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Ureteral stone is a worldwide disease and accounts for 20% of all urolithiasis. There is a widespread discussion on the preferred initial treatment method, whether medical or surgical, and each has its pros and cons. In this study, we aimed to assess the role of both ureteral wall thickness around the stone and inflammatory markers in guiding the decision-making process.In this prospective study, 161 patients who presented with ureteric colic and were diagnosed with ureteral stone with NCCT were included. UWT around the stone was measured, and the NLR and PLR were calculated. The patients were given a single daily dose of tamsulosin 0.4 mg for 4 weeks with weekly follow-up to determine SSP or failure.Of the 161 patients with a mean age 40.12 ± 12.36 SD, 55.9% had a spontaneous stone passage. Receiver operating characteristics showed a cut off value of 2.45 mm UWT of non SSP patients with an 83% sensitivity and 86% specificity. Moreover, there was a significant correlation between higher NLR, PLR and increased UWT (Pearson correlation of 0.314 and 0.426 respectively). The combined higher NLR, PLR and increased UWT were associated with failure of SSP (p-value0.001).Many factors play a role in decision making for management of ureteral stones. Our study concludes that patients with high NLR, PLR, and UWT around the stone have lesser chance of SSP using MET. Their rise can be used as predictors to decide early intervention.

Highlights • Scrotal leiomyomas are benign tumors arising from the dartos layer of the scrotal wall. • It is the disease of the middle aged men. • Malignant transformation to leiomyosarcoma has been reported. • Surgical excision is the main line of management., Introduction Scrotal leiomyomas are benign tumors arising from the dartos layer of the scrotal wall. The exact cause of this tumor is not yet clear. Malignant transformation to leiomyosarcomas has been reported. Case presentation A 52-year-old male who complained of a painless lump on the right side of the scrotum that lasted 12 years. Physical examination revealed a single, firm, and non-tender, mobile lump on the anterior aspect of the right scrotum. Both testes were normal and no inguinal lymph nodes could be palpated. Ultrasound scan of the scrotum showed a 40 mm × 20 mm hypoechoic, poorly vascular lesion in the scrotum. Under spinal anesthesia, the mass has been excised. Histopathological and immunohistochemical findings were consistent with the diagnosis of scrotal leiomyoma. Discussion Leiomyomas may originate from any location in the genitourinary system where there is smooth muscle. Scrotal smooth muscle tumors can be categorized into Leiomyomas, atypical or symplastic leiomyomas, which are not hypercellular and lack mitotic activity, and leiomyosarcomas. Ultrasound is the first-line imaging investigation in patients with suspected scrotal masses. Typical leiomyomas and atypical ones behave similarly. Therefore, they are managed only with surgical excision, while leiomyosarcomas need a wide 3−5 cm margin resection. Both recurrence and malignancy have been described. Close follow-up is required to detect recurrence. Conclusion Scrotal leiomyoma is a rare benign mesenchymal tumor of the middle-aged men. The current report describes the clinical and histopathological characteristics to help reduce erroneous diagnoses of this rare tumor.

Highlights • Bladder injury is an uncommon complication of cesarean delivery with an incidence ranging from 0.0016% to 0.94%. • Delayed blabber rupture post CD may present with urinary ascites and elevated serum creatinine mimicking acute kidney injury. • Cystography is the diagnostic imaging of choice with the reported accuracy of 85%–100%. • Surgical repair is the treatment of choice for intraperitoneal bladder injury. • Conservative management with intraperitoneal and urethral catheter may succeed in properly selected cases., Introduction Bladder injury is an uncommon complication of cesarean delivery (CD) with an incidence ranging from 0.0016% to 0.94%. The risk factors are emergency CDs, subsequent CDs, trial of normal delivery after CD and whether adhesions are present or not. The presentation is either immediate intraoperative event or delayed bladder rupture and urinary ascites. Case presentation A 35-year-old female presented with considerable abdominal distension, shortness of breath, oliguria, straining to void and elevated levels of blood urea and serum creatinine 11 days after an uneventful Caesarean delivery. Abdominal ultrasound showed marked ascites. Immediate resuscitation was done, a urethral catheter and percutaneous intraperitoneal pigtail catheter were inserted confirming urinary ascites. Next day cystoscopy was performed and revealed a perforation at the posterior wall of the bladder. She was kept on conservative treatment with adequate urine diversion through both urethral and intraperitoneal catheter. Her condition improved and responded well. Discussion To the best of our knowledge this presentation of delayed intraperitoneal bladder rupture post CD is the second case reported in literature. Although surgical repair is regarded as the treatment of choice for intraperitoneal bladder injury, conservative treatment may succeed in properly selected cases. Non-operative managements include indwelling transurethral Foley catheter alone, percutaneous peritoneal drain alone or combined Foley catheter and percutaneous peritoneal drain for complete urinary drainage. Conclusion Delayed urinary bladder rupture is a very rare complication of cesarean delivery. Non-operative treatment can be a viable alternative to surgical repair in carefully selected patients.

Objectives To evaluate factors contributing to bleeding after percutaneous nephrolithotomy (PCNL) and ways of managing this complication, as bleeding is a serious sequela that requires prompt management. Patients and methods The demographic and procedural data of 200 patients, who underwent unilateral PCNL during a 20-month period, were prospectively collected. Preoperative, operative, and postoperative details were recorded. The preoperative variables analysed included: age, sex, body mass index (BMI), the presence of hypertension, diabetes mellitus, serum creatinine, degree of hydronephrosis, previous ipsilateral open renal surgery, stone size and complexity. The operative variables analysed included: number of tracts, operative time, size of Amplatz sheath, type of anaesthesia, and complications such as calyceal and pelvic perforation. Results The variables of age, sex, BMI, diabetes, hypertension, and a preoperative creatinine level of >1.4 mg/dL had no significant effect on blood loss (all P > 0.05). However, the rate of bleeding was significantly higher (P ⩽ 0.05) in patients who had a history of previous open renal surgery, intraoperative pelvicalyceal perforations, and Guy’s Stone Score (GSS) grade 3 and 4 complex stones; however, absence of hydronephrosis, larger stone size, operative time (>83 min), more than one puncture, and size of the Amplatz sheath (26–30 F) did not maintain their significance in multivariate analysis. Conclusion According to our present results stone complexity (GSS grade 3 and 4), history of ipsilateral renal stone surgery, and occurrence of intraoperative pelvicalyceal perforation are alarming variables for post-PCNL bleeding.

Objective: The objective is to assess the benefits and adverse effects of routine ureteral stenting after uncomplicated ureteroscopic lithotripsy. Material and Methods: Sixty patients with ureteric calculi amenable to ureteroscopic lithotripsy were randomized to an unstented (30 patients) or a stented (30 patients) treatment group, standard ureteroscopic lithotripsy done using 8 French semirigid ureteroscope, and pneumatic lithotripter used to fragment the stones. They were followed up for postoperative flank pain, lower urinary tract symptoms (LUTS) and hematuria. Results: There was no significant difference in the mean age (stenting 37.8 year and 33.5 year unstenting) of patients, gender and stone size in both groups. No significant difference in the mean flank pain within 3 days postoperative, while at day 14 postoperative flank pain for stenting group was significant (P = 0.03). Dysuria and urgency were high for stenting group (P = 0.002 and 0.011). Hematuria within 3 and 14 days was higher in the stenting group. Conclusion: After uncomplicated ureteroscopy, stents can be safely omitted. Unstented patients have significantly fewer LUTS, haematuria and flank pain.

Background: Monopolar transurethral resection of prostate has long been a standard method of managements of benign prostatic hyperplasia. The safe and superior efficacy of transurethral resection of prostate (TURP) always argues strongly for maintaining it as the primary mode of therapy for patients with benign prostatic hyperplasia (BPH). There is a trend toward early catheter removal after transurethral resection of prostate (TURP) even to the extent of performing it as a day case. We explored the safety and feasibility of early catheter removal and discharging the patient without catheter after TURP. Materials and methods: Forty patients who underwent monopolar TURP were included in a prospective study. The decision to remove catheters on the first morning after surgery was based on the color of the catheter effluent, absence of clots, normal vital signs and adequate urine output. Patients who voided successfully were discharged on the same day as catheter removal. Results: Among the forty patients whose catheters were removed on first postoperative day, 38 patients (95%) voided successfully, and were discharged on the same day. However, two out of forty patients (5%) were recatheterized due to urethral discomfort during micturition. The catheter was removed on the next day. Mean overall duration of catheterization was 18.36 hours, and overall length of patient hospitalization was 21.68 hours. Conclusions: Overnight hospitalization and early catheter removal after transurethral prostatectomy are an appropriate, safe and effective way of patient care with minimal morbidity.

Background: Ipsilateral renal agenesis associated with seminal vesicular cysts is an uncommon finding. Zinner syndrome is a rare variant of wolffian duct anomalies with a triad of seminal vesicle cyst, ipsilateral renal agenesis, and male fertility problems due to ejaculatory duct obstruction (EDO). Case Presentation: A 28-year-old man with 6 years history of primary infertility presented with left-side lower abdominal pain. A palpable cystic mass was found on digital rectal examination. Semen analysis revealed low volume ejaculate azoospermia. Abdominal ultrasonography revealed a single right kidney and transrectal ultrasonography showed an evidence of left EDO. Transurethral resection of the ejaculatory duct was performed. Semen analysis after 2 weeks showed normal sperm count (23M) and acceptable progressive motility (24%). Eight weeks later, his wife was pregnant with a 7-week viable fetus. Conclusion: Although not a common disease, a careful physical examination and thorough semen analysis interpretation should guide clinicians to diagnose a surgically treatable syndromic cause of male infertility.

Objectives To evaluate the safety and effectiveness of ureteric stenting with a JJ stent in pregnant women, to relieve renal obstruction and intractable flank pain. Patients and methods All pregnant patients presenting with intractable flank pain, with or without complications, to a tertiary national teaching hospital in Kurdistan/Iraq, and necessitating ureteric stenting with a JJ stent, were prospectively assessed for this study between March 2008 and March 2010. Results In all, 30 pregnant patients presented with intractable flank pain necessitating JJ ureteric stenting during the 25 months. Intractable flank pain (23 patients, 77%) was the most common indication for ureteric stenting, followed by flank pain with clinical sepsis (six, 20%). All pregnant women had hydronephrosis on ultrasonography (US), and 12 (40%) had evidence of coexisting renal stones on US. All ureteric stents were inserted successfully. The mean (range) indwelling time was 47.4 (3–224) days. Radiologically, 14 (47%) and 15 (50%) had complete resolution of the hydronephrosis on follow-up US in late pregnancy and in the early postnatal period, respectively. Two-thirds of patients had a clinical improvement immediately (15, 50%) and soon after (five, 17%) surgery. Stent encrustation (three, 10%), stent migration (three, 10%) and stent irritation (five, 17%) were reported as complications. The post-natal evaluation confirmed that half the patients had urinary calculus disease. Conclusion Ureteric stenting during pregnancy can be safe, with no intraoperative imaging and even under local anaesthesia. It provides good symptom relief and has a low complication rate. We therefore advocate it as a first-line treatment in pregnant women with therapy-resistant flank pain.

1.1.Purpose: Although percutaneous nephrolithotomy (PNL) has been accepted as a standard method for the management of large renal stones, the incidence of renal hemorrhage is relatively high. This study investigated the variables that affect Haemoglobin (Hb) drop and blood transfusion need during PNL. 1.2.Materials and Methods: The medical records of 200 patients who underwent unilateral PCNL from January 2014 to Octobor 2015 were recorded prospectively. Various clinical preoperative, perioperative and postoperative factors including age, sex, body mass index, diabetes mellitus, hypertention, preoperative creatinine level, previous renal surgery, renalanomalies, history of extracorporeal shock wave lithotripsy (SWL), stone size, stone site, stone complexity (GUY ‘s Stone Scoring System; SSS), degree of hydronephrosis, operative time, type of anesthesia, number of puncture, size of amplatze, method of stentting (double J or ureteric stent), intra operative complication (perforation and extravasation) were assessed. For statistical assessment, univariate and multivariate logistic regression analyses were used. 1.3.Result: The mean+SD of patient’s age was 37.5+14.7 years, ranged from 5 to 75 years. The highest age group was 15-49 years i.e 71%. Male (62.5%) was more common than female (37.5%). Body Mass Index (BMI) was calculated for patients and the results were: under weight (4.5%), normal weight (31.5%), over weight (41.0%) and obese (23%). The overall blood transfusion rate was 14%. One patient (0.5%) underwent angioembolization after surgery. The average blood loss was 1.5±1g/dl. Multivariate stepwise regression analyses showed that the most important factors affecting the rate of blood transfusion were: the intraoperative complication (perforation and extravasation), stone complexity (GUY ‘s Stone Scoring System), operative time (>83 minute) and the most important factors affecting the total Haemoglobin drop were Stone complexity (GUY’s SSS) and preoperative creatinine level( ≥1.4mg/dl.). No correlation between (age, sex, BMI, diabetes mellitus, hypertention, previous renal surgery, SWL, degree of hydronephrosis, size of amplatz, and stentting method) and rate of blood transfusion was found. 1.4.Conclusion: Our results, showed that; i. Stone complexity (GUY’s SSS, grade 3 and 4). ii. Preoperative creatinine level (≥1.4mg/dl). iii. Intra operative complication (perforation and extravasation). iv. Duration of operation (>83 minute). Were the most important factors associated with an increased risk of bleeding and transfusion during PNL in both univariate and multivariate analysis.

Purpose: To assess the effect of extracorporeal shockwave lithotripsy (SWL) on blood pressure, patients’ tolerance to pain andperirenal hematoma in patients with renal stones. Patients and methods: One hundred eighty nine patients between 2007-2009 underwent SWL procedures at 4.5 and 5.5 KV with shockwaves of up to 4,000 and 5,000 shockwaves, they were followed up for post procedure pain, hypertension and perirenalhematoma. For statistical analysis, chi square test was used. Results: One hundred fifty three (81%) patients developed post procedure pain. The degree of pain was of mild that relieved byanalgesia to severe that required hospitalization, increasing energy level did not increase the chance of post SWL pain while thelarger stones caused more post SWL pain ( p = .003). Fifteen patients (7.9%) developed post SWL hypertension, female patientsand age more than 50 years found to increase the risk of post SWL hypertension. Post SWL hypertension is not affected byincreasing energy level and number of shockwaves. Only one patient (0.52%) developed post SWL perirenal hematoma. Conclusion: SWL has a high incidence of post SWL pain. Females and age above 50 years are more prone to develop postSWL hypertension. However the number of shockwaves and energy level did not increase the risk of developing post SWLhypertension. Perirenal hematoma is a rare complication of SWL.

Background: Intracytoplasmic sperm injection (ICSI) is introduced as a treatment modality for severe male factors infertility. It is an effective form of infertility treatment. Progress in the micromanipulation, now is bringing a new way in the treatment of severe male factor infertility to achieve acceptable rates of fertilization and pregnancy success. Objective: To evaluate the difference between ejaculated and surgically retrieved sperm on intra cytoplasmic sperm injection (ICSI) outcomes. Design: A Correlative study. Setting: Dwarozh- IVF center. Patients and Methods: One hundred twenty patients have been taken in Dwarozh and International infertility centers in Sulaimani, for male infertility indications with normoovulatory female partners of ages less than 38 years, from 1st of September 2010 to 1st of September 2013. We divided patients into two groups: patients with normal ejaculation;group one (G1), and patients with surgically retrieved spermatozoa (normal sperms); group two (G2), all underwent Intracytoplasmic Sperm Injection (ICSI) cycles. Main Outcome Measures: Fertilization, cleavage, biochemical and clinical pregnancy rates. Results: The fertilization rate has been found 72.6% in G1, while in G2 it is 60.4% and a significant statistical difference was observed in fertilization rates between the two groups with a P value of less than 0.01. Also it has been found that in G1, 90.2% of oocytes were cleaved, while in G2, 89% of oocytes were cleaved, no significant statistical difference was observed in cleavage rates between the two groups, with a P value of more than 0.05. It has been found that in G1, pregnancy was positive (+ve) biochemically in 65% of the cases, while pregnancy was positive (+ve) clinically in 45% of the cases. In G2 pregnancy were (+ve) biochemically in 28.3%, while pregnancy was (+ve) clinically in 15% of the cases, with significant statistical differences in both biochemical and clinical pregnancies between the two groups with a P value of less than 0.01. Conclusions: It has been found, with the use of ICSI cycles in the treatment of male factor infertility, there are significant differences in reproductive outcomes between cycles using ejaculated and surgically retrieved sperm. The data show that ICSI is aacceptable treatment option in oligospermic and azoospermic males. Acceptable rates of fertilization, cleavage and pregnancy success can be attainwith ICSI from patients with Azoospemia, reaching levels comparable with those of patients using ejaculated spermatozoa for ICSI.

Introduction: Non-invasive selection of developmentally human oocytes may increase the overall efficiency of human assisted reproduction. Morphologic abnormalities in the oocyte are relevant for determining its developmental fate. The objective is to evaluate the influence of MII oocyte morphology on intra cytoplasmic sperm injection (ICSI) outcomes. Material and Methods: 132 patients undergoing ICSI cycles and having female factors of infertility and unexplained infertility. Couples having male factors of infertility were excluded. A total of 1200 oocytes were retrieved from 132 ICSI cycles, of which 1056 MII oocytes were evaluated. The criteria for morphological evaluations were: (i) Normal MII oocytes showing clear cytoplasm with uniform texture and homogenous fine granularity, a round or ovoid first polar body with a smooth surface, and perivitelline space of normal size. (ii) MII oocytes with extra cytoplasmic abnormalities (first polar body and perivitelline space abnormalities). (iii) MII oocytes with cytoplasmic abnormalities (dark cytoplasm, granular cytoplasm, inclusion body and presents of vacuoles). (iv) MII oocytes with combined abnormalities. Result: From 1056 MII oocytes, 180 (17.04%) had normal morphology while 876 (82.95%) had at least one demonstrable morphological abnormality. Cytoplasmic abnormalities were observed in 516 (58.9%) of the oocytes. Extra cytoplasmic abnormalities were observed in 104 (11.87%) while combined abnormalities were responsible for the remaining 256 (29.22%). There were no significant differences in fertilization, cleavage, and embryo quality between the groups but there was a highly significant difference in implantation rate which was higher in the group of normal oocytes morphology than abnormal oocytes morphology, oocytes with cytoplasmic, extracytoplasmic and combined abnormality 11.11%, 7.33%, 9.03%, 2.3%, and 4.34% respectively. Conclusion: MII oocyte morphology did not affect fertilization, cleavage, and embryo quality, but affecting implantation rate.

Background and Objectives: To evaluate the usefulness of laparoscopic varicocelectomy in the management of chronic scrotal pain. Methods: Between 2009 and 2011, 48 patients in total were treated with laparoscopic varicocelectomy for dull scrotal pain that worsened with physical activity and was attributed to varicoceles. All patients were followed up at 3 and 6 months and biannually thereafter with a physical examination, visual analog scale score, and ultrasonographic scan in selected cases. Results: The mean age was 38.2 years (range, 23–54 years). The mean follow-up period was 19.6 months (range, 6–26 months). Bilateral varicoceles were present in 7 patients (14.6%), and a unilateral varicocele was present in 41 (85.4%). The varicocele was grade 3 in 27 patients (56.3%), grade 2 in 20 (41.6%), and grade 1 in 1 (2.1%). The mean preoperative visual analog scale score was 4.8 on a scale from 0 to 10. The mean postoperative visual analog scale score at 3 months was 0.8. After the procedure, 42 patients (87.5%) had a significant improvement in the visual analog scale score (P < .001); 5 (10.4%) had symptom improvement, although it was not statistically significant; and 1 (2.1%) remained unchanged. During follow-up, we observed 5 recurrences (10.4%) whereas de novo hydrocele formation was identified in 4 individuals (8.3%). Conclusion: Laparoscopic varicocelectomy is efficient in the treatment of symptomatic varicoceles with a low complication rate. However, careful patient selection is necessary because it appears that individuals presenting with sharp, radiating testicular pain and/or a low-grade varicocele are less likely to benefit from this procedure.