Elizabeth Mobley, MD, on setting expectations and hydration protocols for the gemcitabine intravesical system

Managing adverse events with the gemcitabine intravesical system (Inlexzo) begins before the first device is placed—and the clinicians who achieve the best patient retention through 6 months of induction and beyond are the ones who build the right expectations from the first conversation, according to Elizabeth Mobley, MD, a urologist and president of Urology Austin in Texas.

Mobley described her first-visit approach as grounded in normalization. Patients receiving the gemcitabine intravesical system are not receiving a standard intravesical instillation; they are receiving a continuously drug-eluting system that remains indwelling for 3 weeks at a time across a 6-month induction course.

"I make sure they understand that this is an in-dwelling system that stays in the bladder for 3 weeks, and it's honestly a continuous drug therapy for 6 months," she said. The most common symptoms—urinary urgency, frequency, and dysuria—are addressed upfront and explicitly framed as expected rather than alarming.

"I lead with that so they understand that's a common thing to experience, so they're not worried that their experience is atypical," Mobley said. The pay-off is measurable: Proactive counseling reduces both patient anxiety and the volume of phone calls generated by expected, manageable symptoms.

The importance of hydration

Hydration is the single most actionable variable Mobley uses to modulate symptom severity. Her protocol follows labeling guidance: a minimum of 1.5 to 2 liters of water daily, with avoidance of carbonated, caffeinated, and highly acidic beverages—although she allows patients to experiment if those beverages are not causing perceptible worsening. The rationale she communicates to patients has 2 components. First, more dilute urine reduces dysuria and irritative symptoms. Second—and Mobley noted this point resonates particularly well—adequate hydration actively supports drug delivery by promoting gemcitabine release from the intravesical system.

"Those 2 things seem to have hit home with my patients, and they tend to follow that protocol and have had good results because of it," she said.

Specificity matters in patient communication. Telling patients to "drink more water" is less effective than giving them a concrete daily target and anchoring it to a familiar reference—a water bottle held up in the exam room, with a clear daily count attached.

"Some people don't understand what 1.5 liters or 2 liters means in ounces—you need to show them a water bottle and say, ‘I want you to drink this many per day,’ " Mobley said.

The clinical consequence of underhydration, in her experience, is primarily symptom burden rather than grade 3 or 4 adverse events, which remain uncommon with this drug delivery system. But that distinction matters less to patients than clinicians might expect.

"They're more interested in, ‘How can I make it through this 6 months—how can I do it in a way that's not going to keep me up all night disrupting myself, my partner or my family, our vacations,’ " Mobley said. Patients who hydrate adequately are less likely to report symptoms disruptive enough to prompt requests for a therapy break or discontinuation—the outcome that ultimately matters most for treatment completion.