Urology for older adults: a blind spot in international guidelines?

The world is ageing. Older adults now represent a rapidly growing share of the global population. This demographic transition is reshaping healthcare demands, with far-reaching implications, including rising health expenditure as a share of national GDP. ¹ From a clinical perspective, age is often accompanied by additional considerations. Comorbidities, frailty, and cognitive impairment frequently coexist, increasing the complexity of care and perioperative risk accordingly.

As a result, older adults now stand at the centre of contemporary urological practice. In a national study of all urological inpatients admitted during 2022 in Poland, 67% were aged 60 or older. ² Urologists are therefore already responding to these evolving needs in their daily practice, and this trend is set to continue in the years ahead.

It is natural, therefore, to consider whether current guidelines are reflecting the clinical realities of our daily practice and, perhaps more importantly, how future guidelines can continue to grow and evolve.

Today’s urological guidelines, of which there are many from different regions of the world, are highly respected, evidence-based frameworks that support high-quality care across diverse clinical scenarios.

We compared the European Association of Urology (EAU) and American Urological Association (AUA) guidelines, excluding paediatric content.^3,4 Each guideline chapter was manually reviewed, focusing on the extent to which age, frailty, and comorbidity are incorporated. In the 2025 EAU guidelines, there is attention to the topic of older adults. ⁵ However, structured and actionable recommendations remain relatively narrow in scope and are mainly concentrated to four areas: frailty-informed treatment selection in prostate cancer and muscle-invasive bladder cancer, age-related pharmacological considerations in female lower urinary tract symptoms, and adapted infection management strategies in older patients. In other areas, age and comorbidity are acknowledged, for example, in surgical decision-making for upper tract urothelial carcinoma, BCG tolerance, trauma outcomes, and treatment selection for renal cell carcinoma, but these observations are not routinely linked to defined assessment pathways or management algorithms. Beyond these domains, there remain large sections and even entire topics that make little or no reference to older adults.

In contrast, our review of the 2025 AUA guidelines revealed a broader and more consistent integration of themes related to older age and frailty across nearly all urological subspecialties, particularly within oncological and functional urology, albeit in a manner that is less formally structured than in those few EAU areas where such considerations are explicitly addressed.

The purpose of this commentary is not to determine which guideline is superior, but rather to highlight that, as the prevalence of urological disease in ageing populations continues to rise, there is an opportunity to expand and harmonise guidance that systematically incorporates frailty assessment, life expectancy, and age-related treatment considerations across the full spectrum of urological care.

The current situation and variation among urological guidelines are understandable. Guideline development is evidence-driven and prioritises high-quality data, yet prospective trials involving older adults remain uncommon. Challenges in recruitment, informed consent, multimorbidity, and long-term follow-up contribute to this, resulting in limited new data between guideline cycles. Existing studies on older adults are often retrospective and prone to selection bias, reducing their influence on recommendations. This limitation may be compounded when guideline panels lack formal geriatric representation, reducing confidence in issuing age-specific guidance.

From a practical perspective, several basic strategies embedded within the guidelines could improve daily clinical decision-making. These include the integration of validated assessment tools such as the Clinical Frailty Scale, the Geriatric 8 (G8) screening tool, and the Barthel Index. There is also a need to move beyond relying on chronological age alone when making treatment decisions, with greater emphasis placed on functional status. This should be accompanied by a focus on treatment goals that reflect patient-centred outcomes, such as maintaining independence and quality of life, rather than focusing solely on oncological or technical success.

Embedding multidisciplinary input, including geriatric expertise and the involvement of allied health professionals such as nursing, social work, and occupational therapy, into routine practice has been shown to improve care within quality improvement frameworks in the United Kingdom. As these approaches become more widely adopted, they may increasingly inform and shape future guideline development, reflecting a more practice-driven evolution in how guideline recommendations are generated.

Taken together, these considerations highlight a shared global challenge rather than a limitation of any single guideline organisation or group. Addressing this gap will require a multifaceted approach, including greater awareness of the issue, incorporation of clinicians with expertise in geriatrics and frailty into panels, and prioritisation of research specifically designed to evaluate outcomes in older and frail populations. Establishing dedicated research groups to support and prioritise this field could help strengthen the evidence base needed for more comprehensive and clinically applicable recommendations in future guideline iterations. ⁶ As populations continue to age, there is an opportunity for future urological guidelines to move beyond a predominantly disease-focused approach and more consistently incorporate frailty, functional status, life expectancy, and patient-centred outcomes across the wider spectrum of urological care.