The importance of embedding an inclusive culture within healthcare teamwork education; an evaluation of implementation methods.

Teamworking is a fundamental concept within most organisations and healthcare is no different. It is at the core of everything we do as professionals and has a multitude of impacts including on patient safety, the quality of care that we provide, and staff morale. This paper looks at why we should prioritize advancing teamwork education; argues the advantages of developing an all-encompassing, inclusive team training approach; and summarizes the different methods of how to implement teamwork education within your organisation. Key messages Good teamworking processes have significant effects on patient safety and staff well-being. Inclusive training has wide-reaching benefits for staff morale, fostering colleague relationships and breaking down hierarchies. Teamwork education should be embedded within all healthcare organisations with the method used depending on organisational culture, hierarchy gradient and learners' starting knowledge.

The need for a course to complete urological education for consultant practice using a simulated 'boot camp' structure at the end of specialist training: A survey-based study.

BACKGROUND AND AIMS: To obtain opinions from urology trainees and consultants regarding the need for, and structure of, a post-specialty training Urology Simulation Boot Camp (USBC) for consultant practice. METHODS AND RESULTS: A survey-based study was conducted, and 'Google Forms' were distributed electronically via social media. Urology specialist trainees (ST) in years 5-7 (ST5-ST7), post-certification of completion of training (CCT) fellows and ST3 boot camp faculty consultants in practice for ≤5 years and >5 years were included. One hundred and seven responses were received. 97.2% of responders thought a pre-consultant USBC was worthwhile; 55.1% selected the course duration to be 2 days. 47.7% felt that the USBC should be delivered post-exam in ST7. 91.6%, 43.9%, 73.8%, 87.9% and 74.8% considered that modules in emergency operative procedures, novel uro-technologies, delivering multidisciplinary team (MDT) meetings, non-clinical consultant roles and responsibilities, stress and burnout to be important, respectively. 62.6% and 31.8% felt that the course should be wholly or part-funded by Health Education England (HEE). CONCLUSIONS: A post-specialty training, pre-consultant, USBC delivered post-exam in ST7, is worthwhile and should include modules on emergency operative procedures, leading MDTs, non-clinical roles and responsibilities and managing stress and burnout in consultant careers. Ideally, it should be fully/part-funded by HEE.

Urinary bladder recurrences following ureteroscopic biopsies of upper tract urothelial cancers: a multi-centre observational study with genomic assessment for clonality.

BACKGROUND AND AIMS: Urinary bladder recurrences (UBRs) after radical nephroureterectomy (RNUx) are a known challenge in patients with upper-tract urothelial cancers (UTUCs). We aim to assess factors associated with UBR and clonal-relatedness with resected UTUC. METHODS: Patients who underwent RNUx for UTUC between 1998 and 2015 in five institutions were identified. Clonal relatedness between primary UTUC and subsequent UBR in a sub-cohort was assessed using next-generation sequencing. A Kaplan-Meier curve was used to assess differences in UBR between two groups (with or without ureteroscopic biopsy). RESULTS: Of 267 patients with complete records, 73 (27.3%) had UBR during follow-up. The five-year UBR-free survival in all patients was 64.7%. The five-year UBR-free-survival was inferior in patients who underwent URS biopsy compared with patients who did not undergo ureteroscopic biopsy (49.9% vs 76.4%, p < 0.001). History of bladder tumour (HR, 95% CI; 2.94, 1.73-5.00, p < 0.001), ureteroscopic biopsy (HR, 95% CI; 2.21, 1.38-3.53, p = 0.001) and preoperative urine cytology ≥C3 (HR, 95% CI; 2.06, 1.24-3.40, p = 0.005) were independently associated with UBR. Patients with ureteroscopic biopsy (n = 3/5) showed identical mutational changes for common genes (TP53 and FGFR3) between primary UTUC and subsequent UBR. CONCLUSIONS: Ureteroscopic biopsy of UTUC is a significant risk factor for UBR. Qualitative clonality assessment showed identical mutational signatures between primary UTUC and UBR.

Molecular profile of pure squamous cell carcinoma of the bladder identifies major roles for OSMR and YAP signalling.

Pure squamous cell carcinoma (SCC) is the most common pure variant form of bladder cancer, found in 2-5% of cases. It often presents late and is unresponsive to cisplatin-based chemotherapy. The molecular features of these tumours have not been elucidated in detail. We carried out whole-exome sequencing (WES), copy number, and transcriptome analysis of bladder SCC. Muscle-invasive bladder cancer (MIBC) samples with no evidence of squamous differentiation (non-SD) were used for comparison. To assess commonality of features with urothelial carcinoma with SD, we examined data from SD samples in The Cancer Genome Atlas (TCGA) study of MIBC. TP53 was the most commonly mutated gene in SCC (64%) followed by FAT1 (45%). Copy number analysis revealed complex changes in SCC, many differing from those in samples with SD. Gain of 5p and 7p was the most common feature, and focal regions on 5p included OSMR and RICTOR. In addition to 9p deletions, we found some samples with focal gain of 9p24 containing CD274 (PD-L1). Loss of 4q35 containing FAT1 was found in many samples such that all but one sample analysed by WES had FAT1 mutation or deletion. Expression features included upregulation of oncostatin M receptor (OSMR), metalloproteinases, metallothioneins, keratinisation genes, extracellular matrix components, inflammatory response genes, stem cell markers, and immune response modulators. Exploration of differentially expressed transcription factors identified BNC1 and TFAP2A, a gene repressed by PPARG, as the most upregulated factors. Known urothelial differentiation factors were downregulated along with 72 Kruppel-associated (KRAB) domain-containing zinc finger family protein (KZFP) genes. Novel therapies are urgently needed for these tumours. In addition to upregulated expression of EGFR, which has been suggested as a therapeutic target in basal/squamous bladder cancer, we identified expression signatures that indicate upregulated OSMR and YAP/TAZ signalling. Preclinical evaluation of the effects of inhibition of these pathways alone or in combination is merited.

Radical Cystectomy Against Intravesical BCG for High-Risk High-Grade Nonmuscle Invasive Bladder Cancer: Results From the Randomized Controlled BRAVO-Feasibility Study.

PURPOSE: High-grade nonmuscle invasive bladder cancer (HRNMIBC) is a heterogeneous disease. Treatments include intravesical maintenance Bacillus Calmette-Guerin (mBCG) and radical cystectomy (RC). We wanted to understand whether a randomized trial comparing these options was possible. MATERIALS AND METHODS: We conducted a two-arm, prospective multicenter randomized study to determine the feasibility in Bacillus Calmette-Guerin-naive patients. Participants had new high-risk HRNMIBC suitable for both treatments. Random assignment was stratified by age, sex, center, stage, presence of carcinoma in situ, and prior low-risk bladder cancer. Qualitative work investigated how to maintain equipoise. The primary outcome was the number of patients screened, eligible, recruited, and randomly assigned. RESULTS: We screened 407 patients, approached 185, and obtained consent from 51 (27.6%) patients. Of these, one did not proceed and therefore 50 were randomly assigned (1:1). In the mBCG arm, 23/25 (92.0%) patients received mBCG, four had nonmuscle invasive bladder cancer (NMIBC) after induction, three had NMIBC at 4 months, and four received RC. At closure, two patients had metastatic BC. In the RC arm, 20 (80.0%) participants received cystectomy, including five (25.0%) with no tumor, 13 (65.0%) with HRNMIBC, and two (10.0%) with muscle invasion in their specimen. At follow-up, all patients in the RC arm were free of disease. Adverse events were mostly mild and equally distributed (15/23 [65.2%] patients with mBCG and 13/20 [65.0%] patients with RC). The quality of life (QOL) of both arms was broadly similar at 12 months. CONCLUSION: A randomized controlled trial comparing mBCG and RC will be challenging to recruit into. Around 10% of patients with high-risk HRNMIBC have a lethal disease and may be better treated by primary radical treatment. Conversely, many are suitable for bladder preservation and may maintain their prediagnosis QOL.

Stage-stratified molecular profiling of non-muscle-invasive bladder cancer enhances biological, clinical, and therapeutic insight.

Understanding the molecular determinants that underpin the clinical heterogeneity of non-muscle-invasive bladder cancer (NMIBC) is essential for prognostication and therapy development. Stage T1 disease in particular presents a high risk of progression and requires improved understanding. We present a detailed multi-omics study containing gene expression, copy number, and mutational profiles that show relationships to immune infiltration, disease recurrence, and progression to muscle invasion. We compare expression and genomic subtypes derived from all NMIBCs with those derived from the individual disease stages Ta and T1. We show that sufficient molecular heterogeneity exists within the separate stages to allow subclassification and that this is more clinically meaningful for stage T1 disease than that derived from all NMIBCs. This provides improved biological understanding and identifies subtypes of T1 tumors that may benefit from chemo- or immunotherapy.

Global Assessment of Urological Endoscopic Skills (GAUES): development and validation of a novel assessment tool to evaluate endourological skills.

OBJECTIVE: To develop and evaluate an assessment tool for endourological skills during simulation including cystoscopy, ureteroscopy (URS) and transurethral resection (TUR) procedures. METHODS: We designed a Global Assessment of Urological Endoscopic Skills (GAUES) tool, comprised of nine endourology task-specific and two global-rating skills items. The tool was developed through two rounds of the Delphi process. The GAUES tool was used to assess acquisition of URS and TUR skills of novices (Year 2 core surgical trainees, CT2) and intermediate level trainees (residents at the start of the UK higher surgical training programme in Urology, Speciality Trainee Year 3, ST3) at the Urology Simulation Boot Camp (USBC) between 2016 and 2018. Validity was evaluated by comparing scores between trainees with different levels of urological experience. Inter-rater reliability was also assessed. RESULTS: We evaluated 130 residents, 52% of trainees were at an intermediate stage of training and 39% were novices. In all, 9% of the anonymous forms were missing demographics. The completion rate of the GAUES tool during the USBC for URS and TUR was 85% and 89%, respectively. Our analysis demonstrated a significant difference in all domains between intermediates and novices at assessment in URS, except for one domain more suited to clinical assessment (P = 0.226). There was excellent intraclass correlation (ICC) overall between the two experts' judgements, ICC = 0.841 (95% confidence interval 0.767-0.893; P < 0.001, n = 88). CONCLUSIONS: We have developed the novel GAUES tool for cystoscopic, URS and TUR skills. Overall, we demonstrated good face, content and construct validity and excellent reliability, suggesting that the GAUES tool can be useful for endourological skills assessment.

Training Nontechnical Skills in Ward Rounds to Improve Team Performance.

OBJECTIVE: To assess the utility of simulated ward rounds to train healthcare professionals in nontechnical skills using a qualitative analysis of participant feedback. DESIGN: We developed simulated scenarios to train members of the surgical healthcare team in nontechnical skills, derived from observations of real ward rounds. Participants performed the simulated ward rounds as a team, led by a Urology trainee. Scenarios were carried out using actors as patients, and a simulated "switchboard" for phone conversations. Throughout the scenarios, distractions were introduced and directed at different members of the participating team. Following each scenario, a whole group debrief took place to discuss and provide feedback on performances. All participants completed a 2-part feedback form comprising of questions answered on a Likert scale, as well as free-text responses. SETTING: All simulations took place in a high-fidelity simulated ward bay. Observers were in a separate room, where the scenarios were projected on a screen in real-time. PARTICIPANTS: Thirty-five healthcare professionals in the department of Urology attended this session. There was no restriction on professional background or seniority for attendees. RESULTS: The qualitative thematic analysis revealed that participants commented positively on the type of scenarios, but would have preferred if more participants could partake in scenarios. The attendees also commended the use of debriefs between scenarios. Suggestions were also given regarding types of scenarios; and involved ensuring that participants are well briefed before each scenario. CONCLUSIONS: This simulated ward round exercise was positively received by participants. The approach to derive scenarios from real ward round observations permitted a variety of the main themes of nontechnical skills to be tested, and improved the fidelity of the simulation. The reflections expressed by participants demonstrate a need for this training, and drives our initiative to raise awareness and develop nontechnical skills in a controlled environment, supported with transparent discussion and feedback.

Current Treatment and Outcomes Benchmark for Locally Advanced or Metastatic Urothelial Cancer From a Large UK-Based Single Centre.

Objectives: To characterize treatment patterns and survival outcomes for patients with locally advanced or metastatic malignancy of the urothelial tract during a period immediately preceding the widespread use of immune checkpoint inhibitors in the UK. Patients and Methods: We retrospectively examined the electronic case notes of patients attending the Leeds Cancer Center, UK with locally advanced or metastatic urothelial carcinoma, receiving chemotherapy between January 2003 and March 2017. Patient characteristics, treatment patterns, and outcomes were collected. Summary and descriptive statistics were calculated for categorical and continuous variables as appropriate. The Kaplan-Meier method was used to estimate median survival and Cox regression proportional hazards model was used to explore relationships between clinical variables and outcome. Results: Two hundred and sixteen patients made up the study cohort, with a median age of 66 years (range: 35-83) and 72.7% being male. First-line treatment consisted of either a cisplatin- (44%) or carboplatin-based regimen (48%) in the majority of patients. Twenty seven percent of patients received a second-line of treatment (most commonly single-agent paclitaxel) following a first-line platinum containing regimen. Grade 4 neutropenia was observed in 19 and 27% of those treated with a first-line cisplatin- and carboplatin-based regimen, respectively. The median overall survival (mOS) of the study cohort was estimated to be 16.2 months (IQR: 10.6-28.3 months). Receipt by patients of cisplatin-based chemotherapy was associated with a longer mOS and this association persisted when survival analysis was adjusted for age, sex, performance status and presence of distant metastases. Conclusions: This study provides a useful benchmark for outcomes achieved in a real-world setting for patients with locally advanced or metastatic UC treated with chemotherapy in the immediate pre-immunotherapy era.

Design, implementation, and evaluation of a novel curriculum to teach transurethral resection of the prostate (TURP): a 3-year experience of urology simulation bootcamp course.

OBJECTIVES: To present the three-year experience of the multi-component TURP module at Urology Simulation Bootcamp Course (USBC) and demonstrate trainee's competence progression and satisfaction. METHODS: During the USBC, a 4-h TURP module was developed and consisted of (a) familiarisation and assembly of resectoscope instrument, (b) didactic lecture on TURP operative techniques and postoperative complications, (c) learning hands-on resection on validated simulators [Samed, GmBH, Dresden, Germany; TURP Mentor™, Simbionix, Israel], and (d) practicing clot evacuation using the Ellik bladder Evacuator. Trainee's level of instrument knowledge, operative competence, and confidence were assessed pre- and post-course. Trainee's feedback was also collected. RESULTS: One hundred thirty trainees participated in the USBC between 2016 and 2018. Eighty-seven percent of trainees scored themselves as 1-3 (low confidence in resection) on a 5-point Likert scale. Trainees significantly improved in their ability to perform resectoscope assembly for resection, coagulation and incision by 33.6% (p < 0.001), 28.1% (p < 0.001) and 34.0% (p < 0.001), respectively. There was a significant improvement in scores in itemised technical skill on the TURP simulator following completion of the TURP module (Mean difference = 3.4 points, 95% CI 2-4, p < 0.001). Ninety-one percent of trainees agreed that the TURP module was useful for their development in urological training. CONCLUSION: Our results demonstrated that it is feasible to develop and implement a focussed module for teaching TURP with significant improvement in learning. Trainee feedback suggests that they were highly satisfied with the teaching provided and models used. This style of training can be implemented for other common surgical procedures.

A Low-Cost Synthetic Abdominal Wall Model ("Raj Model") for the Training of Laparoscopic Port Insertion.

OBJECTIVE: To assess the content validity of a low-cost bench-top model ("Raj Model") for the training of laparoscopic port insertion at the Urology Simulation Bootcamp course (USBC). MATERIALS AND METHODS: A low-cost abdominal wall model of 40 × 40 cm was created to simulate laparoscopic port placement. The model was made using different synthetic materials to represent layers (skin-vinyl sheet, subcutaneous fat-10 mm soft foam, anterior rectus sheath and muscle-floor mat, posterior rectus sheath-masking wall tape, peritoneum-sellotape). Each model was used by up to 3 trainees to practise laparoscopic port placement. The model was assessed for content validity by trainees and experts using a 5-point Likert scale. RESULT: In total, 88 trainees and 6 experts participated in the study. For all aspects of the synthetic abdominal wall, good (4) or very good (5) scores ranged from 52.7-69.2%, whereas very poor (1) rating ranged from 0 to 4.3%. There was no significant difference in responses for the content validity of the model between trainees and experts. There was a high intraclass correlation amongst responses from trainees (0.89) and experts (0.79). Approximately 76.3% of trainees and experts felt that the model is suitable for training. CONCLUSION: This is the first validation study of a low-cost abdominal wall model for teaching laparoscopic port placement for trainees. Our study demonstrates that this synthetic model has high content validity and is useful for surgical training.

Pilot implementation and evaluation of a national quality improvement taught curriculum for urology residents: Lessons from the United Kingdom.

BACKGROUND: We report the immediate educational impact of a previously developed quality improvement (QI) curriculum for UK urology residents. MATERIALS AND METHODS: Prospective pre/post-training evaluation, using the Kirkpatrick framework: residents' QI knowledge, skills and attitudes were assessed via standardized assessments. We report descriptive/inferential statistics and scales psychometric analyses. RESULTS: Ninety-eight residents from across the UK provided full datasets. Scale reliability was good (Cronbach-alphas = 0.485-0.924). Residents' subjective knowledge (Mpre = 2.71, SD = 0.787; Mpost = 3.97, SD = 0.546); intentions to initiate QI (Mpre = 3.65, SD = 0.643; Mpost = 4.09, SD = 0.642); attitudes towards doing QI (Mpre = 3.67, SD = 0.646; Mpost = 4.11, SD = 0.591); attitudes towards QI at work (Mpre = 3.80, SD = 0.511; Mpost = 4.00, SD = 0.495); and attitudes towards influencing QI (Mpre = 3.65, SD = 0.482; Mpost = 3.867, SD = 0.473) all improved post-training (all ps < 0.0001). Objective knowledge remained stable (58%-59%, p > 0.05). Residents' satisfaction was high. CONCLUSIONS: Our novel QI training is educationally sound and feasible to deliver. Longitudinal evaluation and scalability are planned.

Impact of urology simulation boot camp in improving endoscopic instrument knowledge.

Objective: Education and training of surgeons has traditionally focused on the development of individual knowledge, technical skills and decision making. Knowledge about endoscopic instruments is one of the core elements of urological training. We assessed the precourse knowledge of newly appointed urology trainees and the impact of boot camp in improving their knowledge. Methods: Newly appointed specialty trainees in urology took part in a pilot 5-day urology simulation boot camp (USBC). The aim of the USBC was to improve their confidence, procedural performance and non-technical skills, with one of the modules looking at the trainees' knowledge about common endoscopic instruments in urology. Delegates were first asked to identify and assemble the instruments, followed by one-to-one teaching about the instruments. An Objective Structured Assessment Tool was used to assess their knowledge in the identification and assembly of the cystoscope, resectoscope and optical urethrotome, before and at the end of the course. Results: Data of two successive boot camps were collected to assess knowledge of instruments of newly appointed urology trainees. Majority of the trainees had good precourse knowledge of the cystoscopy kit, with 84% able to correctly identify the parts. Seventy-six per cent of candidates were able to identify the resectoscope equipment, but only approximately a third of trainees were able to correctly identify the urethrotome kit. The assembly of cystoscope, resectoscope and urethrotome was performed correctly in 74%, 42% and 32% at baseline and 94%, 90% and 77% postcourse, respectively. Overall performance improved significantly in the postcourse assessment (<0.001). Conclusion: This urology boot camp has addressed gaps in trainees' core equipment knowledge and guided them to improve their knowledge with respect to identification and assembly of cystoscope, resectoscope and urethrotome.

A Method to Evaluate Trainee Progression During Simulation Training at the Urology Simulation Boot Camp (USBC) Course.

OBJECTIVES: To evaluate skills progression at the Urology Simulation Boot Camp (USBC), a course intended to provide urology trainees with 32 hours of 1:1 training on low and high-fidelity simulators. DESIGN: In this single-group cohort study, trainees rotated through modules based on aspects of the United Kingdom urology residency curriculum and undertook a pre and postcourse MCQ. Specific procedural skill was evaluated by an expert and graded as either: "A"-Good (≥4 on a 5-point Likert Scale) or "B"-Poor (Likert scale of 1-3). Competence progression was calculated as the change in score between baseline and final assessments. SETTING: The USBC was held at St James' University Hospital, Leeds, U.K. PARTICIPANTS: Of the 34 trainees attended the second USBC, 33 trainees participated in all the pre and postcourse assessments. The mean duration of urology training prior to undertaking the USBC was 15 months. RESULTS: Competence progression was assessed in 33 urology trainees. Mean MCQ scores improved by 16.7% (p < 0.001) between pre and postcourse assessment. At final assessment, 87.9% of trainees scored "A" in instrument knowledge and assembly compared to 44.4% at baseline (p < 0.001). There was a mean improvement of 439s (p < 0.001) in the time taken to complete the European-Basic Laparoscopic skills assessment. CONCLUSIONS: The USBC has shown to aid trainees in competence progression during the simulation on a variety of urological skills; however, retention of skill in the long-term was undetermined. The use of our grading system is simple to understand and may be used in other simulation courses to guide participants with their future training needs.

Simulation in urology to train non-technical skills in ward rounds.

OBJECTIVE: To report our experience of an exercise designed to train newly appointed urology trainees in non-technical skills on ward rounds as a part of a simulation 'boot camp', through a qualitative analysis of participant feedback on the utility of this method of training. PATIENTS AND METHODS: The simulations took place in a high-fidelity simulated ward bay. Forty-eight doctors with formal urology training ranging between 2 and 60 months (mean 19.1 ± 11.6 months) took part. Thirty-one participants were on a formal urology specialty training pathway. The remaining participants were core (pre-specialty) surgical trainees. The entry requirement was that participants must be junior-level urologists, ideally at the beginning of specialty training. Participants individually led a simulated ward round, which was devised using actors to play patients and a simulated 'switchboard' for telephone conversations. Distractions were introduced deliberately for participants to manage an emergent urology-related scenario. 'Freeze-frames' were used to 'pause' the ward round, whereby observing consultants provided feedback on performance. After the simulated exercises, a whole-group structured debriefing took place. Non-Technical Skills for Surgeons (NOTSS) scores were generated for participants by seven consultant urologists. Participants completed a two-part feedback form. Part one involved nine questions scored on a Likert scale, and part two required free-text responses. RESULTS: The mean (±sd) itemized NOTSS scores for situational awareness, decision-making, communication and teamwork, and leadership were 3.01 (±0.15), 2.95 (±0.16), 3.05 (±0.19), and 2.98 (±0.15), respectively. From the thematic analysis, participants commented positively on the number of scenarios per participant, the use of actors as patients and real staff, and the use of freeze-frames for immediate feedback. Residents also provided suggestions for distractions to be considered in the future. CONCLUSIONS: This simulated ward round was generally well received by participants, and the obtained feedback provides an insight into how this can be adapted to maximize the benefits for new specialty residents. The mean NOTSS scores indicated that non-technical skills performances could be improved. This supports our rationale to train non-technical skills in a safe environment to bolster career transition into positions of greater decision-making autonomy.

Genomic Subtypes of Non-invasive Bladder Cancer with Distinct Metabolic Profile and Female Gender Bias in KDM6A Mutation Frequency.

Bladder cancer incurs a higher lifetime treatment cost than other cancers due to frequent recurrence of non-invasive disease. Improved prognostic biomarkers and localized therapy are needed for this large patient group. We defined two major genomic subtypes of primary stage Ta tumors. One of these was characterized by loss of 9q including TSC1, increased KI67 labeling index, upregulated glycolysis, DNA repair, mTORC1 signaling, features of the unfolded protein response, and altered cholesterol homeostasis. Comparison with muscle-invasive bladder cancer mutation profiles revealed lower overall mutation rates and more frequent mutations in RHOB and chromatin modifier genes. More mutations in the histone lysine demethylase KDM6A were present in non-invasive tumors from females than males.

Radical cystectomy (bladder removal) against intravesical BCG immunotherapy for high-risk non-muscle invasive bladder cancer (BRAVO): a protocol for a randomised controlled feasibility study.

INTRODUCTION: High-risk non-muscle invasive bladder cancer (HRNMIBC) is a heterogeneous disease that can be difficult to predict. While around 25% of cancers progress to invasion and metastases, the remaining majority of tumours remain within the bladder. It is uncertain whether patients with HRNMIBC are better treated with intravesical maintenance BCG (mBCG) immunotherapy or primary radical cystectomy (RC). A definitive randomised controlled trial (RCT) is needed to compare these two different treatments but may be difficult to recruit to and has not been attempted to date. Before undertaking such an RCT, it is important to understand whether such a comparison is possible and how best to achieve it. METHODS AND ANALYSIS: BRAVO is a multi-centre, parallel-group, mixed-methods, individually randomised, controlled, feasibility study for patients with HRNMIBC. Participants will be randomised to receive either mBCG immunotherapy or RC. The primary objective is to assess the feasibility and acceptability of performing the definitive phase III trial via estimation of eligibility and recruitment rates, assessing uptake of allocated treatment and compliance with mBCG, determining quality-of-life questionnaire completion rates and exploring reasons expressed by patients for declining recruitment into the study. We aim to recruit 60 participants from six centres in the UK. Surgical trials with disparate treatment options find recruitment challenging from both the patient and clinician perspective. By building on the experiences of other similar trials through implementing a comprehensive training package aimed at clinicians to address these challenges (qualitative substudy), we hope that we can demonstrate that a phase III trial is feasible. ETHICS AND DISSEMINATION: The study has ethical approval (16/YH/0268). Findings will be made available to patients, clinicians, the funders and the National Health Service through traditional publishing and social media. TRIAL REGISTRATION NUMBER: ISRCTN12509361; Pre results.