology (EAU) Guidelines for non-muscle-invasive Bladder Cancer (NMIBC), TaT1 and carcinoma in situ (CIS). Unless specified otherwise, the information presented is limited to urothelial carcinoma (UC). The aim is to provide practical recommendations on the clinical management of NMIBC with a focus on clinical presentation. Separate EAU Guidelines are available addressing upper tract urothelial carcinoma (UTUC) [1], muscle-invasive and metastatic bladder cancer (MIBC) [2] and primary urethral carcinoma (PUC) [3].

It must be emphasised that clinical guidelines present the best evidence available to the experts, but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients but rather help to focus decisions - also taking personal values and preferences/individual circumstances of patients into account. Guidelines are not mandates and do not purport to be a legal standard of care.

1.2. Panel composition

The EAU Guidelines Panel on NMIBC consists of an international multidisciplinary group of clinicians, including urologists, uro-oncologists, a pathologist and two patient representatives. Members of this Panel have been selected based on their expertise and to represent professionals treating patients suspected of suffering from bladder cancer (BC). All experts involved in the production of this document have submitted potential conflict of interest statements that can be viewed on the EAU website: https://uroweb.org/guidelines/non-muscle-invasive-bladder-cancer/panel.

1.3. Available publications

A quick reference document, the Pocket Guidelines, is available online and in print. This reference document is an abridged version that may require consultation together with the full text version. All documents are accessible on the EAU website: https://uroweb.org/guidelines/non-muscle-invasive-bladder-cancer. An EAU Guidelines App is also available for iOS and Android devices containing the Pocket Guidelines, interactive algorithms and calculators, clinical decision support tools, guidelines cheat sheets and links to the extended guidelines.

1.4. Publication history and summary of changes

1.4.1. Publication history

The EAU Guidelines on NMIBC were first published in 2000. Standard procedure for EAU Guidelines includes an annual assessment of newly published literature in the field to guide future updates These 2026 NMIBC Guidelines present a complete update of the 2025 publication.

1.4.2. Summary of changes

For the 2026 NMIBC Guidelines new and relevant evidence was identified, collated and appraised through a structured assessment of the literature for all sections of the Guidelines. This resulted in the inclusion of 64 updated studies across the Guidelines. Key changes include:

  • Update of Figure 4.1: Schematic representation of tumours according to the WHO 1973, WHO 2004/2022 grading systems and a three-tier and four-tier hybrid combination of the two systems.
  • Update of the levels of evidence and recommendations in Section 4.10: Summary of evidence and recommendations for bladder cancer classification
  • Update of the summary of evidence and recommendation on cystoscopy in Section 5.9: Summary of evidence and recommendations for the primary assessment of non-muscle invasive bladder cancer.
  • Removal and adaption of recommendations in section 5.15: Summary of evidence and recommendations for TURB, biopsies and pathology report.
  • Removal and adaption of the summary of evidence and recommendations in section 6.5: Summary of evidence and recommendations for stratification of NMIBC.
  • Addition of two new tables summarising the treatment options for BCG-unresponsive tumours. Table 7.3 Papillary Ta/T1 and Table 7.4 Carcinoma in situ ± papillary.
  • Addition of a new recommendation relating to the addition of sasanlimab and durvalumab to Bacillus Calmette-Guérin (BCG) with maintenance in selected BCG-naive patients with high and very high-risk NMIBC in Section 7.10: Recommendations for adjuvant therapy in TaT1 tumours and for therapy of carcinoma in situ.
  • Update of Table 7.5: Treatment options for the various categories of BCG failure.
  • Removal and adaption of the recommendations in Section 8.2: Summary of evidence and recommendations for follow-up of patients after TURB for NMIBC.