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Background\ud Multimodal enhanced recovery after surgery (ERAS) regimens have improved outcomes from colorectal surgery.\ud \ud Objective\ud We report the application of ERAS to patients undergoing radical cystectomy (RC).\ud \ud Design, setting, and participants\ud Prospective collection of outcomes from consecutive patients undergoing RC at a single institution.\ud \ud Intervention\ud Twenty-six components including prehabilitation exercise, same day admission, carbohydrate fluid loading, targeted intraoperative fluid resuscitation, regional local anaesthesia, cessation of nasogastric tubes, omitting oral bowel preparation, avoiding drain use, early mobilisation, chewing gum use, and audit.\ud \ud Outcome measurements and statistical analysis\ud Primary outcomes were length of stay and readmission rate. Secondary outcomes included intraoperative blood loss, transfusion rates, survival, and histopathological findings.\ud \ud Results and limitations\ud Four hundred and fifty-three consecutive patients underwent RC, including 393 (87%) with ERAS. Length of stay was shorter with ERAS (median [interquartile range]: 8 [6–13] d) than without (18 [13–25], p < 0.001). Patients with ERAS had lower blood loss (ERAS: 600 [383–969] ml vs 1050 [900–1575] ml for non-ERAS, p < 0.001), lower transfusion rates (ERAS: 8.1% vs 25%, chi-square test, p < 0.001), and fewer readmissions (ERAS: 15% vs 25%, chi-square test, p = 0.04) than those without. Histopathological parameters (eg, tumour stage, node count, and margin state) and survival outcomes did not differ with ERAS use (all p > 0.1). Multivariable analysis revealed ERAS use was (p = 0.002) independently associated with length of stay.\ud \ud Conclusions\ud The use of ERAS pathways was associated with lower intraoperative blood loss and faster discharge for patients undergoing RC. These changes did not increase readmission rates or alter oncological outcomes.\ud \ud Patient summary\ud Recovery after major bladder surgery can be improved by using enhanced recovery pathways. Patients managed by these pathways have shorter length of stays, lower blood loss, and lower transfusion rates. Their adoption should be encouraged.

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.

INTRODUCTION: Tuberculosis was once a disease much more prominent in the minds of UK urologists. The dramatic reduction in incidence following the success of antituberculous therapy has meant that new generation surgeons have little or no experience of the effects and management of tuberculosis of the kidney. With concern over multidrug resistant tuberculosis, human immunodeficiency virus associated tuberculosis and immigration of persons from areas endemic with this disorder, clinicians may see an increase in cases of renal tuberculosis. Renal tuberculosis "autonephrectomy" is the end stage of chronic renal tuberculosis infection and results from the caseous necrosis and progressive cavitation of the kidney. Resultant calcification may mimic the appearances of a renal calculus on plane film X-ray. Back, flank and abdominal pain are non-specific symptoms often investigated by General Practitioners using plane film X-ray. Clinicians not considering a diagnosis of renal tuberculosis may confuse the radiographic appearances with that of a renal calculus as occurred in our case. Once a diagnosis of tuberculosis autonephrectomy is made the next decision is whether any further investigations and treatment is necessary as the condition has been reported to be a cause of hypertension and reactivation of tuberculosis is also possible. \ud \ud CASE PRESENTATION: We describe the case of a 66 year old Caucasian female who presented to her General Practitioner with left sided lumber and loin pain. A lumbar spine X-ray showed a calcified mass reported as a renal calculus. Urological opinion was sort and a computerised tomogram confirmed a renal tuberculosis "auto nephrectomy". The patient had been diagnosed with tuberculosis aged 16. The patient had no lower urinary tract symptoms and normal urinalysis. Although there is some evidence to suggest nephrectomy is beneficial in treating hypertension in these patients (the patient in our case was on two anti hypertensive preparations), the patient did not want to consider surgery as her symptoms had settled spontaneously. \ud \ud CONCLUSION: Although very rare in non endemic countries clinicians still need to consider a diagnosis of renal tuberculosis in patients with previous tuberculosis exposure and calcification of the urinary tract. In cases of uncontrolled hypertension consideration should be given to nephrectomy in cases of end stage renal tuberculosis. This decision should be made in consultation with a nephrologist.