PERKEMIHAN

GANGGUAN SISTEM

dr A. Yuda Handaya SpB,FInAC,FMAS Bagian Bedah RSUD Kabupaten Malang

UROLOGI
Tractus urinarius Tractus genitourinarius
The Urinary System consists :

kidneys ureters bladder urethra

RUANG LINGKUP
Kelainan Bawaan / Kongenital Trauma Radang / Infeksi Batu Saluran Kemih Obstruksi Saluran Kemih Emergency Urologi (non trauma) Infertilitas pada pria Disfungsi Ereksi (DE) Andropause (Male aging) Keganasan

Urinary tract consist of

Kidney: parenchyma pelvicaliceal Ureter Bladder urethra

Anatomi Fisiologi

Embryology
Pronephros Mesonephros Metanephros

Renal parenchyma

Ureteric bud

Pelvicalyceal system ureter

Pronephros Mesonephros

Metanephros
Renal parenchymal
Mesonepric duct Ureter bud

Pelvicalyceal system Ureter

Epididimis-vas deferens

Kelainan Bawaan / Kongenital

dr A. Yuda Handaya SpB,FInAC,FMAS Bagian Bedah RSUD Kabupaten Malang

Anomalies of the Upper Urinary Tract

Anomalies of Number A. B. Agenesis (bilateral or unilateral) Supernumerary Kidney

Anomalies of volume and structure Anomalies of Ascent

A. B. C. A. B. C. A.

Hypoplasia Multicystic kidney Polycystic kidney Ectopic kidney Pelvic kidney Thoracic kidney Crossed ectopic with or without fusion: (1) Unilateral Fussed kidney, (2) Sigmoid kidney, dan (3) Lump kidney Horseshoe kidney
Incomplete Reverse Excesive Accessory, aberant,a or multiple vessels Renal artery aneurism Arteriovenous fistula

Anomalies of Form and Fusion

B. Anomalies of Rotation A. B. C. A. B. C.

Anomalies of Renal vasculature

Anomalies of Number A.Agenesis (bilateral or unilateral) B. Supernumerary Kidney

Ascent of Kidney

Anomalies of Ascent

A.Ectopic kidney B.Pelvic kidney C.Thoracic kidney

Anomalies of Ascent
Ectopic kidney Pelvic kidney Thoracic kidney

Anomalies of Form and Fusion

Crossed ectopic with or without fusion: (1) Unilateral Fussed kidney, (2) Sigmoid kidney, dan (3) Lump kidney Horseshoe kidney

Anomalies of Structure (polycystic kidney)

Bilateral kidney Cyst in another organ 2 types: Infant and adult type Progressive renal failure Tx: renal transplantation

Anomalies of volume and structure

A.Hypoplasia B.Multicystic kidney C.Polycystic kidney

Anomalies of Structure (Simple Cyst)

Tx marsupialitation if:
Bleeding Infection Very huge cyst will obstruct PCS

Anomalies of volume and structure

A.Hypoplasia B.Multicystic kidney C.Polycystic kidney

Anomalies of Pelvioureteric System

Normal Ureteral Bud and Metanephric Development

Anomalies of pelvio-ureteric system

Anomalies of Termination Ectopic ureter

Anomalies of Number

Duplication Complete or incomplete Ureterocele

Anomalies of Structure

Obstruction

Pelvio-ureteric junction.

Embryology of incomplete double system

Incomplete double system

Y-type ureter:
Asymptomatic Yo-yo phenomena

V-type ureter:

Asymptomatic VUR

Embryology of complete double system

Complete double system

Weighert-Meyers Law: Upper pole ureter more distal than lower pole

Normal orificium ureter

Ectopic ureter

Ureterocele with ectopic ureteric

A big ureterocele will obstruct bladder neck Filling defect on cystogram phase of IVP.

Pieloureteric Junction Obstruction

UPJ stenosis

Aberrant vessel obstruct UPJ

TRAUMA

dr A. Yuda Handaya SpB,FInAC,FMAS Bagian Bedah RSUD Kabupaten Malang

GINJAL
Paling sering
Trauma tumpul, tajam / tembak
Langsung Tak langsung (deselerasi)

Mudah cidera
Hidronefrosis Kista ginjal Tumor ginjal TBC ginjal

ginjal patologis

MEKANISME TRAUMA GINJAL

Dikutip dari Smiths General Urology

GRADE TRAUMA GINJAL

 DIAGNOSIS
Trauma Hematuria Jejas/Massa pada pinggang Nyeri Tanda perdarahan/syok

PENCITRAAN
USG IVU CT-scan

PENANGANAN

Tusuk/tembak Tumpul :
Konservatif Operatif

Eksplorasi laparotomi

Renorafi Partial/total nefrektomi Penyambungan vaskuler

KOMPLIKASI
SEGERA: Perdarahan, Ekstravasasi urin
Urinoma Abses perirenal Fistula renokutan Sepsis

LAMBAT :
Hipertensi Hidronefrosis AV Shunt Batu PNC

URETER
IATROGENIK
Op. Endourologi Op. Kebidanan Op. Digestive

DISTAL

Terjerat Crushing robek/putus Devaskularisasi nekrosis

 Diagnosis
Durante operationum Pasca bedah

Pencitraan
Retrogade pyelografi IVU

Stab wound of right ureter

Dikutip dari Smiths General Urology

TINDAKAN
Lepas jeratan Anastomosis end to end Neoimplantasi/Boari flap Trans uretero Ureterostomi Nefrostomi Ureterocutaneoustomi Nefrektomi

KANDUNG KEMIH
JENIS TRAUMA: IATROGENIK TUR terutama buli-buli Litotripsi TAJAM : Tembak, tusuk TUMPUL : Fr. Pelvis (90%) SPONTAN : Patologis RISIKO : - VU penuh - patologis

MEKANISME

Dikutip dari Smiths General Urology

KLASIFIKASI

KONTUSIO
RUPTUR Intra peritoneal Ekstra peritonel Intra & ekstra

25 45% 45 60% 2 12%

KLINIS
Trauma Abdomen bawah Nyeri Hematuria/miksi(-) Tanda Fr. Os pubis Tanda-tanda cairan bebas Peritonismus Cidera organ yang lain

DIAGNOSIS
KLINIS R : SISTOGRAFI
DI SELA-SELA USUS INTRAPERITONEUM

PERIVESIKAL EKSTRAPERITONEUM

NEGATIF PALSU
Robekan kecil

TEST BULI-BULI SISTOSKOPI

Extraperitoneal bladder rupture

Intraperitoneal bladder rupture

Dikutip dari Smiths General Urology

PENANGANAN
KONTUSIO : Kateter 7 10 hari INTRAPERITONEUM : Laparotomi/eksplorasi
Jahit Pasang drain Sistostomi Kateter uretra

EKSTRAPERITONEUM :
Kateterisasi Jahit pasang kateter

KOMPLIKASI SEPSIS ABSES PERIVESIKAL KELUHAN MIKSI PERITONITIS

URETRA

Dikutip dari Smiths General Urology

Trauma Urethra
Trauma urethra posterior
Urethra pars prostatika Urethra pars membranosa

Trauma urethra anterior

Urethra pars bulbosa Urethra pars pendulosa

Uretra Anterior
IATROGENIK STRADDLE INJURY
KLINIS

Trauma Perdarahan per uretram Miksi (+)/(-) Hematoma Perineum seperti kupu-kupu Scrotum/penis

DIAGNOSIS

Klinis Uretrografi Ekstravasasi kontras

STRADDLE INJURY

Dikutip dari Smiths General Urology

Ruptur bulbar (anterior) urethra following straddle injury

Dikutip dari Smiths General Urology

PENANGANAN KONTUSIO
Terapi (-)
Follow up 4 6 bulan

GOLDEN PERIOD ( < 6 8 jam)

HEMATOMA MINIMAL Primary repair : pasang kateter dan sistostomi
HEMATOMA LUAS :
Multipel insisi Sistostomi Late repair

KOMPLIKASI
STRIKTURA URETRA
FISTULA URETEROKUTAN

Uretra Posterior

FR. PELVIS / SIMFISIS PUBIS MERUSAK PELVIC RING

ROBEKAN URETRA POSTERIOR Ligan Prostatomembranacea robek Hematoma yang luas dalam cavum ret2ii VU dan Prostat terdorong ke cranial FLOATING PROSTATE

INJURY OF POSTERIOR URETHRAL

Dikutip dari Smiths General Urology

KLASIFIKASI (Colapinto McCollum)

1) Uretra posterior utuh, stretching o Uretrogram : memanjang, ekstravasasi(-) 2) Uretra posterior putus, diafragma uretra anterior utuh o Uretrogram : ekstravasasi kontras terbatas di atas diafragma uretra anterior

3) Uretra posterior, diafragma uretra anterior, dan uretra pars bulbosa bag. proksimal rusak o Uretrogram : ekstravasasi yang luas

Ruptur prostatomembranous urethra

Dikutip dari Smiths General Urology

KLINIS
TRAUMA TANDA-TANDA PERDARAHAN/SYOK PERDARAHAN PER URETRAM RETENSI URIN HEMATOMA SUPRAPUBIK TANDA-TANDA FR. PELVIS RT : FLOATING PROSTATE
KLINIS R : URETROGRAFI

DIAGNOSIS:

Repair of urethral injury

Dikutip dari Smiths General Urology

PENANGANAN

ATASI SYOK SISTOSTOMI TERBUKA LATE REPAIR P.E.R

KOMPLIKASI STRIKTUR GANGGUAN EREKSI INKONTINENTIA

Catatan:

Pada setiap kecurigaan ruptur uretra TIDAK BOLEH dilakukan kateterisasi !!

PENIS
TRAUMA TUMPUL TRAUMA TAJAM (AMPUTASI PENIS / REPLANTASI) FRAKTUR PENIS
Robekan T. Albuginea dalam keadaan ereksi bengkok dan hematoma

STRANGULASI/TERJERAT
Karet Cincin Logam

SCROTUM
TRAUMA TAJAM TRAUMA TUMPUL LUKA BAKAR CRUSHING AVULSI

Infeksi Saluran Kemih

dr A. Yuda Handaya SpB,FInAC,FMAS Bagian Bedah RSUD Kabupaten Malang

What are the causes the UTI ? Normal urine : sterile, contains fluid, salt, waste product, free of bacteria, viruses, fungi.

DEFINISI
Infeksi Saluran Kemih atau bakteriuria adalah didapatkannya mikroorganisme sebanyak 102 CFU/mL 104 CFU/mL Kriteria bakteriuria: 104 CFU/mL

Infection
when microorganisms, usually bacteria from the digestive tract, to the opening of the urethra and begin multiply. (Escherichia coli) first bacteria growing in the urethra Urethritis bacteria move to the bladderCystitis, bacteria go up the ureters Ureteritis infect the kidney Pyelonephritis

Chlamydia and Mycoplasma UTI in male and female, limited in the urethra and reproductive system, sexually transmitted, require treatment both partner

Common urinary bacterial pathogens (Escherichia Coli, Streptococcus Faecalis, Proteus spp, Pseudomonas spp, Klebsiella spp)

Who is at risk ? abnormality of urinary tract, obstructs the flow of urine (kidney stone) enlarged prostate gland slow the flow of urine from catheter ( urinary retention, unconscious, critically ill, nervous system disorder / lost bladder control

Diabetes changes in immune system, disorder suppresses the immune system infant, infant, born with abnomalities urinary tract (corrected by surgery) rarely seen in young men and boys in women UTIs gradually increases by age

women more UTIs then men (the urethra is short, bacteria quick access to the bladder, near the anus and vagina /sources bacteria, sexual intercourse) women use a diaphragm more develop UTIs than other forms of birth control women whose partners use condom with spermicidal foam

What are the symptoms of UTI ? not everyone with UTI has symptoms symptoms (frequent urge to urinate and painful, burning in the area bladder and urethra during urination, feel uncomfortable pressure ebove the pubic bone, fullness in the rectum)

 despite the urge small amount

of urine is passed the urine look milky, cloudy, even reddish if blood is present nausea, vomiting and pain in the back / side below the ribs kidney infection

 UTIs in children is not characteristic : irritable, is not eating normally, unexplained fever, incontinence, loose bowel, is not thriving change in urinary pattern

Features of UTIs UTIs in adults is common, particularly in women Cystistis produces symptoms, frequency, dysuria, urgency Pyelonephritis typically present with loin pain, fever, malaise UTIs less common in men urethral extra length prevent colony bacteria the bladder

How is UTI diagnosis ? urine test for bacteria or pus (midstream urine in sterile container) urinalysis test is examined for white, and red blood cells and Chlamydia, Mycoplasma can detected by special bacterial cultures

 If an infection does not clear up with treatment order IVP ( gives images the bladder, ureters, kidneys Recurrent UTI recommend USG internal organ, cystoscopy (see the bladder by cystoscope from the urethra)

How is UTI treated ? with antibacterial drugs (the chois and the length of treatment depend urine test, the offending bacteria)

 Quinolones : ofloxacin (Floxin), norfloxacin (Noroxin), ciprofloxacin (Cipro ) and trovafloxin (Trovan) UTI can be cured 1 2 days treatment doctor ask to take antibiotics for a week or two week to ensure the infection has been cured Single dose treatment is not recommended (kidney infection, diabetes, structural anatomy, prostate infections)

 infection caused by Mycoplasma, Chlamydia, longer treatment is also needed treated with (tetracycline, trimethroprin, sulfamethoxazole / TMP,SMZ, doxocycline) urinalysis help to confirm UT is infection free note : symptoms may disappear, before the infections is fully cleared

 severe ill patients (kidney infections hospitalized) until they can take fluid and drugs on their own 2 weeks theraphy with TMP/SMZ as effective 6 weeks, on kidney infections various drugs is available to relieve the pain in UTI

a heating pad also help drinking water helps cleanse the urinary tract from bacteria ovoid drinking coffee, alcohol, spicy foods
Uncomplicated urinary infections usually responds to 3 days course of antibiotic

EPIDEMIOLOGI UTI OK KATETERISASI

Lebih dari 25% pasien yang dirawat di RS menggunakan kateter Risiko bakteriuria pd kateterisasi tunggal (single catheterization) adalah 1 2% (Sedor & Mulholland, 1999) Penggunaan kateter menetap (indwelling catheter) kemungkinan terjadinya bakteriuria adalah 3 10% (dengan rerata 5%) setelah 30 hari

Faktor Risiko Timbulnya ISK Karena Kateterisasi

Faktor
Lama kateterisasi > 6 hari

Risiko relatif
5,1-6,8

Wanita
Pemasangan kateter di luar kamar operasi Tindakan urologi Terdapat infeksi di tempat lain

2,5-3,7
2,0-5,3 2,0-4,0 2,3-2,4

Diabetes
Malnutrisi Azotemia (kreatinin > 2,0 mg/dl) Kateter ureter

2,2-2,3
2,4 2,1-2,6 2,5

Monitor produksi urine

Terapi antimikroba
(dikutip dari Maki & Tambyah, 2001)

2,0
0,1-0,4

Etiopatogenesis dan Perjalanan Penyakit

Kateterisasi
30%

Bakteriuria

Bakteriemia

< 4%
Sepsis 12,3% Kematian

(dikutip dari Saint & Lipsky,1999)

Cara Mikro-organisme Memasuki Saluran Kemih pada Pemakaian Kateter Menetap

(dikutip dari Maki & Tambyah, 2001)

Pencegahan ISK yang Berhubungan dengan Kateterisasi

Indikasi pemasangan kateter menetap pada pasien yang menjalani rawat inap di rumah sakit
Obstruksi infravesikal (Bladder outlet obstruction)
Pemasangan sementara untuk mengatasi retensi urine Dipasang dalam jangka waktu lama karena terdapat kontraindikasi tindakan pembedahan

Inkontinensia urine tanpa obstruksi

Terdapat luka pada daerah perineum dan sakral Permintaan pasien

Monitor produksi urine

Pada pasien kritis Pasien tidak mampu mengumpulkan urine

Selama pembedahan yang lama dengan pembiusan umum atau regional

Pencegahan
Pemasangan kateter sistostomi (suprapubik) pada pria Penggunaan kateter kondom Antibiotika (??) Higiene pada saat memasang dan selama kateter terpasang Sistem pengaliran tertutup (closed drainage system)

Morbiditas Kateterisasi
Faktor risiko berkembangnya bakteriuria menjadi bakteriemia
Pria Infeksi yang disebabkan oleh Serratia marcescens Penyakit traktus urinarius lain yang tidak terinfeksi (nefrolitiasis, BPH) Terdapat kateter uretra menetap

Rangkuman
Pemakaian kateter ISK/Bakteriuria Bakteriuria akan berkembang menjadi bakteriemia, yang menyebabkan morbiditas maupun mortalitas Pembentukan biofilm kuman sulit diberantas dengan antibiotika

Profile
Dr Yuda Handaya SpB FInaCS,FMAS

Contact Person Jl. Bromo 98-100 Kepanjen,Kabupaten Malang,Jawa Timur,Indonesia Phn/sms/mms 0341-7304141; 08175404141 ; 08122966805 Fax 0341-394979 email : yudahandaya@yahoo.com

PROFESSIONAL QUALIFICATIONS Specialist of General Surgery, University of Gadjah Mada, Indonesia PROFESSIONAL LICENSURE Indonesian Medical Council No : 34.1.1.101.1.06.005789