Bilateral large cell calcifying Sertoli cell tumours: A testicular preservation approach in a young male.

Testicular Large cell calcifying Sertoli cell tumours (LCCSTs) are extremely rare. The primary challenge in benign LCCSTs, which are typically multifocal and bilateral tumours affecting young males, is to confirm the diagnosis to avoid radical intervention and preserve fertility potential. Patient clinical presentation, laboratory results, diagnostic radiological tests along with confirmatory histopathological studies, are the cornerstones in such cases, nevertheless genetic testing is warranted, as LCCSTs can be part of genetic syndrome such Carney complex. We present a case of bilateral benign LCCSTs in young male managed with testicular preservation approach with characteristic clinical, radiological and histopathological features.

Recurrent urinary retention due to seminal vesicle cyst a report of rare entity.

Male pelvic cyst rarely causes symptoms; here, we are presenting a case of a 48-year-old gentleman who presented with acute urinary retention stemming from a pelvic cyst. This presentation has been recurrent despite undergoing repeated TRUS aspiration of the cyst to relieve the symptoms. We performed a robotic pelvic cyst excision with peritoneal window in an attempt to cure the patient. Based on the MRI and histopathology, it was likely a seminal vesicle cyst that is causing these recurrent episodes. On 3 months follow-up, the patient was symptom free without any complaints.

The role of Rezum in the management of refractory urinary retention due to benign prostate hyperplasia: A literature review.

Background: Benign prostatic hyperplasia is the most common cause of urinary retention in men (BPH). The gold standard surgical treatment is transurethral resection of the prostate (TURP). However, due to the morbidity and mortality associated with TURP, more minimally invasive treatments, such as vaporizing the prostate with the Rezum system, have been introduced. We investigated the efficacy of Rezum in the treatment of refractory urinary retention due to BPH in this review. Methodology and materials: To conduct this review, the Cochrane methodology for systematic reviews was used. All studies that used Rezum to treat catheter-dependent patients with enlarged prostates were included. The literature search showed 111 studies, 84 of which were excluded due to non-relevance based on titles and 18 due to lack of relevance based on abstract review. Full manuscripts were reviewed in nine studies, three of which were excluded because they did not meet the inclusion criteria. Results: This review included 301 patients in total. The rate of a successful trial of voiding post Rezum therapy was 85%. The complication rated between 3.8 and 4.3% all of which were mild and self-limited. As there was no major complication of Rezum (clavien dindo >2), the procedure-related morbidity is negligible. Conclusion: In this review, Rezum was found to be an efficacious and safe alternative in the treatment of refractory retention with mild complications and minimal morbidity.

Reinventing Patient Support and Continuity of Care Using Innovative Physician-staffed Hotline: More than 60,000 Patients Served Across 15 Medical and Surgical Specialties During the First Wave of COVID-19 Lockdown in Qatar.

Rising disease prevalence early during the COVID-19 pandemic in the State of Qatar led to stoppage of all non-emergency health care services. To maintain continuity of care and information exchanges for non-emergency patients, a physician-operated telephone hotline was set up that involved triage followed by immediate consultation with a specialized physician. We describe the initiation and evaluate the operations of the Urgent Consultation Centre (UCC) hotline manned by 150 physicians and aimed at urgent non-life-threatening consultations at Hamad Medical Corporation, the public health provider in Qatar. UCC established a hotline to triage inbound patient calls related to 15 medical and surgical specialties. For calls between April-August 2020, we describe call volume, distribution by specialty, outcomes, performance of UCC team, as well as demographics of callers. During the study period, UCC received 60229 calls (average 394 calls/day) from Qatari nationals (38%) and expatriates (62%). Maximum total daily calls peaked at 1670 calls on June 14, 2020. Call volumes were the highest from 9 AM to 2 PM. Response rate varied from 89% to 100%. After an initial telephone triage, calls were most often related to and thus directed to internal medicine (24.61%) and geriatrics (11.97%), while the least percentage of calls were for pain management and oncology/hematology (around 2% for each). By outcome of consultation, repeat prescriptions were provided for 60% of calls, new prescriptions (15%), while referrals were to outpatient department (17%), emergency department/pediatric emergency center (5%), and primary health care centres (3%). We conclude that during a pandemic, physician-staffed telephone hotline is feasible and can be employed in innovative ways to conserve medical resources, maintain continuity of care, and serve patients requiring urgent care.

Memokath for treating ureteric stricture post cryoablation of renal mass: A case report of rare complication and proposed alternative management.

The use of cryoablation in the management of small renal masses is widely acceptable. Although rare but ureteral injury during the procedure with subsequent stricture formation can result in devastating effects on renal function. On the other hand, the management of such strictures requires reconstructive surgery as gold standard. Unfortunately, in some cases the reconstructive surgery might not be feasible, and the treatment usually is ureteral stent insertion that need to be changed regularly. Here we present a case of a 53-year-old gentleman who developed an upper ureteric iatrogenic stricture post cryoablation in which the reconstructive surgery was not feasible due to high procedural risk. We used metallic ureteral stent (Memokath) instead of regular ureteral double J stent. We found that if the reconstructive surgery is not possible the usage of Memokath in treating iatrogenic ureteral strictures is associated with better quality of life, lower costs and a similar functional outcome when compared to ureteral double J stent that needs regular frequent changes.

COVID-19 and renal involvement: a prospective cohort study assessing the impact of mild SARS-CoV-2 infection on the kidney function of young healthy males.

PURPOSE: COVID-19 frequently affects the kidneys with symptoms ranging from mild proteinuria to progressive acute kidney injury. This prospective study aimed to assess the short- and long-term impact of asymptomatic and mild COVID-19 on the renal function of healthy young adults, and to determine the correlation between viral load and kidney function among these patients. METHODS: This was a prospective cohort study conducted over a period of 6 months. Patients were followed-up at baseline, and then after 3 and 6 months, respectively. Real-time PCR cycle threshold (CT) was used to determine the viral load and disease activity. Patients were classified into two groups with either asymptomatic COVID-19 or mild pneumonia. The assessment parameters were variables that could directly or indirectly relate to the renal function. RESULTS: A total of 48 patients were included and evaluated. The majority of patients (62.5%) had asymptomatic COVID-19 disease. Patients with mild pneumonia had significantly higher serum creatinine (SCr) at the time of COVID-19 diagnosis (beta = 12.836, 95% CI = 2.405-23.268, P = 0.019), after 3 months (beta = 14.345, 95% CI = 1.149-27.542, P = 0.035), and after 6 months (beta = 14.100, 95% CI = 0.730-27.470, P = 0.040) compared to asymptomatic patients. Mild pneumonia was also significantly associated with lower serum albumin level at the time of COVID-19 diagnosis (beta = - 6.317, 95% CI = - 9.448-- 3.185, P < 0.001). CONCLUSION: Mild COVID-19 is associated with mild renal involvement without AKI. Changes in the renal function appear to be related to reduced creatinine clearance and possible albumin leakage in the acute phase of the disease. The reduction in creatinine clearance is not predicted by viral load, and it appears to be a long-term effect of the disease that can last for at least 6 months.

Synchronous Bilateral Testicular Tumors With Discordant Histopathology: A Rare Case in an Infertile Male.

Testicular cancer, accounting for 1-1.5% of male malignancies, rarely presents bilaterally, with only 2-3% of cases being bilateral and a mere 10% being synchronous, typically sharing histological patterns in both testes. Discordant histological presentation is exceedingly rare, with only a few reported cases. In this report, we detail a case involving a 35-year-old infertile male with bilateral synchronous testicular tumors, each exhibiting different histopathologies. This case highlights the diagnostic intricacies and the necessity for tailored management in the face of such uncommon presentations. The implications of oncological treatment and fertility preservation significantly affect the patient's overall quality of life.

Primary bladder amyloidosis mimicking bladder cancer complicated by bladder rupture: A case report.

Amyloidosis is related to the extracellular deposition of abnormal protein fibrils in various tissues. It can be either localized to an organ or generalized, affecting multiple systems. Amyloidosis of the urinary bladder is a rare histopathological finding. It is clinically interesting that such cases' clinical, radiological, and even endoscopic presentation mimic urothelial carcinoma to a great extent. Here, we discuss a case of a 49-year-old gentleman who presented with frank painless hematuria. The patient was diagnosed with a bladder mass suspicious of malignancy depending on the clinical presentation aided by the cystoscopic and radiological evaluation. Histopathologic samples of the transurethral resection of the mass proved to be primary bladder amyloidosis. This case is of unique clinical interest in that it is the first case reported of bladder amyloidosis that is complicated by extraperitoneal bladder rupture post-operatively. However, no immediate intraoperative perforation to the bladder wall during resection was evidenced.

Evaluation of how users interface with holographic augmented reality surgical scenes: Interactive planning MR-Guided prostate biopsies.

BACKGROUND: User interfaces play a vital role in the planning and execution of an interventional procedure. The objective of this study is to investigate the effect of using different user interfaces for planning transrectal robot-assisted MR-guided prostate biopsy (MRgPBx) in an augmented reality (AR) environment. METHOD: End-user studies were conducted by simulating an MRgPBx system with end- and side-firing modes. The information from the system to the operator was rendered on HoloLens as an output interface. Joystick, mouse/keyboard, and holographic menus were used as input interfaces to the system. RESULTS: The studies indicated that using a joystick improved the interactive capacity and enabled operator to plan MRgPBx in less time. It efficiently captures the operator's commands to manipulate the augmented environment representing the state of MRgPBx system. CONCLUSIONS: The study demonstrates an alternative to conventional input interfaces to interact and manipulate an AR environment within the context of MRgPBx planning.

Combined percutaneous and transurethral cystoscopy for large urethral foreign bodies: A case report and literature review.

Since early reports in the literature, cases with urethral foreign bodies have been extremely variable and interestingly challenging. Various presentations have been reported, including self-insertion for sexual pleasure, assaults, trauma, and foreign bodies migration. Management by endoscopic surgery is usually a preferred option for small foreign bodies. Open surgery is reserved for large objects with difficult access. We present a case of self-insertion of a large urethral foreign body with a caliber of 45F in a young gentleman. Endoscopic extraction of the foreign body was safely successful using combined percutaneous and transurethral cystoscopy.

End-user evaluation of software-generated intervention planning environment for transrectal magnetic resonance-guided prostate biopsies.

BACKGROUND: This study presents user evaluation studies to assess the effect of information rendered by an interventional planning software on the operator's ability to plan transrectal magnetic resonance (MR)-guided prostate biopsies using actuated robotic manipulators. METHODS: An intervention planning software was developed based on the clinical workflow followed for MR-guided transrectal prostate biopsies. The software was designed to interface with a generic virtual manipulator and simulate an intervention environment using 2D and 3D scenes. User studies were conducted with urologists using the developed software to plan virtual biopsies. RESULTS: User studies demonstrated that urologists with prior experience in using 3D software completed the planning less time. 3D scenes were required to control all degrees-of-freedom of the manipulator, while 2D scenes were sufficient for planar motion of the manipulator. CONCLUSIONS: The study provides insights on using 2D versus 3D environment from a urologist's perspective for different operational modes of MR-guided prostate biopsy systems.

Diagnostic performance of multi-parametric MRI to differentiate benign sex cord stromal tumors from malignant (non-stromal and stromal) testicular neoplasms.

PURPOSE: Testicular stromal tumors are uncommon, although mostly benign. The purpose of this study is to assess the role of multi-parametric MRI in differentiating benign testicular stromal tumors from malignant testicular neoplasms (non-stromal and stromal). METHODS: A single-center retrospective study comparing benign stromal tumors (STs) to malignant testicular neoplasms (MTNs) was conducted. MR imaging assessment included tumor size, T2- and T1-weighted signal intensity, T2- and T1-weighted texture pattern, diffusion restriction, presence of hemorrhage and/or necrosis, and measurement of apparent diffusion coefficient and dynamic contrast enhancement (DCE). Inter-observer agreement was assessed using Cohen's kappa and Bland-Altman and data were compared using independent t-tests or χ2. Receiver operating characteristic curve analysis was used to test models incorporating various imaging features. RESULTS: Radical orchiectomy and histopathology revealed 20 testicular neoplasms: seven STs (35%) and thirteen MTNs (65%). MTNs were significantly larger in size than STs (5.1 ± 2.36 cm vs. 1.27 ± 0.56 cm; p-value < 0.001). STs demonstrated more hypointense T2W signal (85.7% vs. 46.2%; p-value < 0.09), less T2W heterogeneous texture (14.3% vs. 61.5%; p-value < 0.04), and less diffusion restriction (16.7% vs. 83.3%; p-value < 0.01) in comparison to MTNs. STs demonstrated mainly homogenous post-contrast enhancement pattern (71.4% vs. 7.7%; p-value < 0.004), while MTNs showed primarily heterogeneous enhancement pattern (77% vs. 14.3%; p-value < 0.02). STs revealed greater corrected venous phase enhancement (STs: 0.59 ± 0.29; MTNs: 0.25 ± 0.25; p-value < 0.03). STs showed higher ADC values, though the difference was not statistically significant (p-value < 0.25). A model combining T2W, DWI, and DCE features showed the best overall diagnostic accuracy with area under ROC curve of 0.99 and confidence interval ranging from 0.94 to 1. CONCLUSION: Multi-parametric MRI can potentially differentiate benign stromal tumors from malignant testicular neoplasms, which can help to avoid radical orchiectomy. However, future studies using larger sample sizes are needed to validate our results.

Targeting Wnt/EZH2/microRNA-708 signaling pathway inhibits neuroendocrine differentiation in prostate cancer.

Prostate cancer (PC) castration resistance has been linked to the differentiation of PC luminal cells into hormone-refractory neuroendocrine (NE) cells. However, the molecular mechanisms controlling the emergence of lethal NE prostate cancer (NEPC) remain unclear. The present study aimed to investigate the mechanisms underlying the transition from prostate adenocarcinoma to NEPC. The microRNA miR-708 was involved in NE differentiation and was downregulated in NEPC cells and tumor specimens. miR-708 targeted Sestrin-3 to inhibit Forkhead Box O1 (FOXO1) phosphorylation, resulting in apoptosis of prostate adenocarcinoma cells and AKT-inactivated NEPC cells, the latter of which was consistent with the progression of tumor xenografts in mice under miR-708 treatment. In silico analysis of PC and NEPC tumor specimens suggested that the polycomb repressive complex subunit Enhancer of zeste homolog 2 (EZH2) was particularly overexpressed in NEPC. Notably, EZH2 bound to the miR-708 promoter and induced its silencing in NEPC. Inhibition of EZH2 prevented NE differentiation of PC cells. EZH2 expression was regulated by both Cyclin Dependent Kinase 1 (CDK1) and Wnt signaling. Silencing transcription factor 4 (TCF4), as a key protein in Wnt signaling, prevented NEPC formation. These results provide a molecular basis for the roles of miR-708 and EZH2 in NE differentiation in PC and highlight a new paradigm in NEPC formation and survival.

Geographical differences in semen characteristics of 13 892 infertile men.

OBJECTIVE: To assess the relationship between geographical differences and all semen parameters, across 13,892 infertile men of 84 diverse nationalities, recruited at a specialised tertiary hospital that represents the main healthcare provider in Qatar. Male infertility is an important and global public health problem. Despite this, there is a significant scarcity of epidemiological male infertility and semen analysis research in the Middle East and North Africa (MENA) region, as well as geographical comparisons with other parts of the world. PATIENTS AND METHODS: Retrospective study of semen findings of 13 892 infertile men assessed at the Male Infertility Unit at Hamad Medical Corporation, in Qatar between January 2012 and August 2015. Based on country of origin, patients were categorised into those from the MENA region (n = 8799) and non-MENA patients (n = 5093). The two groups were compared across demographic features and semen characteristics: age, sperm volume, sperm total motility, sperm progressive motility (PMot), abnormal sperm forms (ABF), and sperm DNA fragmentation (SDF). RESULTS: The whole sample's mean (SD) age was 35.7 (0.7) years, sperm concentration was 32.3 (0.25) × 106 sperm/mL, total motility was 45.4 (0.2)%, sperm PMot was 25.1 (0.2)%, and ABF was 79.9 (0.2)%. Overall, 841 patients had azoospermia (6.05%), 3231 had oligospermia (23.3%), 4239 had asthenospermia (30.5%) and 6772 had teratospermia (48.7%). SDF (1050 patients) was abnormal in 333 patients (31.7%). MENA patients were significantly younger than their non-MENA counterparts and had a greater semen volume. Non-MENA patients had significantly higher sperm counts, total motility and PMot, and lower ABF. SDF showed no statistical difference between the two groups. MENA patients had significantly higher prevalence of oligospermia, asthenospermia, and teratospermia; and lower prevalence of normal sperm concentration, normal motility, and normal morphology. Throughout the 4 years of the study, MENA patients constantly had significantly lower sperm counts; generally lower sperm total motility percentage and generally lower quality sperm morphology. We compared patients by age (≤40 and >40 years): in the patients aged ≤40 years, the same results as for the overall study were reproduced; in the >40-years group, the same results were reproduced with the exception of morphology, which was not significantly different between the MENA and non-MENA patients. CONCLUSION: Semen quality is generally lower in male infertility patients from the MENA region compared to non-MENA regions.

Oxidation-reduction potential and sperm DNA fragmentation, and their associations with sperm morphological anomalies amongst fertile and infertile men.

OBJECTIVE: To assess seminal oxidation-reduction potential (ORP) and sperm DNA fragmentation (SDF) in male infertility and their relationships with sperm morphology in fertile and infertile men. PATIENTS AND METHODS: Prospective case-control study comparing the findings of infertile men (n = 1168) to those of men with confirmed fertility (n = 100) regarding demographics and semen characteristics (conventional and advanced semen tests). Spearman rank correlation assessed the correlation between ORP, SDF, and different morphological indices. Means of ORP and SDF were assessed in variable levels of normal sperm morphology amongst all participants. RESULTS: Infertile patients had a significantly lower mean sperm count (32.7 vs 58.7 × 106 sperm/mL), total motility (50.1% vs 60.4%), and normal morphology (5.7% vs 9.9%). Conversely, infertile patients had significantly higher mean head defects (54% vs 48%), and higher ORP and SDF values than fertile controls. ORP and SDF showed significant positive correlations and significant negative correlations with sperm head defects and normal morphology in infertile patients, respectively. ORP and SDF were significantly inversely associated with the level of normal sperm morphology. Using receiver operating characteristic curve analysis, ORP and SDF threshold values of 1.73 mV/106 sperm/mL and 25.5%, respectively, were associated with 76% and 56% sensitivity and 72% and 72.2% specificity, respectively, in differentiating <4% from ≥4% normal morphology. CONCLUSION: A direct inverse relationship exists between seminal ORP and SDF with various levels of normal sperm morphology. Using ORP and SDF measures in conjunction with standard semen morphology analysis could validate the result of the fertility status of patients.

What Is the Role of α-Blockers for Medical Expulsive Therapy? Results From a Meta-analysis of 60 Randomized Trials and Over 9500 Patients.

Use of α-blockers for medical expulsive therapy (MET) has been the subject of huge debate in urology. Moreover, there have been a number of randomized controlled trials with differing results. We conducted a systematic review and meta-analysis of randomized controlled trials investigating the efficacy of α-blockers for MET. This review confirms there is a role for α-blockers in MET for ureteric stones specifically in stones >5 mm and distal ureteric stones, which is associated with improved stone expulsion. However, there is a slight increase in risk of nonsignificant side effects.

Prostate cancer small non-coding RNA transcriptome in Arabs.

BACKGROUND: Prostate cancer (PCa) is a complex disorder resulting from the combined effects of multiple environmental and genetic factors. Small non-coding RNAs (sRNAs), particularly microRNAs (miRNAs), regulate several cellular processes and have an important role in many human malignancies including PCa. We assessed the sRNA profiles associated with PCa in Arabs, a population that has rarely been studied. METHODS: We used next generation sequencing technology to obtain the entire sRNA transcriptome of primary prostate tumor formalin-fixed paraffin-embedded tissues, and their paired non-tumor tissues, collected from Bedouin patients (Qatari and Saudi). The miRNA and the target gene expression were evaluated by real-time quantitative PCR. miRNA KEGG pathway and miRNA target genes were subsequently analyzed by starBase and TargetScan software. RESULTS: Different expression patterns of several sRNA and miRNA editing were revealed between PCa tumor and their paired non-tumor tissues. Our study identified four miRNAs that are strongly associated with prostate cancer, which have not been reported previously. Differentially expressed miRNAs significantly affect various biological pathways, such as cell cycle, endocytosis, adherence junction and pathways involved in cancer. Prediction of potential targets for the identified miRNAs indicates the overexpression of KRAS, BCL2 and down-regulation of PTEN in PCa tumor tissues. CONCLUSION: These miRNAs, newly associated with prostate cancer, may represent not only markers for the increased risk of PCa in Arabs, but may also reflect the clinical and pathological diversity as well as the ethno-specific heterogeneity of prostate cancer.

Does the number of veins ligated during microsurgical subinguinal varicocelectomy impact improvement in pain post-surgery?

BACKGROUND: We examined the impact of the number of veins ligated during varicocelectomy on post-surgical improvement of pain in a group of men presenting with clinical varicocele and pain as an indication for surgery. METHODS: This is a retrospective study of patients presenting with clinical left varicocele to the male infertility unit at a teaching hospital in Qatar. Files of all patients who underwent sub-inguinal microsurgical varicocelectomy were retrieved and categorized into three groups indicating the number of spermatic veins ligated during varicocelectomy. The presence of pain was assessed during pre- and post-operation (at 3 and 6 months). Statistical analysis was performed using Kruskal-Wallis test (K) and Chi-square test (C). RESULTS: Out of 675 records, 207 (30.7%) patients did left varicocelectomy for pain. Their mean age was 35.3±9.2 years. Pain was assessed in 106/207 (51.2%) patients post operatively, of whom 89 (84%) reported complete resolution of symptoms. This improvement was maintained irrespective of the number of veins ligated during surgery (<5 veins: 90.0%, 5-10 veins: 81.5%, and >10 veins: 85.7%). CONCLUSIONS: Microsurgical subinguinal varicocelectomy is a valid treatment method for patients with a symptomatic clinical varicocele. While a significant post-surgical (at 6 months) reduction of pain was detected, the number of veins ligated intraoperatively was not predictive of post-operative improvement of pain in this study population.

The world's contribution to the field of urology in 2015: A bibliometric study.

OBJECTIVE: To explore factors associated with a successful research atmosphere by investigating the distribution of articles published in the field of urology in 2015 amongst different world regions, as research is undoubtedly a valuable tool that can help shape the future of human health. METHODS: The Scopus® database was searched for publications made by Urology journals enlisted in the SCImago journal and country rank website. Details about each article type, language, and country of origin were collected. Journals' bibliometric measures, as well as their country of origin and the number publications since the year 1996 were also collected. Countries were divided according to the United Nations geoscheme. RESULTS: In all, 80 of 93 registered Urology journals publishing a total of 10,181 articles were included in the study. Results reveal that the highest contribution came from North America (37.4%) followed by Europe (29.4%), Asia (26.5%), South America (2.2%), Africa (1.9%), and Oceania (1.7%). Bibliometric analysis of the published articles showed significantly higher impact measures amongst North American publications, followed by those from Europe, Oceania, South America, Asia, and Africa (P < 0.001). A slight drop in the number of publications was noted in 2015. Finally, a statistically significant regional correlation was detected between the corresponding authors' affiliation and the journals' publishing region (P < 0.001). CONCLUSION: North America had the highest contribution to the field of urology in 2015. A significant correlation exists between the origin of the published article and the publishing journal's region.

Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial.

BACKGROUND: The excruciating pain of patients with renal colic on presentation to the emergency department requires effective analgesia to be administered in the shortest possible time. Trials comparing intramuscular non-steroidal anti-inflammatory drugs with intravenous opioids or paracetamol have been inconclusive because of the challenges associated with concealment of randomisation, small sample size, differences in outcome measures, and inadequate masking of participants and assessors. We did this trial to develop definitive evidence regarding the choice of initial analgesia and route of administration in participants presenting with renal colic to the emergency department. METHODS: In this three-treatment group, double-blind, randomised controlled trial, adult participants (aged 18-65 years) presenting to the emergency department of an academic, tertiary care hospital in Qatar, with moderate to severe renal colic (Numerical pain Rating Scale ≥ 4) were recruited. With the use of computer-generated block randomisation (block sizes of six and nine), participants were assigned (1:1:1) to receive diclofenac (75 mg/3 mL intramuscular), morphine (0.1 mg/kg intravenous), or paracetamol (1 g/100 mL intravenous). Participants, clinicians, and trial personnel were masked to treatment assignment. The primary outcome was the proportion of participants achieving at least a 50% reduction in initial pain score at 30 min after analgesia, assessed by intention-to-treat analysis and per-protocol analysis, which included patients where a calculus in the urinary tract was detected with imaging. This trial is registered with ClinicalTrials.gov, number NCT02187614. FINDINGS: Between Aug 5, 2014, and March 15, 2015, we randomly assigned 1645 participants, of whom 1644 were included in the intention-to-treat analysis (547 in the diclofenac group, 548 in the paracetemol group, and 549 in the morphine group). Ureteric calculi were detected in 1316 patients, who were analysed as the per-protocol population (438 in the diclofenac group, 435 in the paracetemol group, and 443 in the morphine group). The primary outcome was achieved in 371 (68%) patients in the diclofenac group, 364 (66%) in the paracetamol group, and 335 (61%) in the morphine group in the intention-to-treat population. Compared to morphine, diclofenac was significantly more effective in achieving the primary outcome (odds ratio [OR] 1·35, 95% CI 1·05-1·73, p=0·0187), whereas no difference was detected in the effectiveness of morphine compared with intravenous paracetamol (1·26, 0·99-1·62, p=0·0629). In the per-protocol population, diclofenac (OR 1·49, 95% CI 1·13-1·97, p=0·0046) and paracetamol (1·40, 1·06-1·85, p=0·0166) were more effective than morphine in achieving the primary outcome. Acute adverse events in the morphine group occurred in 19 (3%) participants. Significantly lower numbers of adverse events were recorded in the diclofenac group (7 [1%] participants, OR 0·31, 95% CI 0·12-0·78, p=0·0088) and paracetamol group (7 [1%] participants, 0·36, 0·15-0·87, p=0·0175) than in the morphine group. During the 2 week follow-up, no additional adverse events were noted in any group. INTERPRETATION: Intramuscular non-steroidal anti-inflammatory drugs offer the most effective sustained analgesia for renal colic in the emergency department and seem to have fewer side-effects. FUNDING: Hamad Medical Corporation Medical Research Center, Doha, Qatar.