This publication represents a summary of the updated 2025 European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC). The aim is to provide practical recommendations on the clinical management of MMIBC with a focus on diagnosis, treatment, and follow-up.
For the 2025 guidelines, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Databases searched included Medline, EMBASE, and the Cochrane Libraries. Recommendations within the guidelines were developed by the panel to prioritise clinically important care decisions. The strength of each recommendation was determined according to a balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences.
The key recommendations emphasise the importance of thorough diagnosis, treatment, and follow-up for patients with MMIBC. The guidelines stress the importance of a multidisciplinary approach to the treatment of MMIBC patients and the importance of shared decision-making with patients. The key changes in the 2025 muscle-invasive bladder cancer (MIBC) guidelines include the following: a new recommendation for the use of susceptible FGFR3 alterations to select patients with unresectable or metastatic urothelial carcinoma for treatment with erdafitinib; significant adaption and update of the recommendations for pre- and postoperative radiotherapy and sexual organ-preserving techniques in women; new recommendation related to radical cystectomy and extent of lymph node dissection based on the results of the SWOG trial; recommendation related to hospital volume; new recommendations for salvage cystectomy after trimodality therapy and for the management of all patients who are candidates for trimodality bladder-preserving treatment in a multidisciplinary team setting using a shared decision-making process; significant adaption and update to the recommendation for adjuvant nivolumab in selected patients with pT3/4 and/or pN+ disease not eligible for, or who declined, adjuvant cisplatin-based chemotherapy; and addition of a new recommendation for metastatic disease regarding the antibody-drug conjugate trastuzumab deruxtecan in case of HER2 overexpression; in addition, removal of the recommendations on sacituzumab govitecan as the manufacturer has withdrawn the US Food and Drug Administration approval for this product; update of the follow-up of MIBC; and full update of the management algorithms of MIBC.
This overview of the 2025 EAU guidelines offers valuable insights into risk factors, diagnosis, classification, treatment, and follow-up of MIBC patients and is designed for effective integration into clinical practice.
European urology. 2025 Mar 17 [Epub ahead of print]
Antoine G van der Heijden, Harman Max Bruins, Albert Carrion, Richard Cathomas, Eva Compérat, Konstantinos Dimitropoulos, Jason A Efstathiou, Rainer Fietkau, Mithun Kailavasan, Anja Lorch, Alberto Martini, Laura S Mertens, Richard P Meijer, Param Mariappan, Matthew I Milowsky, Yann Neuzillet, Valeria Panebianco, Sæbjørn Sæbjørnsen, Emma J Smith, George N Thalmann, Michael Rink
Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands. Electronic address: ., Department of Urology, Zuyderland Medisch Centrum, Sittard/Heerlen, The Netherlands., Department of Urology, Vall Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain., Department of Medical Oncology, Kantonsspital Graubünden, Chur, Switzerland., Department of Pathology, Medical University Vienna, General Hospital, Vienna, Austria., Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK., Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA., Department of Radiation Therapy, University of Erlangen, Erlangen, Germany., Department of Urology, Victoria Hospital, London, Ontario, Canada., Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland., Department of Urology, University of Cincinnati, Cincinnati, OH, USA., Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands., Department of Oncological Urology, University Medical Center, Utrecht, The Netherlands., Edinburgh Bladder Cancer Surgery (EBCS), Western General Hospital, University of Edinburgh, Edinburgh, UK., Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA., Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France., Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy., European Association of Urology Guidelines Office, Arnhem, The Netherlands., Department of Urology, Inselspital, University Hospital Bern, Bern, Switzerland., Department of Urology, Marienkrankenhaus Hamburg, Hamburg, Germany.