Urologist Elizabeth Mobley, MD, discusses advances in bladder and kidney cancer

In this interview, recorded at the 2025 LUGPA Annual Meeting, Elizabeth Mobley, MD, a urologist and president of Urology Austin in Texas, discusses major developments in bladder cancer, kidney cancer, and non-oncology conditions such as benign prostatic hyperplasia (BPH), highlighting how new therapies and technologies are transforming options for patients.

In non–muscle invasive bladder cancer, Mobley describes an “embarrassment of riches” compared with just a few years ago, when BCG was the only real option and shortages posed serious challenges. With multiple newer agents available, along with more coming, patients now have meaningful alternatives to radical cystectomy. She notes that these newer treatments also offer flexibility in dosing and scheduling, improving access for patients who travel long distances for care.

In muscle-invasive disease, she calls recent data from the NIAGARA and KEYNOTE-905/EV-303 trials “game changing,” with perioperative immunotherapy likely to become standard of care. The use of circulating tumor (ctDNA) testing, she adds, is transforming how clinicians determine which patients truly need adjuvant treatment.

Mobley also reflects on how her group has integrated immunotherapy into kidney cancer management by establishing an in-house infusion center, allowing patients to remain under the care of their urologist throughout treatment.

On the benign side, she outlines her broad approach to treating BPH, offering minimally invasive options such as UroLift and iTind, as well as prostate artery embolization (PAE) for select patients. She emphasizes the importance of individualized work-ups focused on preserving bladder health.

Finally, Mobley discusses challenges in treating overactive bladder (OAB), noting that although guidelines now support earlier procedural interventions, payers have yet to align. She hopes that greater access to options such as neuromodulation and onabotulinumtoxinA (Botox) will help more patients achieve meaningful relief.

Overall, she views this as an exciting time in urology, with rapid progress across multiple disease states.

Could you reflect on how the non–muscle invasive bladder cancer space has changed over the past several years, and how that has affected your practice?

It’s almost like we have an embarrassment of riches at this point, and those options are soon to expand even further. We went from having BCG—and dealing with shortages of BCG and not many other options, maybe gem/doce [gemcitabine/docetaxel] for patients who failed BCG or couldn’t tolerate it vs radical cystectomy—to now having first Adstiladrin [nadofaragene firadenovec], then Anktiva [nogapendekin alfa inbakicept-pmln], and now Inlexzo [gemcitabine intravesical system], and there’s more to come.

So it’s been a really exciting time to be able to offer patients options who otherwise were staring down the barrel of a cystectomy, which they either didn’t want or weren’t great candidates for. Gem/doce is great, but it’s a harder protocol for patients to stick with, just because of the time commitment. And many community urologists, especially, would have trouble being able to administer that in the clinic, because they’re not equipped to mix chemotherapeutic drugs like docetaxel.

It’s really nice that we now have newer options—and on top of that, dosing and timing flexibility. Some patients come from really far away to get their bladder cancer care, and having an option that’s only administered every 3 months vs every 6 weeks with maintenance is a big relief. They definitely take that into consideration when deciding what treatment to go with.

It’s also nice that we’ve had some time to get payers on board with these drugs. There’s been a bit of sticker shock, and that continues to grow a little, but we’re coming to terms with it, and the payers seem to be cooperating. It’ll be interesting to see where things go and what ultimately stands out as the preferred regimen once we have longer-term data.

With muscle-invasive bladder cancer, there have been some important studies recently with NIAGARA along with KEYNOTE-905/EV-303 at the 2025 European Society for Medical Oncology Congress. What impact have these advances had on your practice, and do they affect when you would refer patients to a medical oncologist?

In terms of when I refer to a medical oncologist for those cases—for my patients who develop muscle-invasive bladder cancer, I involve medical oncology early. I’ve always sent them for neoadjuvant chemotherapy consultations, and in the appropriate settings, they would get that before their radical cystectomy.

But now, with the NIAGARA protocol, they’re not just getting chemotherapy; they’re getting chemo plus immune checkpoint inhibitors neoadjuvantly, and then continuation of adjuvant immune checkpoint inhibitors. It’s sort of game-changing. If it’s not already the standard of care, it should be shortly—that’s my anticipation.

Then you add in the really compelling data on ctDNA testing—that’s another game changer, in terms of deciding who might need adjuvant immunotherapy and who can safely avoid it. It’s been a pretty exciting year in the muscle-invasive bladder cancer space, and I think there’s more coming—using the gemcitabine intravesical drug delivery system and maybe employing bladder-sparing techniques more freely and with more confidence. So we’ll see what the future holds, but all exciting changes with the addition of immune checkpoint inhibitors.

What has your experience been with ctDNA thus far?

If I’m being honest, I don’t have a ton of patients right now with muscle-invasive bladder cancer, but I would absolutely use it if I did. I have been using it in my patients with kidney cancer—less data there so far, but I’ve found it very helpful. I’m familiar with the test and have used it more in patients who are on immunotherapy. So I can’t speak as much to its use in muscle-invasive bladder cancer, but I’ve seen the data, and I love the test. I think it’s super helpful.

Has the ongoing BCG shortage affected your practice, and if so, how have you navigated this challenge?

Yes. Last year around this time, we kind of had an SOS moment where we were running short on BCG. We do a ton of bladder cancer clinical trial work, and we needed BCG for some of those trials. I remember reaching out to colleagues across the country saying, “Hey, we’re short on BCG and need it for these trials. Does anybody have any extra?” Thankfully, people from Tennessee came to the rescue and shipped us some extra BCG.

This year, we’ve had very good inventory management, and we have plenty of BCG—so we’re not facing shortages now. But recently, someone called me saying they had a doctor in the outskirts of Austin, in the Marble Falls area, who was short on BCG and had patients who needed therapy. We were able to pay it forward and get them some vials to make sure their patients were taken care of.

So right now, it’s not been a problem—but it has been before. Hopefully, we’ll avoid future shortages. I think there are some new manufacturing facilities coming online soon, so hopefully that’s not a recurring issue.

Shifting gears to kidney cancer, how has your treatment of this disease changed over the past 3 to 5 years?

In our group, we try to be as progressive as possible. We set up our own infusion center so we could administer Keytruda (pembrolizumab) to patients who had locally advanced, high-grade stage II and stage III kidney cancers—clear cell renal carcinomas.

We took that first slightly scary step of saying, “Hey, we’re going to start administering immunotherapy,” and a few of us stepped forward to do that for the group. It’s gone really well. Patients are happy to stay under the care of their urologist—the person they already know and just had surgery with.

Of course, we’ve had our fair share of immune-mediated [adverse events], but we’ve been able to manage them. We’ve developed a team around us with medical oncology, GI, endocrinology, and dermatology specialists we can rely on if patients have [adverse events] we’re not comfortable managing. And if a patient progresses on therapy, I’ll call up my medical oncology colleagues and refer them on.

We don’t do much dual therapy—if a patient needs that, I’d have medical oncology manage it, because the higher [adverse event] profile can add up quickly.

It’s been a really rewarding experience. It’s kind of like when we first started administering advanced prostate cancer drugs in our clinic. We’ve shown we can do it safely with kidney cancer, too.

One of the other conditions you treat is BPH. What treatments do you currently offer patients?

We’re also very active in the BPH clinical trial space, and I’ve participated in many of those. We like to get as many patients on trials as possible to keep advancing BPH care.

Outside of that, for minimally invasive therapies, I offer UroLift and iTind. I personally don’t do Rezūm, but I discuss it with patients and refer them to my partner who does. I’ve also done Optilume—I’ve done 4 of those. We were one of the centers that helped get that trial through the FDA.

In terms of surgery, I offer Aquablation—I love Aquablation. It’s fantastic. I’ve done many TURPs [transurethral resection of the prostate] and still offer TURP for the right patient, but if a patient meets criteria for Aquablation and their prostate is the right size, it’s an excellent option. It’s very reproducible, has a short learning curve, and has fewer risks compared to TURP—especially fewer sexual [adverse events].

It’s typically an hour or less regardless of prostate size, with minimal risk for erectile dysfunction and reduced risk of ejaculatory dysfunction. The outcomes have been fantastic.

We also have our own PAE center and do a fair number of PAEs for patients who are averse to surgical intervention. That’s gone well, and patients often seek us out specifically for that. I incorporate it into discussions of treatment options, going through pros and cons. There are still advantages to surgery over PAE, but not everyone is comfortable with that. So we can start with PAE, and if it’s not sufficient, we have plenty of surgical back-up options.

How do you determine which BPH treatment is best for the individual patient?

When I talk to patients with urinary symptoms, I joke that the prostate at this point in their life is pretty much a liability—it’s either going to get large and cause urinary problems, get cancer, or get infected. Unless you’re trying to have children, it’s not playing a critical role, but it’s not an organ you can remove without consequences.

What’s really important is bladder health. Many men don’t realize the impact that prostate obstruction or bladder outlet obstruction has on their bladder function long term. I really emphasize that so they understand what’s at stake if they let this go untreated for too long.

That conversation gets patients engaged in the work-up. My work-up includes diagnostic cystoscopy—to assess for urethral stricture disease, estimate prostate size and shape, look at the bladder neck, and assess bladder tone or trabeculation. I also rule out bladder pathology or a large intravesical median lobe, which plays a big role in deciding treatment.

I’ll do a prostate ultrasound—transabdominal or transrectal, depending on prior imaging—and get a size assessment. I perform urinary flow rate testing, and sometimes urodynamics if I suspect more bladder dysfunction. I also use at-home flow monitoring tools, which are great when symptoms vary throughout the day.

Once we have all that data, we can sit down and say, “Okay, you have a 60-g prostate with a large intravesical median lobe—here’s what your options are.” Then we narrow it down to the options that best fit their anatomy and talk about surgical risks, preferences, and make a decision together.

How have the new American Urological Association guidelines on OAB changed your treatment of this condition?

The problem is that even though the guidelines have changed, payers haven’t caught up. It’s frustrating. I tell patients that ideally, I’d love to offer them the full menu of options from day 1 and let them choose—but most insurances still require failure of 1 or 2 drugs and other conservative measures first.

I’m cautious about medications, especially in older patients. I try to avoid anticholinergics as much as possible and primarily choose beta-3 agonists if we go the medication route—but those can be hard to get covered, too. So we’re constantly fighting that battle on behalf of our patients.

It would be nice to move to procedural intervention earlier, because those treatments work better and avoid the [adverse events] and drug interaction risks of medications. Hopefully, payers will catch up to the guidelines soon.

There have been exciting updates—like implantable tibial nerve modulators in addition to sacral nerve modulators, and of course Botox, which has been around a while and remains a great option.

Many patients with OAB also have bowel dysfunction, and these are significant quality-of-life issues. Unfortunately, they often don’t bring it up because it’s embarrassing or they don’t know there are treatments. Our goal at Urology Austin is to improve our OAB and incontinence pathways to get these therapies into more patients’ hands.

It’s kind of like with BPH—only 2% to 3% of patients ever get procedural intervention, and despite all these new options over the past decade, that number hasn’t changed. It’s the same with OAB, and that needs to change.