Abc

No Tanggal Nama Usia Alamat
1 4-Sep-14 An Bagas 5 Kebon sari - blitar
2 5-Dec-14 an. Moch Hamzah 7 th petulangan tengah 18 B
purabaya pasar 57
3 29-Jun-15 An. Andika Herin S 7 th
surabaya
4 27-Jul-15 an andika hervin septian 7th dutat jaya pasar 57
5 4-Aug-15 an mas adhi 5th
perum sumber permai

6 21-Oct-15 an. Leonaldi 12 thn
jember
7 8-Jan-16 An M zaibidin 8 bojonegoro
Sendang trawas
8 13-Jan-16 An. Farahan 4 th
Mojokerto
9 3-Mar-16 By Valorian 1 bln Surabaya
10 1-Apr-16 Ny.Samianah 48 Jombang
11 15-Apr-16 Tn. Eko Ari 18 Surabaya
12 28-Jun-16 An Ahmad Wildan 11 TH Janti Wots Kediri
Kalibongkor I/26 A
13 19-Aug-16 sdr Sugeng 14 th
Surabaya
14 27-Oct-16 Ny.Fitri Handayani 28th Polosari
Wonokromo kulon 4/3

15 2-Dec-16 Ny. Sarigati 59 th
surabaya
16 6-Dec-16 Ny. Samianah 48 th Ampera bareng Jombang
17 19-Dec-16 Sdr Bagas H 15 th Surabaya
18 4-May-17 Ny. Tities Patriawaty 67 th Kupang
15-May-17 Gebangan, Gemarang,

19 Tn. Catur RH 24 th
Madiun
20 24-Jul-17 Ny. Marcelina B. 48 th Kupang
21 1-Aug-17 Ny.Erik Choriyah 56 th Kr tembok
22 15-Aug-17 Ny. Astutik 38 th Kediri
23 10-Oct-17 kanang sudarma 13th kartoharjo
24 18-Dec-17 Ny. Nur Khayati 29th Kec Bancan Kab tuban

tn deni budi
2-Jan-18 Tn Ahmad Subarna 72 Sidoarjo
3-Jan-18 Tn Sukadi 65 Jombang

28-Dec-17 Ny Endang S 47 Kandangan, gunung tamsi
Ny Wijiyanti 51 Palangkaraya
28-Dec-17 Marshendi PE 11 th Jember
28-Dec-17 Ahmad M. AU 3 th Bojonegoro

28-Dec-17 An Wahyu A Sampang
28-Dec-17 An M. F. Ilhamsyah Surabyaa
FISTEL
No. Telepon No. RM Diagnosis Planning
Fistel Ureterocutan post Thorax, Re - Do
O85755269209 12188381
chordectomy + urethroplasty Urehtroplasty
fistel uretrocutan post
82245268688 12321914 repair fistel uretrocutan
chordectomy uretroplasty
Fistel urethrocutan post
O82331456948 10775492 repair fistel
chordectomy dan uretroplasty
fistel uretrokutan post chordectomy
+ uretroplasty ec hipospadia
82331456948 10775492 scrotalis + scrotum bifidum + post Repair fistel uretrokutan
orchidectomy S + klienefelter
syndrome
082132208142/ fistel uretrocutan post chordectomy
12259714 repair fistel uretrocutan
081332618211 + urethroplasty
hipospadia perineal post
085336483583/ chordectomy 3x - uretroplasty + laparoskopi diagnostik k/p
12411398
085749993811 fistel uretrokutan + meatal stenosis orchidopexy -> repair fistel
+ UDT D/S
fistel uretrokutan post
O85228635046 10786027 sistokopi k/p repair fistel
vesicolitotomi + uretrolitotomi
Fistula subcutan scrotum + Post

81333931877 12080092 sigmoidostomy + post repair buli Explore fistulektomy
+ post herniotomy
083831988005 / Epispadia + Repair Epispadia

12397898 Repair Epispadia
083831988007 Urethroplasty
85784250555 12489179 Fistelvesica vaginahbufa tah-brot Sistocopy=repaifistel
Fistel Uretrokutan post chordektomi

85733133192 10621906 Repair Fistula
+ post uretroplasti + repair fistula
Fistel Uretrocutan + Urinoma

85233588004 10974945 Uretroscopy + Repair Fistel
riwayat Hipospadia
Fistel ureterocutan + Hipospadia
81359813011 12383809 Repair fistel ureterocutan
+ cordectomy + ureteroplasty
Fistel Ureterokutan post
81368411541 12231582 chordectomy + uretroplasty ec Repair fistel
hipospadia
RPG D/S + repair fistula

87855112127 12537141 Fistel ureterovagina
ureterovagina
085784350555 / Fistel vesikovagina post repair fistel Sistokopi + RPG D k/p + PNS
12489179
085607008954 + TAH BSO D + APG D
Fistula urethrocutan+post
Repair fistula+test ereksi k/p
85645290354 10837623 chordectomy +
chordectomy
urethroplasty+post repair fistula
Fistula vesicovagina + Susp. Sistoskopi + RPG S + k/p URS

81249007306 12553870 Uretrovagina + HN sedang S S + Explor coper
Fistul Urethrocutan + Hipospadia

85735917133 /
12586750 Coronal + Post Chordectomy + Chordectomy + Urethroplasty
085856220770
Urethroplasty
fistel vesicovagina + Ca cervix

082141036048/0
12590207 IVB metastatic paru infiltrasi buli PNL D
81337330860
rectum
Fistula vesicovagina + Ca cervix ureterpcutaneostomi D/S k/p

81357962239 10118528
III b + mestastae ureter open nefrostomi
Susp.Fistel retrogram dd Fistel

vesicovagina + HN ringan - Sistoskopi + tes methylen
085784982784/ 12439198 sedang S + stenosis ureter distal S blue + RPG S k/p Neo
085749037049 + non visualized Ren S + post implantasi Ureter S
kistictomy ovarii D/S
085733747095/ fistula urethrocutan post
10603607 re-do urethroplasty
08121785449 urethroplasty BMG
853321343999 sistoskopi + eksplorasi + repair

12635525 fistula vesikouterine
fistula vesikouterina
Striktur uretra parsial pars Pre end to end anastomosis
O85790633636 12529321 bulbosa + post end to end urethra
anastomose
Striktur urethra total pars end to end anastomose
O81274162695 12628291 bulbosa + riwayat open urethra
Batu pyelum dextra + batu
sekunder pole bawah ren dextra URS D. Jika-->lancar/ stenosis (-)
O81357312725 12636557 PCNL D
+ HN grd I-II D
O85250014187 12631883 Ca Cervix III B + kemoterapi DJ stent D/S
O85859350355 12637870 Hipospadia subcoronal + chordae Chordectomy + urethroplasty
Hipospadia mid shaft + post Repair fistule + redo

O85284188249 12523149 chordectomy + urethoplasty urethroplasty
O81939393681 12637895 Hipospadia distal chordectomy + urethroplasty
O82301955951 12632030 UDT D/S Laparoskopi diagnostik D/S
Kelas Update Keterangan
BPJS kelas III bersedia operasi
BPJS I bersedia operasi
BPJS kelas III bersedia operasi
BPJS III bersedia operasi
SPM bersedia operasi
BPJS II bersedia operasi
BPJS kelas II bersedia operasi
bersedia operasi
Umum bersedia operasi
Jamkesmas bersedia operasi

BPJS I Bersedia Operasi
Umum bersedia operasi
bpjs III bersedia operasi
BPJS II Bersedia operasi
BPJS II Bersedia Operasi

BPJS III Bersedia operasi
BPJS III
BPJS III besedia operasi


H
sidosermo 4-15 blok
1 20-Jun-15 an isbat istikha mumin 14th
D12
wirogunan 4/2
2 23-Jun-15 an azril maulana 4th
pasuruan
perum sumber
4 21-Oct-15 an. Leonaldi 12 thn
permai jember
Langkah Buntu I/41

5 22-Sep-15 an. Wildan T 5 th
Surabaya
6 5-Feb-16 An. Wisnu energik 3 th
7 15-Feb-16 An, Arga Prayoga 11 th Batam
8 23-Feb-16 An. Andi Moga 5 th Banyakan Kediri
9 23-Feb-16 An. Risal Ubudillah 2 th mandagi sampang
10 29-Feb-16 An M. Riko Fernando 4 th Surabaya
11 27-May-16 An. M. Fathur Rahman 14 th menganti gresik

Wonorejo 4/36
12 7-Jun-16 An. M Zakirul 15 th
Surabaya
Margorukun I
13 20-Jun-16 An Moch Saiful 13 TH
Buntu 10B Sby
Desa Ngontep 3/1
14 20-Jun-16 An Andika 3 TH
Magetan
Jl. Pemuda 5/ 490 A
15 1-Jul-16 An Rizky Aulia 11 Th
Tuban
Sidotopo Wetan
16 28-Jul-16 An M Syahrul 11 Bln
5/44 Sby
17 9-Aug-16 ilham syafaat 14th lakar santri RT 2/4
18 12-Aug-16 An Ilham Aji D 10 th Medayu Utara 2/18
Manukan INdah 19
19 30-Aug-16 An. Damar Tangguh 8 th
L/5 SUrabaya
Tandengan 2/5
20 6-Sep-16 An. Rizky Saputra 11 th 11th
Cermei, Gresik
Karang penang
21 17-Oct-16 An. Dianatul F. 2 th 7 bln
sampang
Desa Lajukan,
22 27-Dec-16 An Nazalim Hicman A 11 th
Porong
23 20-Feb-17 An Alvaro 4 th
Bandung sekarang
24 20-Feb-17 Fathan Anugerah 4 th
balongpanggang
25 23-Feb-17 An fajar sodiq 14 th labang bangkalan
26 23-Mar-17 An. M. Abid Sulaiman 3,5 th
sidowarek
27 30-Mar-17 An. Achad yusuf afandi 7 th menganti gresik
28 17-Apr-17 An. M. Fathur Rahman 14 th menganti gresik
pasar look
29 20-Jul-17 tn deni budi 1 th Surabaya
Gading,
30 7-Aug-17 an. Mustafa 15 bln
Probolinggo
Taman Pikatan
31 7-Aug-17 an. Nurul Hidayat 12 th
Gading Probolinggo
dukuh nogo karang

32 31-Aug-17 ibrohim mubarok 9 th waluh sampun
33 16-Sep-17 an alfian rifky
34 18-Sep-17 an. Muh. Amirul 1,5 th Sidoarjo

36 2-Jan-18 Tn Ahmad Subarna 72 Sidoarjo
37 3-Jan-18 Tn Sukadi 65 Jombang
Jl. Bunga No. 10

38 an. Fariz N 3,8 th Mojoroto Kediri
39 5-Oct-17 an. Moch. Fakhri 9 th Lamongan
40 5-Oct-17 an. Azril A. 2 th Sidoarjo
Pekalongan
41 12-Oct-17 an. Syaiful 17 bln Sampang
42 26-Oct-17 an galang 10 th sidotopo
43 13-Nov-17 an m fakri setia
muhammad harijuddin
44 16-Nov-17 9th sugihwaras nganjuk
mubarok
45 16-Nov-17 an fahmi 11 thn nganjuk
wadungasih
46 23-Nov-17 alrafaeyza dirgantara 2 th buduran
47 21-Dec-17 An M Yoga kurniawan 8 th Pakal. Surabaya
48 21-Dec-17 An M Anif S 11 th
49 21-Dec-17 Tn Shivam 17 th
50 28-Dec-17 Marshendi PE 11 th Jember
51 28-Dec-17 Ahmad M. AU 3 th Bojonegoro
52 28-Dec-17 An Wahyu A Sampang
53 4-Jan-18 an yoga adhitya 7th lamongan
54 4-Jan-18 an eko hardinata 10th gresik
55 4-Jan-18 an akbar fadilah 12th gresik
56 11-Jan-18 an Tri Egi 11 th Tuban
57 15-Jan-18 an ahmad FA. gresik
58 15-Jan-18 an M. Adam bangil
59 15-Jan-18 an Bayu suraya gresik

60 15-Jan-18 an nur habib gresik
Kandangan,
28-Dec-17 Ny Endang S 47 gunung tamsi
HYPOSPADIA
No. Telepon No. RM Diagnosis
hipospadia mid shaft post chordectomy
85646236825 12254596
urethroplasty
087856760791/
12415314 hipospadia scrotum
085646428091
fistel uretrokutan post chordectomy + uretroplasty

82331456948 10775492 ec hipospadia scrotalis + scrotum bifidum + post
orchidectomy S + klienefelter syndrome
hipospadia perineal post chordectomy 3x -

085336483583/
12411398 uretroplasty + fistel uretrokutan + meatal stenosis
085749993811
+ UDT D/S
85101770046 12442690 Hipospadia penoscrotal + chorde
Hipospadia penil post chordectomy +

O8573609095 12018251
uretroplasty
O81277892114 12475524 Hipospadia penoscrotal + Chordae berat
Hipospadia scrotalis + Post chordectomy +

O85257807804 12380403
transposisi scrotum
O82301212805 12413242 Hipospadia penoscrotal post chordectomy
81233689485 12480511 Hipospadia Subcoronal + chordae
81335097294 12553778 Hipospadia scrotal + UDT D + DSD

081703451283/0851 Hipospadia subcoronal post ocrdektomy +
12430505
00022974 ureteroplasty
85232405822 12300126 Hipospadia post chordectomy+ ureteroplasty
82112953606/82139
12511018 Hipospadia penile proximal + cordae
643719
81359990181 12513129 Hipospadia Glandular + Chordae
81230402922 12480740 USD/ UDT(s)+ Hil(s)+ Hipospadia Penoscrotal
85645132242 10745001 hipospadia penoscrotal + scrotum bifidum +

chordectomy + multiple congenital anomaly
087855571663/
12564017 Hipospadia + Chordae
087862229086
Hipospadia Midshaft + Penile + Chorcodae +
81331006439 12510187
UDT D/S
085733146088/0815 Hipospadi penoscrotal + Rectractile Ren d/s +
12518284
53709098 VSD + Tb Paru
85604111798 12465466 Hipospadia scrotalis + scrotum bifidum + Chordae
Hipospadia + Korde + Skrotum Bifidum +

85707804180 12555697
Mikrotestis
O81233029611 12568723 Hipospadia penil diuctal + Chordae
O81333689686 12225433 Hipospadia penoscrotal + hipospadia

hipospadia skrotum + Chordae berat
82334190202 12568758 +hidrokel testis D
Hipospadia subcoronal + UDT D + down

83849035692 12242236 syndrom
085335989754/08 12572205 Hiposapadia penoscrotal + chordae

5102675447
81335097294 12553778 Hipospadia scrotal + UDT D + DSD
Hipospadia Phenoscrotal + Chordae berat +

85645400817 12528019 UDT D/S + Developmental delay
81363100827/08384
12605207 hipospadia penoscrotal+chordae berat
7176527
hipospadia penoscrotal+retractile testis+ scrotum

82334119454 12587482
bifidum+chordae berat
cripple hypospadia + korde postkordektomi 2x +

85224558767 12239625 uretroplasty
085903627639/ hipospadia penoscrotal + chordee + CHD +

12580088
085338521185 Scrotum bifidum
085606311133/085 Hipospadia Midshaft penile+Chordae post

12615442
607556944 sirkumsisi
Striktur uretra parsial pars bulbosa + post end to
O85790633636 12529321 end anastomose
O81274162695 12628291 Striktur urethra total pars bulbosa + riwayat open
085648448888/081 hypospadia post uretroplasty + fistel

12612029
220448888 uretrocutan+chordae
081357839277/082 hypospadia phenoscrotal+scrotum bifidum+post

12615177
140885131 orchidopexy D/S
85790493836 12618637 hypospadia phenoscrotal+chordae
082231845656/082 12620281 hypospadia phenoscrotal+chordae berat

333047400
081362794438/ hipospadia penoscrotal + chordee + scrotum

12624926
081334000920 bifidum
081554208326/ hiposadia penoscrotal + chordee + scrotum

12620161
085607781299 bifidum
hipospadia penoscrotal + scrotum bifidum +

85785837090 12384965 chordee + retractil testis S + dev delay +
mikrocephali
hipospadia skrotalis + chordee berat post
82139689100 12466561 cordectomy + scrotum bifidum post transposisi
scrotum
89628929262/ 12628403 hipospadia penoscrotal + chordee

085730427551
O83119728378 12637528 hipospadia coronal + chordae
O81938486947 12635590 Hipospadia subcoronal + chordae
O85706205480 12362063 CRPPG hipospadia post urethoplasty + BMG

Hipospadia mid shaft + post chordectomy +
O85284188249 12523149 urethoplasty
O81939393681 12637895 Hipospadia distal
85330429780/ 12573109 hipospadia penil distal
085733754213
85755125113 / 12637481 hipospadia penoscrotal
085746580670
085101522292/ 12637844 hipospadia penile distal
085236110323
085812604825/08 hipospadia penoscrotal + chorde post
12637742
507587292 chordectomy urethroplasty
085649977414 12629610 hipospadia skrotalis + chordae scrotum
085336088481/08 12643408 hipospadia
5859801002
85730163881 12499500 hipospadia penoscrotal
81357560735 12642092 hipospadia subkoronal
Batu pyelum dextra + batu sekunder pole
O81357312725 12636557 bawah ren dextra + HN grd I-II D
O85250014187 12631883 Ca Cervix III B + kemoterapi
12523149 Hipospadia midurethoplasty
shaft + post chordectomy +
O85284188249
O82301955951 12632030 UDT D/S
Planning Kelas Update Keterangan
re-do urethroplasty ASKES II/III bersedia operasi
panendoskopy + tes ereksi k/p re

jamkesmas bersedia operasi
chordectomy + urethroplasty
Repair fistel uretrokutan BPJS III bersedia operasi
laparoskopi diagnostik k/p

orchidopexy -> repair fistel
belum pernah operasi,

Chordectomy + Urethroplasty BPJS kelas II
bersedia
Re-uretroplasty BPJS III bersedia dioperasi
Re-chordectomy + re uretroplasty BPJS III bersedia
Uretroplasty BPJS III bersedia
uretroplasty BPJS III bersedia
chordectomy + urethroplasty BPJS kelas I blm pernah operasi bersedia
Laparoscopy diagnostic D +
chordectomy uretroplasty - BPJS III Bersedia Operasi
transposisi scrotal
3x operasi, rencana operasi
Choedectomy + urethroplasty BPJS II ke 4 karena ada kebocoran
(fistel)
Repair Fistel Uretrocutan BPJS II bersedia repair fistel
Cordektomi + ureteroplasty BPJS III bersedia
Glanuloplasty + Chordectomy BPJS III bersedia
Urethrocytoscopy dgn GA Jamkesmas bersedia
chordectomy + urethroplasty BPJS III bersedia operasi
Chordectomy + Uretroplasty BPJS III bersedia
Prolaparoscopic Diagnostik +
BPJS I bersedia
Orchidoplexy D/S
MRS Diskusi Multidisoplin +
BPJS III bersedia
Orchydoteksi d/s
Chordectomy + uretroplasty BPJS III blelum perna operasi
bersedia, belum pernah

Chordectomy + Uretroplasty BPJS II
operasi
choerdectomy-uretroplasty BPJS II bersedia
Chordectomy + urethroplasty BPJS II bersedia

chordectomy uretroplasty k/p 2 BPJS III Bersedia Operasi
tahap + hidrokeloktomy inguinal D
orchidopexy D + laparoscopy BPJS III Bersedia Operasi

diagnostic D + sirkumsisi
chordectomy urethroplasty BPJS III Bersedia Operasi
Laparoscopy diagnostic D +
chordectomy uretroplasty - BPJS III Bersedia Operasi
transposisi scrotal
Analisis kromosom + orchidopexy BPJS II Bersedia Operasi

+ uretroplasty
belum pernah operasi,

Chordectomy+uretroplasty BPJS III
bersedia
orchidopexy D/S I+ II Chordaectomy belum pernah operasi,

BPJS III
+ III uretroplasty bersedia
chordectomy + uretroplasty BPJS III bersedia operasi
Chordectomy + uretroplasty Bersedia Operasi

Pre end to end anastomosis urethra BPJS III Bersedia operasi
end to end anastomose urethra BPJS III Bersedia Operasi
chordectomy+repair+fistel BPJS III Bersedia Operasi

uretrocutan
chordectomy uretroplasty BPJS I Bersedia Operasi
chordectomy+urethroplasty BPJS III Bersedia Operasi
sedang mengurus
chordectomy+uretroplasty Bersedia Operasi
BPJS
cjordectomy - urethroplasty 1 tahap + JAMKESMAS bersedia operasi

scrotoplasty
chordectomy + scrotoplasty + BPJS III bersedia operasi

urethroplasty
chordectomy + scrotoplasty + BPJS III bersedia operasi

urethroplasty
urethroplasty BPJS III bersedia operasi
chordectomy + urethroplasty BPJS II bersedia operasi
Chordectomy + urethoplasty BPJS II bersedia operasi
Chordectomy + urethoplasty BPJS I bersedia operasi
Johansen I BPJS I bersedia operasi
Chordectomy + urethroplasty BPJS III bersedia operasi

Repair fistule + redo urethroplasty BPJS III bersedia operasi
chordectomy + urethroplasty bpjs iii bersedia operasi
chordectomy kalo perlu BPJS III bersedia operasi

urethroplasty
chordectomy urethroplasty bpjs ii bersedia operasi
chordectomy + urethroplasty BPJS III

chordectomy + urethroplasty JKN
chordectomy + urethroplasty KIS
URS D. Jika lancar/ stenosis (-) --> BPJS III besedia operasi
PCNL D
DJ stent D/S BPJS III besedia operasi
Laparoskopi diagnostik D/S BPJS II bersedia operasi
No Tanggal Nama Usia
1 7-Mar-13 An. Fariz Adjie 1 th
2 10-Jun-14 Petrus Adobala 1 th
3 11-Feb-16 An. Muh rafi 5
4 3-Oct-16 Sdr. Endah Wijayanti 26 th
5 25-Oct-16 Tn. Aghozi 18th
6 27-Oct-16 Ani Kusanah 16th
7 11-Nov-16 Verrel Abrison 12th
8 14-Nov-16 Zidan Dwi 8th
9 4-May-17 An. Throttle al-Khalifi Pramono 1 th

10 27-Jul-17 An. Moch El zafran 15 bl
11 7-Aug-17 an. Gerardus E 8 th
12 31-Aug-17 an. Ahmad GH
13 4-Sep-17 an. Aditia 3 th
14 25-Sep-17 an. Moh. Nasrul M. 9 th
15 2-Oct-17 an. M. Tsabit 9 th
16 12-Oct-17 an nikolas ahmad Y 15 bulan

17 16-Oct-17 an m iqbal ardani 2th
18 13-Nov-17 an achmad zidan al khalifi 3 th
19 23-Nov-17 moch rizky hendrawan 2th
20 21-Dec-17 An Sifan 16 bln
22 28-Dec-17 An M. F. Ilhamsyah
21 4-Jan-18 an axel brandon 7th

tn deni budi
2-Jan-18 Tn Ahmad Subarna 72
3-Jan-18 Tn Sukadi 65
28-Dec-17 Ny Endang S 47
Ny Wijiyanti 51
28-Dec-17 Marshendi PE 11 th
28-Dec-17 Ahmad M. AU 3 th
28-Dec-17 An Wahyu A
28-Dec-17 An M. F. Ilhamsyah
UNDECENCUS TESTIS
Alamat No. Telepon
0852 03871110 -
Darmo Indah Selatan 7/9 Surabaya
085645509298 - 081230903399
Lewoleta, Maumere 81334334129
Surabaya O87853663999
Sememi Jaya 5/63 Surabaya 081336964042/ 082390934442
Godangan 081386984317 / 08563101794
Kediri 85735424091
Ponorogo 081249794870/ 082140841738
Blitar 85655900737
Wonorejo Indah timur 1/KAV 115 surabaya 83857006300

Mojokerto 085784551554/085755020205
Cendrawasi Sedang 081331385330/08563099521
Kalijaten 34 SDA 87754289460
Balong Bendo Jombang 85748513671
Suci Manyar Gresik 0851050918180/085731148300
Mojokerto 085707840033/085649433429
082257300999/ 085257032596
083830644969/ 085234788402
lamongan 85735992018
garuda 123 betro sedati 085730022772/ 085107134252
O8224447000
Surabyaa O82301955951
sidoarjo 85331333300/ 08123290467
Sidoarjo O85790633636
Jombang O81274162695
Kandangan, gunung tamsi O81357312725
Palangkaraya O85250014187
Jember O85859350355
Bojonegoro O85284188249
Sampang O81939393681
Surabyaa O82301955951
UNDECENCUS TESTIS
No. RM Diagnosis
12203926 Undecencus testis bilateral + Hipospadia scrotal
12334250 UDT D/S+phimosis
12228226 recurrent UDT S
12503995 UDT D/S + Hipospadia Perineal
12487351 UDT D
12452677 UDT D/S
12533387 UDT D/S
12386205 UDT D/S
12499151 UDT S + Cornela

retractile testis D + hidrocele S + phimosis +
12497313 hidrocephalus post VN shunt + paraplasia post
eksisi cele
12604847 UDT bilateral +retractile testis S
12590408 UDT D/S
12410620 UDT S
12607970 Hypospadia + Chordectomy+UDT D/S
12617912 UDT D/S + Hypospadia phenoscrotal+Chordae
12517770 UDT D/S + Phymosis + burried penis +

12450481 UDT S+ retractile testis D
12626598 webbed penis + retractile testis D
congenital penile curvature + parameatal cyst + high

12627596 scrotal D + retractile testis S
12624302 UDT S + multiple kongenital anomali
12632030 UDT D/S

12639329 UDT sin
Striktur uretra parsial pars bulbosa + post end to
12529321 end anastomose
12628291 Striktur urethra total pars bulbosa + riwayat open

Batu pyelum dextra + batu sekunder pole bawah
12636557 ren dextra + HN grd I-II D
12631883 Ca Cervix III B + kemoterapi
12637870 Hipospadia subcoronal + chordae
Hipospadia mid shaft + post chordectomy +
12523149 urethoplasty
12637895 Hipospadia distal
12632030 UDT D/S
Planning Kelas
1. Laparoscopy Dx Orchidopexy D/S + 2.

Hipospadia - evaluasi ulang
laparoscopy diagnosis+orchidopexy Askes III
Re-Laparoskopic dx k/p orchidopexy S BPJS kelas III
Laparoscopy diagnostic + Urethroplasty BPJS I
Laparoscopy diagnostic k/p Orchidectomy D BPJS II
Uretroplasty KIS
Laparoscopic diagnostic orchidopeksi kp

BPJS II/III
orchidektomy
Evaluasi dengan GA bila palpableàorchidopexy BPJS II
Orcidopexy S BPJS I
Hidrokelektomy S + Orchidectomy D + sirkumsisi BPJS III
orchidopexy D/S BPJS III
Orchidopeksi D/S
laparosscopy diagnostic + orchidopexy

BPJS III
S+sirkumsisi
laparoskopi diagnostik+orchidopexy D/s, diskusi ulang BPJS III

rechordectomy, uretroplasty
OrchidopexyD/S+Chordectomy+uretroplasty BPJS I
orchidopexy D/S Urgent BPJS III

orchidopexy D/S BPJS III
rekonstruksi penis + orchidopexy D BPJS III
orchidopexy D/S + chordectomy + eksisi kista BPJS II
Orchidopexy S BPJS I
Laparoskopi diagnostik D/S BPJS II

urgent laparoskopik diagnostik + orchidopexy sin bpjs i
Pre end to end anastomosis urethra BPJS III
end to end anastomose urethra BPJS III

URS D. Jika lancar/ stenosis (-) --> PCNL D BPJS III
DJ stent D/S BPJS III
Chordectomy + urethroplasty BPJS III
Repair fistule + redo urethroplasty BPJS III
chordectomy + urethroplasty BPJS III
Laparoskopi diagnostik D/S BPJS II
update Keterangan
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
Bersedia operasi
bersedia operasi
bersedia operasi
Bersedia operasi
besedia operasi
besedia operasi
bersedia operasi
bersedia operasi
bersedia operasi
bersedia operasi
BPH
No Tanggal Nama Usia Alamat No. Telepon No. RM
1 20-Jun-17 Tn Iswanto 65 th Surabaya 82140439138 12221914
2 26-Jul-17 Tn. Misdi 72 th Simo Ponorogo 85259513002 12585203
Jl Gadel tengah III O85101834425 12555725

3 22-Dec-17 Tn Tarlim 56 th no 19. Surabaya
4 11-Jan-18 Tn. Nur Wachid Surabaya 085256735818 12630869

tn deni budi
2-Jan-18 Tn Ahmad Subar 72 Sidoarjo O85790633636 12529321
3-Jan-18 Tn Sukadi 65 Jombang O81274162695 12628291

28-Dec-17 Ny Endang S 47 Kandangan, gunung O81357312725 12636557
Ny Wijiyanti 51 Palangkaraya O85250014187 12631883
28-Dec-17 Marshendi PE 11 th Jember O85859350355 12637870
28-Dec-17 Ahmad M. AU 3 th Bojonegoro O85284188249 12523149
28-Dec-17 An Wahyu A Sampang O81939393681 12637895

28-Dec-17 An M. F. Ilhamsyah Surabyaa O82301955951 12632030
Diagnosis Planning Kelas Update Keterangan
striktur uretra pars
bulbomembranacea +
panendoscopy K/P bersedia
post Trochar BPJS II operasi
uretroplasty+BMG
Sistostomi+ BPH
grade II
Ca Buli T1/2NxM0 +
Simple cyst ren S +
TUBT Staging BPJS II bersedia operasi
BPH Gr. II + Elongasi
retro + HN St.II
BPH grd II + retensio VTP - TURP (join bersedia

urin + batu ren D BPJS II
orthopedi) operasi
pole atas + R/ ORIF
BPH grd II + retensio VTP - TURP BPJS II

urin
Striktur uretra parsi Pre end to end anaBPJS III Bersedia operasi
Striktur urethra
total pars bulbosa + end to end anasto BPJS III
riwayat open
Batu pyelum dextra +URS D. Jika lancar/ BPJS III besedia operasi
Ca Cervix III B + kem DJ stent D/S BPJS III besedia operasi
Hipospadia
subcoronal + Chordectomy + ureBPJS III bersedia operasi
chordae
Hipospadia mid
shaft + post Repair fistule + re BPJS III bersedia operasi
chordectomy +
urethoplasty
Hipospadia distal chordectomy + uretBPJS III bersedia operasi
UDT D/S Laparoskopi diagnoBPJS II bersedia operasi
Darmo Indah Selatan

7/9 Surabaya
2 10-Jun-14 Petrus Adobala 1 th Lewoleta, Maumere
3 12-Aug-16 Tn Miyanto 44 th Pucangan Palang tuban
4 20-Oct-16 Tn. Sadimin 57 th Tengah Sampang
5 20-Dec-16 Tn. Muhamad 46 th Pamekasan
6 30-Mar-17 Sdr. Gilang bagus 19 th Pandean kawedanan
tambak osowilangun
7 16-Jun-17 Zainul Arifin 30 th
10/4 Surabaya
8 20-Jun-17 Tn Iswanto 65 th Surabaya
9 8-Aug-17 tn. Sukoili 54 th

10 22-Aug-17 Tn. Abdu Ghofur 55 th Kamal madura
Sumengko, Duduk
11 24-Aug-17 Tn. Musfik 39 th
Sampean, Gresik
12 31-Aug-17 Tn. Nur Salim Surabaya
13 11-Sep-17 Tn. Massari 75 th Beringinan Talago
14 25-Sep-17 Tn. Slamet Adi 25 th Kebon Agung Pacitan
15 6-Oct-17 Tn. Satuhan 39 th Madura, Sampang
16 19-Oct-17 misnadi 67th situbondo
14-dec-17 londalem galis

17 tn mat nasir 66th
bangkalan
18 14-dec-17 sugeng 48th kupang jaya 2/54

20 3-Jan-18 Tn Sukadi 65 Jombang
tn deni budi


0852 03871110 -
Undecencus testis bilateral +
085645509298 - 12203926
Hipospadia scrotal
081230903399
Epispadia + Repair Epispadia

81334334129 12334250
Urethroplasty
Pan uretra stricture post johansen I

81333149974 12474735
+ BT ren D/S
Striktur uretra pars

87853508414/878510 bulbomembranacea + post
12454325
63353 repair buli e.c ruptur buli
iatragenik + diverticulosis buli

87816733446 12534821
bulbomembranacea post open
stricture uretra parsial post

reudalens post chordectomy
81555674103 12360621 uretroplasty + repair fistel post
johansen 1 + eksisiretral plate +
brackie procedur
striktur uretra pars membrana

83830045923 12564845
prostatika+status sistostomi
striktur uretra pars

bulbomembranacea + post
82140439138 12221914
Trochar Sistostomi+ BPH grade
II

82139901345 12584113 membranosa + LUTS berat +
sistostomy striktur
Striktur uretra parsial pars
82338405838 12603219 bulbosa + post Troichart
Sistetomy
Striktur uretra pars bulbosa

81556652695 12591157
totalis + post open sistostomi
retensio urin ec striktur uretra

082141134473/08123 parsial pars bulbomembranacea
125995591
5544146 + sistoskopi+ sistostomi status +
HT stg 1
Strictur uretra parsial pars

85232405188 12579842 pendulare post uretroplasty
BMG+sistostosmi
085298135864/08788 Striktur uretra pars

12426374
2592783 bulbomembranacea post EEA
striktur uretra total pars

87849969786 12607238 bulbomembranacea+post open
sistostomi
striktur total urethra pars

082335919592/
085230376443 12621260 pendulare post TURP +
sistostomi statis
striktur uretra parsial + retensio

081931055111/
087852323727 12629003 urin+ R/ open prostatectomy +
ESBL (kultur urin)
89678202729/ striktur urethra + post

081249318816 12563089
urethrolithotomy
Striktur uretra parsial pars

O85790633636 12529321 bulbosa + post end to end
anastomose
Striktur urethra total pars
O81274162695 12628291 bulbosa + riwayat open
O85790633636 Striktur
12529321
uretra parsial pars bulbosa + post end to end anastomose
Striktur urethra total pars
O81274162695 12628291 bulbosa + riwayat open
O81357312725 Batu pyelum
12636557
dextra + batu sekunder pole bawah ren dextra + HN grd I-II D
Hipospadia subcoronal +
O85859350355 12637870 chordae
Hipospadia mid shaft + post
O85284188249 12523149 chordectomy + urethoplasty
O82301955951 12632030 UDT D/S
1. Laparoscopy Dx
Orchidopexy D/S + 2. bersedia operasi
Hipospadia - evaluasi ulang
laparoscopy
Askes III bersedia operasi
diagnosis+orchidopexy
Pro Johansen II (MRS setelah

bulan 9)
Pro uretrografi di OK + End to

end anastomose uretra
Uretroscopy end-to end

bersedia operasi
anastomosa uretra
tahap II brack procedur BPJS II bersedia operasi
uretroscopy di OK (Oktober
2017)
panendoscopy K/P
uretroplasty+BMG
End to end anastomosis uretra BPJS III bersedia operasi

Pan Endoskopi + end to end
anastomose uretra
panendoskopi + end to end

anastomose uretra
uretrosistoskopi k/p
sachse/TUIP
AFF DK + uretrografi BPJS III bersedia operasi
BVCUG di OK + EEA BPJS III bersedia operasi
uretrografi di OK k/p end to end

anastomose uretra setelah 3 BPJS III bersedia operasi
bulan
End to end anastomosic urethra

k/p BMG
urethroscopy + urethrosplasty +
BMG
Uretrography k/p urethroplasty BPJS III bersedia operasi
Pre end to end anastomosis BPJS III Bersedia operasi

urethra
end to end anastomose urethra BPJS III bersedia operasi
Pre end to end anastomosis urethra BPJS III Bersedia operasi
end to end anastomose urethra BPJS III
URS D. Jika lancar/ stenosis (-) --> PCNL DBPJS III besedia operasi

CAL
1 12-Jan-15 Ny asminarti 52th jojoran 2/41
2 19-Feb-15 NY darsih 54th tuban
3 19-Jan-16 Ny Khumrotin 39 Psuruan
4 9-Feb-16 Ny. Nur hasanah 30 pamekasan
Kapas Gading Madya 4 / 19

5 21-Apr-16 Ny. Tatik 37
Surabaya
Dukuh Bulak Banteng 1/6

6 11-Oct-16 Tn. Matosan 59 th
Surabaya
7 14-Oct-16 Ny. Siti Romlah 51 th Gebang wetan 24 surabaya
Tn. Sugiyono 58 th
8 21-Oct-16
12539051
58 th Wonorejo 2/69 Surabaya
9 2-Nov-16 Ny.Wartini 69th Margo Rukun
10 7-Nov-16 Ny.Devi Amil 55th Kramat Jagu Taman
11 19-Nov-16 Ny. Sri Ayoh Pajaran Utara muri Sidoarjo

Tn. Rakhmat Eko
12 15-Dec-16 26 th Lobo RT7/2 Sidoarjo
Nur
Tambak suri selatan

13 17-Jan-17 Tn. Rachmad 24 th
2/10surabaya
Ny. Uswatun
14 28-Feb-17 24 th Gumuk probolinggo
Hasanah
15 5-May-17 Ny nurul Muchayah 45 th Petemon Surabaya
Kembang kuning keramat

16 20-Jun-17 Ny. Supeni 63 th
2/34 SBY
17 13-Jul-17 Ny. Sri Ani 51 th Mojokerto
18 14-Jul-17 Ny. Supiah 27 th Surabaya
19 31-Jul-17 Tn. Sapari 57 th Benowo
20 4-Aug-17 Tn. Abd Shomad 67 th Siwalan, Panji, Buduran
21 7-Aug-17 Ny Masideh 50 th Banyuates Sampang

22 10-Aug-17 Ny Sri Susilowati 53 th pasuruan
23 10-Aug-17 Ny. Sumiyatun 37 th bangkalan
Jl. Ikan Hiu gang 4/37

24 21-Aug-17 tn deni budi 44th
Probolinggo
NTT/ Astana Ampel No. 34

25 28-Aug-17 Ny. Solfiana Surabaya
26 28-Aug-17 Tn. Wariono 45 th Sukodono Sidoarjo
27 29-Aug-17 Tn. Moh. Sujadid 35 th Jalan Basuki Rahmad 286a Tuban
28 4-Sep-17 Ny. Nur Lailah 45 th Bima NTB
29 11-Sep-17 Tn. Ridoi 55 th Kemayoran Surabaya
30 11-Sep-17 Ny. Juwanah 31 th
31 18-Sep-17 Tn. Abdul Malik 49 th Jrenggol Sampang

32 26-Sep-17 Ny. Dwi Yuniarti 40 th Bojonegoro
35 6-Nov-17 Ny. Amiana 62th Surabaya
36 24-Nov-17 Ny mujianah 66th genting tombak dalam
37 24-Nov-17 tn syakir 57th bangkalan
24-Nov-17 Tn. Milkianus ambon

38 49th
dominggus
39 28-Nov-17 Ny marniyah 46th
40 5-Dec-17 ny tio swan nio 63th sby
41 11-Dec-17 ny rukeni 58th sulati, ngoro
42 13-Dec-17 tn koe guslin

43 29-Dec-17 Ny Tutik Lestari 54 Surabaya
44 15-Jan-18 ny Sulikah 52 Kupang
45 15-Jan-18 Tn. Sentot Priyo 45 th Nganjuk


CALCULI RENAL
batu ren S pole tengah + DM + HT +

82336066212 12300652 PNL S
ISK
Batu staghorn + batu pyelum S + HN RPG D/S + pasang DJ stent

85335980903 12386250
sedang berat S S
Batu Staghorn ren S + S. Batu ureter S
O82132988910 12439210 RPg - URS S + PNL S
+ Caontracted Ren S
Multiple Bt opaque pole tengah - RPG D +
O87850680718 12466127
bawah D + HN D gr IV pyelonefrolithotomi D k/p
12461853 Batu Pole Atas Ren S + HN ringan S Pro PNL S
Residual sone ren D post

85100922514 12535588 nefrolitotomi D + HN ringan + DJ PNL D
stent D
81335052145/856 Batu calyx atas ren D + HN gr I +

12537421 PCNL D
45418651 DM type 2
8121753482/85331 Batu multiple ren D post open ren D +

12539051 PNL D
396934 HN gr III D
82245645402 12536036 Batu Renal D PCNL D
Batu Pyelum D + HN gr II D + Batu

85852051092 12535833 PNL D
Multiple
85707846103 12538775 Batu ren D pole bawah + batu ren S PNL D

Batu pyelum ren (D)+HN St I (D)
82213000308 12548958 +double system incomplete ren (D) PNL (D) senior
+Batu ren (S) pole bawah
RPG S + Laparoskopi
81289074264 12560056 Ectopia ren S + Non Visualis ren S
nefrektomi S
batu ren D pole bawah + HN gr I

85213957334 12560754 PNL D
Ren D
Batu multiple renal D pole tengah +

Btu multiple renal pole atas S + RPG D/S + URS D + k/p DJ
81217703606 12233556 batu uereter distal D + HN ringan S stent S + PNL D + PNL S
+ CKD st IV + HT st II
Batu ren S Multipel pole bawah +s.
Batu uretra D 1/3 Proximal dd PNL S-konsul anestesi
83854957194 638826
stenosis ureter+AKI dd Ackd +post setelah MRS
open Ren S+post CABG+post repair
085101227001/08 Batu pyelum S + UPJ Stenosis S +

12583747 PNL S
5103463832 UPJ Stenosis S + HN Grade II/III S
Batu pyelum D + Batu Multipel

87852746708 12595837 Sekunder Pole Bawah D + HN RPG D + PNL D
grade Sedang D + MR ringan
Batu UPC D = Batu pole bawah ren

81314618623 10996129 RPG k/p URS
D + HN sedang D + batu ren S
081230203038/0 bt pole tengah+pole bawah Ren

12603071 PNL D
85606065949 D+residual+ HN+AKI
Batu upj S + batu skunder pole atas
bawah rsn S + HN berat S +
085259879467/085257830645
12595035 Contracted Ren D + HT stage II + PNL S
Asidosis metabolic teregulasi +
Oligouri + Anemia
82301504297 12605932 Batu Pyelum S PNL S
Batu multiple ren D + DJ Stent in

085845809363/085852806715
12595085 PNL D
situ D + Post ESWL 2x
Batu ureter proximal D + batu Ren

81336159703 12607321 URS D +PNL S
S +HN Sedang Bilateral + GERD
Bt staghorn S+Bt sekunder pole

81330165994 12602123 Bivalve Nephrolitotomi S
atas D+HN grade III S
Single kidney+ Bt pyelum D+HN berat

081235175966/08121 RPG D +
12353985 D+DM type II+TB paru post OAT PS ASA
6311365 pyelonephrolithotomy D
II
081331091011/08224 Batu ren D pole atas tengah+HN grade III

12533914 Aff DJ stent D+ PNL D
4250801 D+ DJ stent + Post PNL D
Batu pyelum D + post open Ren D+

085237381766/085337952076
12611987 PNL D
post URS D
8123236311 Batu staghorn D/S + DJ Stent insitu Lepas Dj Stent

12600068
D/S D+Bivalve Nefrotomi S
81252580762/0857
12612059 Batu pyelum S + HN grade II S PNL S
31295893
TCC Buli T4bNxM0+Post TURBT

085608429952/08 Sistoscopy
12608855 2x+Batu Reb Pole bawah
1553362227 Biopsi/TURBT
D+Riwayat Ureterolitotomi
Batu Ren D Multiple + Batu Ren S
82331529905 12203582 Pole bawah+HN Grade II D +post PNL D/S
ESWL
O85790633636 Striktur uretra parsial pars bulbosa + Pre end to end anastomosis
12529321
post end to end anastomose urethra
batu pole bawah ren D + HN ringan

82143727247/ sedang D + Hidroureter 1/3 proximal RPG D k/p, URS D + PNL
08563014872 D + Hep C Kronik + susp stenosis D
ureter D
batu pyelum S + batu pole atas S +

081344395380/ RPG S+ PNL S atau open
12617117 Susp UPJ stenosis S + Hnringan S +
083830523636 pyeloplasty S
DM
Batu ureter distal D + batu pyelum

81939302440 12624056 URS D + pasang DJ stent
S + batu sekunder ren S + HN gr III
S + PNL S
D/S
082195080228/ 12630068 batu ren S pole bawah PNL S

081343561177
single kidney S post nephrectomy D +

087806806347/ Batu staghorn S + batu ren S pole
085940461651 12622398 Aff DJ Stent S + PNL S
bawah + DJ stent S + post RPG URS S
+ Riw. Aka
81357978632 batu pyelum S + Batu pole bawah ren

12621306 PNL S
S + HN gr I S
batu pyelum D + HN berat D + serous

83830095613/
085707793796 12593877 cystadenoma ovarium S post TAH aff DJ stent D + PCNL D
-BSO + CML
81295515593 batu ren D pole tengah + batu ren S PNL D

Batu pyellum D + batu sekunder
O85331291544 12165979 PNL D
pole bawah ren D + HN gr III D
085239126352/0 12640942 batu staghorn S + HN gr I-II Bivalve nephrolitotomy
81339005390
Batu Staghorn D + HN Ringan D + bt
082233783696 12215251 PCNL D
ren pole bawah S + bt UVJ S
Batu pyelum dextra + batu
URS D. Jika lancar/
O81357312725 12636557 sekunder pole bawah ren dextra + stenosis (-) --> PCNL D
HN grd I-II D
Chordectomy +
O85859350355 12637870 Hipospadia subcoronal + chordae urethroplasty
O85284188249 12523149 chordectomy + urethoplasty urethroplasty
chordectomy +
O81939393681 12637895 Hipospadia distal urethroplasty
Laparoskopi diagnostik
O82301955951 12632030 UDT D/S D/S
BPJS kelas III Bersedia operasi
BPJS kelas II Bersedia operasi
BPJS Kelas III Bersedia operasi
BPJS I/II/III Bersedia operasi
BPJS Bersedia operasi

BPJS 1 Bersedia operasi
BPJS III Bersedia Operasi
BPJS I Bersedia operasi

BPJS II bersedia Operasi
BPJS III bersedia

belum konfirmasi, masih diskusi

BPJS III
keluarga
jamkesmas bersedia oprasi
BPJS III mandiri bersedia operasi
tidak aktif
BPJS I


CALCU
Tn. Kristovel
1 6-Jun-14 39 th Sudirman 23 Kupang
Mavolly
Jokotole II/4 Pamekasan
2 23-Dec-14 Ny. Nurhasanah 42 th
Madura
3 22-Feb-16 Ny. Rumilah 50 th tropodo 1 barat
Lebak timur asli gg masjid

4 30-May-16 Ny. Istiyah 57 th
IA/19 SBY
5 27-Oct-16 Ny. Evi Kadiyarini 42th Sumenep
KRT Nangala 12 Amban Papua

6 7-Jul-17 Ny. Watminah 44 th
Barat
7 7-Aug-17 Ny. Maridah 50 th Banyuatos Sampang
8 10-Aug-17 An Nur Maulidah 2 th MT Haryono18B, Pasuruan
9 18-Aug-17 Ny. Lailatul F 31 th HalmaheraPasuruan
10 29-Aug-17 Ny. Irianti Balong Bendo Krian

11 7-Sep-17 an. Iffa Amelia 6 th Jati Tamban Jabar
12 24-Oct-17 Nn. Maghfiroh 22th Nganjuk
13 24-Nov-17 tn syakir 57th bangkalan
14 4-Jan-18 Tn M Huri 36 th lamongan
15 4-Jan-18 tn hanafi 44th surabaya
16 4-Jan-18 ny lipan jungkluh 59 th surabaya
17 12-Jan-18 Tn. Syaihullah 25 th gresik
18 4-Jan-18 tn hanafi 44th surabaya

tn deni budi


CALCULI URETER
Batu ureter 1/3 medial Planning
81337237999 12333438 + HN grade II RPG+URS k/p
D+Hidroureter D
batu ureter proximal
85257210108 12382139 URS S+ ESWL S
S+Batu pole atas ren S
susp. Stenosis ureter distal

S dd batu non opaque RPG -URS D k/p
O83849100013
ureter distal D + HN gr III neoimplantasi ureter
D + hidroureter D
RPG D --> URS D k/p

BT ureter Prox D +
85231487987 1232330 open uretrolitotomy
HN gr IV D
prox D
RPG +
Batu Ureter distal D +
87816947576 12541349 Ureterolitotomi distal
HN gr III D
D
Batu ureter 1/
proximal D+batu
multipel pole bawah 1. URS D dorong
81344241823 12597486 Ren D+Batu sekunder batu+PNL D 2.
pole atas + Batu diskusi ulang
multipel Ren S+HN
grade II
Batu UVJ S+Batu
085259879467/0852578 sekunder pole atas
12595035
30645 +bawah S +HN berat
S
Batu ureter distal S + RPG S +

89679173043 12478432 HN berat S + ureterolithotomy
hidroureter S distal S
Batu ureter proximal

D + HN grade III D URS dorong batu +
85706987266 12608473
+Hydroureter PNL D
proximal D
Bt Ureter 1/3 Proximal
URS+PNL D k/p
D+Bt Multiple Ren D
81233709623 12525541 Bivalve
pole bawah HN
nephrolitotomi
sedang D +Ca cx IIIB
Batu ureter 1/3 tengah
Laparoskopy
D + batu ureter 1/3
085784546775/081380214400 12613337 ureterolitotomy D
distal D + HN sedang
(transperitoneal)
D
batu ureter prox D + HN

085755498883/ RPG-URS dorong batu
085655998323 12533308 berat D + tumor
-> PNL D k/p open
parathyroid S
Batu ureter distal D +

81939302440 12624056 batu pyelum S + batu URS D + pasang DJ
sekunder ren S + HN stent S + PNL S
gr III D/S
batu ureter proksimal

sin + batu pyelum sin URS sin dorong batu +
82333806055 12636359 + post ekspulsi batu PNL sin
buli
batu pole tengah

ureter sin +
85228908161 12604036 parenchymal kidney PNL sin
disease bilateral + PJK
omi + DM

85230051855 12636325 dekstra + HN berat dx RPG URS dx
+ nefrocalsinosis
085606665152/0857078 Bt. UPJ S + HN Berat S
12639029 RPG-URS S + PNL S
12169 + HT I
batu pole tengah

ureter sin +
85228908161 12604036 parenchymal kidney PNL sin
disease bilateral + PJK
omi + DM
Striktur uretra parsial
pars bulbosa + post Pre end to end
O85790633636 12529321 end to end anastomosis urethra
anastomose
Striktur urethra total end to end

O81274162695 12628291 pars bulbosa + anastomose urethra
riwayat open
Batu pyelum dextra +
batu sekunder pole URS D. Jika lancar/
O81357312725 12636557
bawah ren dextra + stenosis (-) --> PCNL D
HN grd I-II D
Ca Cervix III B +
O85250014187 12631883 DJ stent D/S
kemoterapi
Hipospadia subcoronal Chordectomy +
O85859350355 12637870
+ chordae urethroplasty
Hipospadia mid shaft + Repair fistule + redo
O85284188249 12523149 post chordectomy + urethroplasty
urethoplasty
chordectomy +
O81939393681 12637895 Hipospadia distal urethroplasty
Laparoskopi
O82301955951 12632030 UDT D/S diagnostik D/S
BPJS II Bersedia
BPJS kelas II bersedia oprasi
BPJS II bersedia oprasi

BPSJ III bersedia oprasi
jamkesmas bersedia oprasi
BPJS ? bersedia operasi
BPJS II
BPJS ? bersedia operasi

BPJS III


CALCULI BU
1 2-Apr-15 tn rifai 49th
2 20-Feb-17 Ny Bibit wahyuni 48 th Satria sidoarjo
4 26-Jul-17 Tn. Misdi 72 th Simo Ponorogo
6 27-Oct-17 sugeng 36th banyuwangi
13-Dec-17 wedoro utara wanu

7 tn moch iksan 72th
sidoarjo
4-Jan-18 Jl. Banyu urip Kidul 1/28

8 Ny. Srini 68 th
Surabaya
9 4-Jan-18 Tn M Huri 36 th lamongan

10 11-Jan-18 an Umar M 1 th Kupang
tn deni budi


CALCULI BULI
Sistoskopi + litotripsi +
batu buli + batu ren S
85233435415 12397456 RPG D k/p URS S +
pole atas
ESWL S
Sistoskopi +colcup biopsi

TCC Buli T2NxMo ;post
85234763135 12559145 KP URS S + sistectomi
TURBT
radical
fistel vesicovagina + Ca
082141036048/0813 cervix IVB metastatic
12590207 PNL D
37330860 paru infiltrasi buli
rectum
Ca Buli T1/2NxM0 +
Simple cyst ren S + BPH
85259513002 12585203 TUBT Staging
Gr. II + Elongasi retro +
HN St.II
TCC Buli
T4bNxM0+Post
085608429952/0815 Sistoscopy
12608855 TURBT 2x+Batu Reb
53362227 Biopsi/TURBT
Pole bawah D+Riwayat
Ureterolitotomi
ca buli TxNxM0 Post

082234958380/ 12613862 TURBT + AKI dd re-TURBT
082353395674
ACKD + Anemia
tumor buli TxNxM0 +

85706239623 hidronefrosis sedang S
12618569 TURBT staging
+ hidroureter S + kista
ginjal D
TCC Buli Ct2cN0M0 post

81330231288 10183291 Sistoskopi k/p Biopsi
TURB

82333806055 12636359 sin + batu pyelum sin + URS sin dorong batu +
PNL sin
post ekspulsi batu buli
Bt Buli + Stenosis ureter
082144374833/0821 D/S +HN ringan D/S AFF DJ Stent D/S
12621214
46517827 +phimosis post RPG dengan GA
URS D/S
O85790633636 Striktur12529321
uretra parsial pars bulbosa + post
Preend
endtotoend
endanastomose
anastomosis urethra
Striktur urethra total
O81274162695 12628291 pars bulbosa + riwayat
end to end anastomose urethra
open
O81357312725
Batu pyelum
12636557
dextra + batu sekunder poleURS
bawah
D. Jika
renlancar/
dextra +stenosis
HN grd(-)
I-II-->
D PCNL D
Hipospadia subcoronal
O85859350355 12637870 Chordectomy + urethroplasty
+ chordae
Hipospadia mid shaft +
O85284188249 12523149 post chordectomyRepair
+ fistule + redo urethroplasty
urethoplasty
O81939393681 12637895 Hipospadia distal chordectomy + urethroplasty
O82301955951 12632030 UDT D/S Laparoskopi diagnostik D/S
ASKES I bersedia operasi

BPJS II
BPJS III

26-Nov-15 jl sunan kaijaga a1 babat

1 ny siti zainab 57th
lamongan
2 8-Nov-16
Tn. Misdar 53 th Jombang
3 17-Jan-17 Tn sutrisno 50 th madiun
4
5 20-Feb-17
Ny Bibit wahyuni 48 th Satria sidoarjo
6 4-Mar-17 Ny. Sulistian 53 th
7 9-Mar-17 Tn. Agus Subagio 51 th
8 15-May-17
Ny. Sumariyah 45 th Lamongan
9 17-Jul-17 Ny. Sumiati 48 th
10 26-Jul-17
Tn. Misdi 72 th Simo Ponorogo
Jl. Banyu urip Kidul 1/28
11 11-Sep-17 Ny. Srini 68 th Surabaya
12 11-Sep-17 Ny. Srini 68 th Surabaya
14 18-Sep-17 Tn. Soekadi 77 th Juwingan 1/16 Surabaya
15 12-Oct-17 Ny. Karmini 41 th Nganjuk Sukomoro

16 27-Oct-17 sugeng 36th banyuwangi
17 20-Nov-17 ny maryati sulistyani 39th Surabaya
18 11-Dec-17 ny sugianti 39th gemblangan surabaya
tesan 10/5 babat

20 12-Dec-17 ny kustining 47th lamongan
21 14-Dec-17 paeran 70th girilaya 10/33A
22 15-Dec-17 Ny. Kasiyati 49th puri mojokerto
23 10-Jan-18 Tn. Muhajir Sidowungu Menganti


neglected dj stent D/S + HN berat D/S +
081217103207/
12228310 ca cervix IIIB post ER AFL + post kemo
081703433656
5x metastase primer
85203283271 12525288 Bladder TCC T4aNXM0

81233979515 12545191 Tumor ren D cT1NoMo
85234763135 12559145 TCC Buli T2NxMo ;post TURBT
85730307012 Tumor ginjal kanan T4NxMo
85234354048 12548306 Adenoprostat GS (5+4) T4NxMo
83857500707 /
85732373889 12577000 Ca Renal Dx CT2aMxMo
085755290476/08 susp. Ca Blader TxNxMo + fistel

12507967
3845170742 rectovesica + HN ringan D + Efusi Pleura D
Ca Buli T1/2NxM0 + Simple cyst ren S +

85259513002 12585203 BPH Gr. II + Elongasi retro + HN St.II
81330231288 10183291 TCC Buli Ct2cN0M0 post TURB
81330231288 10183291 TCC Buli Ct2cN0M0 post TURB
TCC Buli T4bNxM0+Post TURBT 2x+Batu

085608429952/08 12608855 Reb Pole bawah D+Riwayat
1553362227 Ureterolitotomi
Bladder Cancer T2NxM0+HT St II+HN

082257392113/08 18001513 Grade IV D+HN Grade IIIS+Hydroureter
121770560 D/S
082332374626/08 Cacx IIb post kemoradiasi + HN ringan
12554370
2388451261 S+HN Berat D+DJ Stent D insitu
082234958380/ ca buli TxNxM0 Post TURBT + AKI dd
12613862
082353395674 ACKD + Anemia
08175040314/ ca cervix std IIIB on chemo + HN sedang
12620457
087852819088 D + HN ringan S + DVT
081235154449/ 12570055 tumor adrenal kanan + HHD + DMT2
081235108090
83830095613/ 12593877 cystadenoma ovarium S post TAH -BSO +
085707793796 CML
ca cervix Iib post ERAFC 25x + kemoterapi
8151532759 12485474 3x + HN sedang S
085232058558/ adeno ca prostat GS 8 T1cNxM0 post
081330630920 TURP + parkinson disease
085748704230 / 12632864 Ca Cervix IIIB Pro ERAFC + HN gr III D
085853269090
087712883842/0 SCC Penis T2N0M0 partial penektomi
12614206
83849244003 + kemoterapi
Batu pyelum dextra + batu sekunder pole
O81357312725 12636557 bawah ren dextra + HN grd I-II D
Hipospadia mid shaft + post chordectomy
O85284188249 12523149 + urethoplasty
O82301955951 12632030 UDT D/S
pro ganti DJ stent D/S urgent bpjs II urgent bersedia operasi
bersedia operasi
Radikal sistektomi +Bricker procedure BPJS III
laparoscopic radical nefrectomy BPJS III bersedia operasi
bersedia operasi
Sistoskopi +colcup biopsi KP URS S +
sistectomi radical BPJS III
Radical nephrectomy D BPJS III Bersedia Operasi
TURP de obstruksi + subscapular BPJS II Bersedia dioperasi

orchidectomy
bersedia operasi
Radikal Nefrektomy Dx BPJS III
Cistoscopy berseme narskoss, onko uro BPJS III Bersedia operasi

rekonstruksi urologi
bersedia operasi
TUBT Staging BPJS II
Sistoskopi k/p Biopsi BPJS III bersedia operasi
Sistoskopi k/p Biopsi BPJS III Bersedia operasi
Sistoscopy Biopsi/TURBT BPJS III Bersedia Operasi
TURBT BPJS III Bersedia Operasi
ganti DJ Stent D coba pasang DJ Stent S BPJS III (urgent) Bersedia Operasi
re-TURBT BPJS II bersedia
pasang Djstent D/S BPJS III bersedia operasi
laparoscopic adrenalectomy kanan BPJS iii bersedia operasi
aff DJ stent D + PCNL D BPJS III mandiri bersedia operasi
DJ stent D/s k/p internal stenting D k/p BPJS III bersedia operasi
UCS D
radikal prostatektomi BPJS I bersedia operasi
DJ stent D/S BPJS II/III bersedia operasi
pro kemoterapi BPJS II

URS D. Jika lancar/ stenosis (-) --> PCNL D BPJS III besedia operasi

No Tanggal Nama Usia Alamat No. Telepon
Jl. Wiyung IV/06

1 14-Jul-14 Ny. Darmisih 72 th 85815678256
Surabaya
2 19-Feb-15 NY darsih 54th tuban 85335980903
085732342686/
3 7-May-15 an kevin 4.5 th tulangan sby
081231474102
jl sunan kaijaga a1 babat 081217103207/

4 26-Nov-15 ny siti zainab 57th
lamongan 081703433656
Bandu Urip Kidul

5 23-Aug-16 Ny. Minorsih 53th 81938097244
8F/22 Surabaya
Wonosari Mulyo 3/39 085652621926 /

6 19-Dec-16 Ny. Sundiyah 57 th
Surabaya 081330389980
082141036048/08
1337330860
8 2-Jan-18 Tn Ahmad Subarna 72 Sidoarjo O85790633636
9 3-Jan-18 Tn Sukadi 65 Jombang O81274162695
Bandarojo 2/5 Semiwi

10 Ny. Sutiwik 51 th 81232303329
Benowo
7-Sep-17 an. Iffa Amelia 6 th Jati Tamban Jabar

085784546775/08
11 1380214400
81252580762/085
731295893
Hayam Wuruk I
13 12-Sep-17 Nn. Nadiyah 20 th 85102177010
Kaliwates Jember
82140015228/087
14 14-Sep-17 Ny. Bonatin 49 th Banyuwangi
85256776
085655365957/08
15 15-Sep-17 Ny. Sri Suhartini 61 th Lamongan
1615034628
Juwingan 1/16 082257392113/08

16 18-Sep-17 Tn. Soekadi 77 th
Surabaya 121770560
17 26-Sep-17 Ny. Dwi Yuniarti 40 th Bojonegoro 82331529905
085704822574/08
18 2-Oct-17 Ny. Siti Nuryani 43 th Nganjuk
2264058074
082337600778/08
19 5-Oct-17 Ny. Srinah 50 th Banyuwangi
23344868929
082332374626/08
2388451261
19-Oct-17 an katharine 3,7th

081331470996/
21 082131038335
24-Oct-17 Nganjuk
085755498883/
22 Nn. Maghfiroh 22th 085655998323
23 2-Nov-17 ny sri wahyuni 55th lempung maly 81331928768
81937220259/
24 14-Nov-17 tn buri bin ijuman 72th 085235402631
sukorejo tengah
25 17-Nov-17 Tn bachtiar 59th 81263963000
surabaya
margarheta ditri
26 20-Nov-17 hardini 13 th dorok 2/2 manggis puncu 81330049729
20-Nov-17 Surabaya
08175040314/
27 ny maryati sulistyani 39th 087852819088
24-Nov-17 081344395380/
28 Ny mujianah 66th genting tombak dalam
083830523636
29 24-Nov-17 tn syakir 57th bangkalan 81939302440
5-Dec-17 081233105333/
31 nandes sulis 33th tanah merah utara
081931565000
32 5-Dec-17 ny tio swan nio 63th sby 81357978632
33 11-Dec-17 reza kurniawan 11th gresik 39 asrama brimob 83856275814
11-Dec-17
83830095613/
34 ny rukeni 58th sulati, ngoro 085707793796
12-Dec-17 tesan 10/5 babat 8151532759

35 ny kustining 47th
lamongan
15-Dec-17 Ny. Kasiyati 49th puri mojokerto

085748704230 /
36 085853269090
jl pucagan II no 97
37 18-Dec-17 Tn Suwadi 38 th 81249480679
surabaya
38 29-Dec-17 Ny Tri suhartini 65 lamongan O85645479259
39 4-Jan-18 ny lipan jungkluh 59 th surabaya 85230051855
40 11-Jan-18 an. Abdullah 2 th Jombang 081216565119
41 11-Jan-18 an Adinda 3 th Sidoarjo 85746752460
085707725270/08
42 12-Jan-18 ny Musyarafah mojokerto 5608607590
Kandangan, gunung
28-Dec-17 Ny Endang S 47 O81357312725
tamsi
Ny Wijiyanti 51 Palangkaraya O85250014187

28-Dec-17 Marshendi PE 11 th Jember O85859350355
28-Dec-17 Ahmad M. AU 3 th Bojonegoro O85284188249
28-Dec-17 An Wahyu A Sampang O81939393681

28-Dec-17 An M. F. Ilhamsyah Surabyaa O82301955951
No. RM Diagnosis Planning Kelas
Ca cx IIB+HN ringan D/S DJ stent D/S k/p internal

12586893 BPJS II
pro kemoradiasi stenting S k/p URS S
Batu staghorn + batu pyelum S
12386250 RPG D/S + pasang DJ stent S jamkesmas
+ HN sedang berat S
HN sedang D + post release
tes ereksi k/p chordectomy +
12014846 band D + simple D + retraktil BPJS III
orchidopexy
testis S
neglected dj stent D/S + HN

berat D/S + ca cervix IIIB post
12228310 pro ganti DJ stent D/S urgent bpjs II urgent
ER AFL + post kemo 5x
metastase primer
Sistoskopi K/P Eksisi

11052256 Caranculus Uteri Residif ASKES II
Carunculae
Ca Ovarium III Bpost
optimal + HN berat (S) ec RPG –USD (D) + DJ Stent
10889963 BPJS II
susp stenosis ureter (D) + (D) k/p Open (D)
HHD + AKI
fistel vesicovagina + Ca
12590207 cervix IVB metastatic paru PNL D BPJS I
infiltrasi buli rectum
Striktur uretra parsial pars Pre end to end anastomosis
12529321 bulbosa + post end to end BPJS III
urethra
anastomose
Striktur urethra total pars end to end anastomose

12628291 BPJS III
bulbosa + riwayat open urethra
Ca-cx IIIB + HN D+Pro ER-

12590755 DJ Stent D/S BPJS III
AFL+TB Paru
Batu ureter 1/3 tengah D +

batu ureter 1/3 distal D + HN Laparoskopy ureterolitotomy D
12613337 BPJS III
(transperitoneal)
sedang D
12612059 Batu pyelum S + HN grade II S PNL S BPJS III
Ca rectosigmoid residif +
12594165 HN Sedang D+ hydroureter RPG D + DJ Stent D/S BPJS III
S + Colostomi status
Ca-cx IIIB + HN sedang S
12404200 Pasang DJ Stent D/S BPJS III
prokemoradiasi
Ca-cx IIIB pro ER-AFL+

12606917 HN ringan D+HN sedang Pasang DJ Stent D/S BPJS III
S+Nonvisualized REN S
Bladder Cancer
T2NxM0+HT St II+HN
18001513 TURBT BPJS III
Grade IV D+HN Grade
IIIS+Hydroureter D/S
Batu Ren D Multiple + Batu
12203582 Ren S Pole bawah+HN Grade PNL D/S BPJS III
II D +post ESWL
OAB+Urge
12599965 Inkontinensia+Batu Ren D/S RPG URS+PNL D+ESWL S BPJS II
pole bawah + HN grade II
Batu Staghorn D/S+HN

12606652 PNL D/S BPJS III
Ringan D+HN Berat S
Cacx IIb post kemoradiasi +

ganti DJ Stent D coba pasang
12554370 HN ringan S+HN Berat D+DJ BPJS III (urgent)
DJ Stent S
Stent D insitu
VUR gr IIS + Susp UVJ Stenosis RPG D/S + neoimplantasi D/S

12619475 BPJS II
D + HN Berat D/S
batu ureter prox D + HN berat RPG-URS dorong batu -> PNL

12533308 BPSJ III
D + tumor parathyroid S D k/p open
HN sedang D + batu pole
bawah ren D + HN sedang S +
10273425 susp stenosis ureter S + RPG - URS D/S + ESWL BPJS I
contacted ren D/S + riw open
ren D + riw PJK
12605820 staghronj ren S + HN sedang
RPG S k/p URS S, PNL S BPJS III
S + Hidroureter S
batu pole atas D + HN gr II

12622960 PNL D upper pole puncture BPJS I
D
Ectopic ureter D + ectopic sistoskopi RPG D k/p

12620491 BPJS III
upper moity ren D neoimplantasi ureter D
ca cervix std IIIB on chemo +
12620457 HN sedang D + HN ringan S + pasang Djstent D/S BPJS III
DVT
batu pyelum S + batu pole atas

RPG S+ PNL S atau open
12617117 S + Susp UPJ stenosis S + BPJS II
pyeloplasty S
Hnringan S + DM
Batu ureter distal D + batu
12624056 URS D + pasang DJ stent S
pyelum S + batu sekunder jamkesmas
+ PNL S
ren S + HN gr III D/S
RPG D k/p neoimplantasi

12622003 HN berat + hidroureter D BPJS II
ureter
batu pyelum S + Batu pole

12621306 PNL S BPJS II
bawah ren S + HN gr I S
hhidronefrosisberat D +
hidroureter proksimal D +
12454950 URS D BPJS II
stenosis uretra D + batu pole
bawah ren D
batu pyelum D + HN berat D +
12593877 serous cystadenoma ovarium S aff DJ stent D + PCNL D BPJS III mandiri
post TAH -BSO + CML
ca cervix Iib post ERAFC 25x

DJ stent D/s k/p internal
12485474 + kemoterapi 3x + HN sedang BPJS III
stenting D k/p UCS D
S
Ca Cervix IIIB Pro ERAFC + HN

12632864 DJ stent D/S BPJS II/III
gr III D
batu ren S pole tengah

bawah + batu ureter distal D RPG D/S K/p URS D/S, PNL S
12635953 umum
+ batu ureter proksimal S +
HN ringan D + HN sedang S
Ca cervix IV B + DJ stent D in Ganti DJ stent D, coba
12606917 situ pasang stent S
12636325 dekstra + HN berat dx + RPG URS dx BPJS III
nefrocalsinosis
HN Berat (S) + HN Sedang
12621467 RPG D/S K/P Open BPJS III
(D) susp UPJ
complete double system S + sistoskopi -RPG S +
12641169 BPJS II
dilatasi ureter S neoimplantasi ureter
Ca Cervix III B + HN Berat D DJ stent D/S k/p internal
12438783 BPJS III
+ HN ringan S stenting S k/p UCS S
Batu pyelum dextra + batu URS D. Jika lancar/ stenosis
12636557 sekunder pole bawah ren BPJS III
(-) --> PCNL D
dextra + HN grd I-II D
12631883 Ca Cervix III B + kemoterapi DJ stent D/S BPJS III

Hipospadia subcoronal + Chordectomy +
12637870 BPJS III
chordae urethroplasty

12523149 BPJS III
chordectomy + urethoplasty urethroplasty
chordectomy +
12637895 Hipospadia distal BPJS III
urethroplasty
12632030 UDT D/S Laparoskopi diagnostik D/S BPJS II
Update Keterangan
Bersedia operasi
setelah
radioterapi
bersedia
operasi
bersedia
operasi
bersedia
operasi
Bersedia operasi
bersedia
operasi
Bersedia
Operasi
Bersedia
operasi
Bersedia
operasi
Bersedia
operasi
Bersedia
operasi
(urgent)
bersedia
Bersedia
operasi
Bersedia
operasi
Bersedia
operasi
Bersedia
Operasi
Bersedia
Operasi
Bersedia
Operasi
Bersedia
Operasi
Bersedia
Operasi
bersedia
operasi
bersedia
bersedia
bersedia
bersedia
operasi
bersedia
operasi
bersedia
operasi
bersedia
operasi
bersedia
oprasi
bersedia
operasi
bersedia
operasi
bersedia
operasi
bersedia
operasi
bersedia
operasi
Bersedia
Operasi
sudah
operasi
bersedia
operasi
bersedia
operasi
besedia operasi
besedia operasi
bersedia operasi
bersedia operasi
bersedia operasi
bersedia operasi
EPISPADI
No Tanggal Nama Usia Alamat No. Telepon No. RM
1 8-Dec-15 rizki maklidani 3th ploso klaten 82245502431 12451400
083831988005 /
2 3-Mar-16 By Valorian 1 bln Surabaya 12397898
083831988007
tn deni budi
2-Jan-18 Tn Ahmad Subarna 72 Sidoarjo O85790633636 12529321
3-Jan-18 Tn Sukadi 65 Jombang O81274162695 12628291

28-Dec-17 Ny Endang S 47 Kandangan, gunungO81357312725 12636557
Ny Wijiyanti 51 Palangkaraya O85250014187 12631883
28-Dec-17 Marshendi PE 11 th Jember O85859350355 12637870
28-Dec-17 Ahmad M. AU 3 th Bojonegoro O85284188249 12523149
28-Dec-17 An Wahyu A Sampang O81939393681 12637895

28-Dec-17 An M. F. Ilhamsyah Surabyaa O82301955951 12632030
ADI
Diagnosis Planning Kelas Update Keterangan
epispadia +
bersedia
dianthesis simphisis repair epispadia BPJS III
operasi
pubis
Epispadia + Repair
bersedia
Epispadia Repair Epispadia Umum
operasi
Urethroplasty
Striktur uretra pars Pre end to end anaBPJS III Bersedia operasi
Striktur urethra
total pars bulbosa end to end anasto BPJS III
+ riwayat open
Batu pyelum dextra +URS D. Jika lancar/ BPJS III besedia operasi
Ca Cervix III B + kemDJ stent D/S BPJS III besedia operasi
Hipospadia
subcoronal + Chordectomy + ureBPJS III bersedia operasi
chordae
Hipospadia mid
shaft + post Repair fistule + re BPJS III bersedia operasi
chordectomy +
urethoplasty
Hipospadia distal chordectomy + uretBPJS III bersedia operasi
UDT D/S Laparoskopi diagnoBPJS II bersedia operasi
No. Tanggal Nama Usia Alamat
Darmo Indah Selatan 7/9

Surabaya
2 10-Jun-14 Petrus Adobala 1 th Lewoleta, Maumere
3 20-Jun-15 an isbat istikha mumin 14th sidosermo 4-15 blok D12
4 23-Jun-15 an azril maulana 4th wirogunan 4/2 pasuruan
6 4-Aug-15 an mas adhi 5th
8 21-Oct-15 an. Leonaldi 12 thn perum sumber permai jember
9 8-Dec-15 rizki maklidani 3th ploso klaten
10 8-Dec-15 An. Rizki maulidani 3 th ploso kediri
11 8-Jan-16 An M zaibidin 8 bojonegoro
12 13-Jan-16 An. Farahan 4 th Sendang trawas Mojokerto
13 5-Feb-16 An. Wisnu energik 3 th
14 11-Feb-16 An. Muh rafi 5 Surabaya

15 15-Feb-16 An, Arga Prayoga 11 th Batam
16 23-Feb-16 An. Andi Moga 5 th Banyakan Kediri
17 23-Feb-16 An. Risal Ubudillah 2 th mandagi sampang
18 29-Feb-16 An M. Riko Fernando 4 th Surabaya
19 3-Mar-16 By Valorian 1 bln Surabaya
20 20-Jun-16 An Moch Saiful 13 TH Margorukun I Buntu 10B Sby
21 28-Jul-16 An M Syahrul 11 Bln Sidotopo Wetan 5/44 Sby
22 12-Aug-16 An Ilham Aji D 10 th Medayu Utara 2/18
24 3-Dec-16 an.reza fahlevi 6 th madura
25 17-Oct-16 An. Dianatul F. 2 th 7 bln Karang penang sampang
26 27-Dec-16 An Nazalim Hicman A 11 th Desa Lajukan, Porong
27 5-Jan-17 Nur Isa 13 th ngetep Jiwan Madiun
28 26-Jan-17 Moh Aji 8 th Kramat Sampang

29 16-Feb-17 an.slamet 2 th
Putat Gede Timur 4/40

30 20-Feb-17 an. Alvaro 4 th
Surabaya
Bandung sekarang
31 20-Feb-17 Fathan Anugerah 4 th
balongpanggang
32 20-Feb-17 An Alvaro 4 th
33 23-Feb-17 An fajar sodiq 14 th labang bangkalan
34 3-Mar-17 An Moch. Saiful F. 5 th
35 23-Mar-17 An. M. Abid Sulaiman 3,5 th
36 30-Mar-17 An. Achad yusuf afandi 7 th sidowarek menganti gresik
37 17-Apr-17 An. M. Fathur Rahman 14 th menganti gresik
An. Throttle al-Khalifi

38 4-May-17 1 Wonorejo
th Indah timur 1/KAV 115 surabaya
Pramono
39 12-Jun-17 An. Iqbal roy 15 th
40 20-Jul-17 An. M. Fahreza 1 th pasar look Surabaya
41 27-Jul-17 An. Moch El zafran 15 bl Mojokerto
42 7-Aug-17 an. Mustafa 15 bln Gading, Probolinggo

Taman Pikatan Gading
43 7-Aug-17 an. Nurul Hidayat 12 th
Probolinggo
44 7-Aug-17 an. Gerardus E 8 th Cendrawasi Sedang
45 10-Aug-17 An Nur Maulidah 2 th MT Haryono18B, Pasuruan
46 10-Aug-17 An. Shaqilla 3 th sukorame watang lamongan
47 14-Aug-17 An. Fauzi 10 th kedung cowek surabaya
48 28-Aug-17 an. M. Irham 8 th Krembangan Surabaya
49 28-Aug-17 an. M. Aditia S 8 th Krajan Asem Probolinggo
50 31-Aug-17 an. Ahmad GH Kalijaten 34 SDA
51 31-Aug-17 an. Ahmad GH Kalijaten 34 SDA
dukuh nogo karang waluh

52 31-Aug-17 ibrohim mubarok 9 th sampun
Bati ombo Bander Banteng

53 4-Sep-17 an. Muzhaffar 16 bln
Jateng
54 4-Sep-17 an. Aditia 3 th Balong Bendo Jombang

Bati ombo Bander Banteng
55 4-Sep-17 an. Muzhaffar 16 bln Jateng
56 4-Sep-17 an. Aditia 3 th Balong Bendo Jombang
58 7-Sep-17 nur wahid hasyim 14th sumberwaras
60 16-Sep-17 an alfian rifky
61 18-Sep-17 an. Muh. Amirul 1,5 th Sidoarjo
62 25-Sep-17 an. Andika Putra 13 bln KH A. Dahlan Nganjuk
63 25-Sep-17 an. Moh. Nasrul M. 9 th Suci Manyar Gresik
64 28-Sep-17 an. Syarif Banyuanyar Probolinggo
Jl. Bunga No. 10 Mojoroto

65 28-Sep-17 an. Fariz N 3,8 th Kediri
66 2-Oct-17 an. M. Tsabit 9 th Mojokerto

67 5-Oct-17 an. Moch. Fakhri 9 th Lamongan
68 5-Oct-17 by. Abidz Nizam 8 bln Surabaya
69 5-Oct-17 an. Azril A. 2 th Sidoarjo
70 10-Oct-17 kanang sudarma 13th kartoharjo
71 12-Oct-17 an nikolas ahmad Y 15 bulan
72 12-Oct-17 an. Syaiful 17 bln Pekalongan Sampang
73 16-Oct-17 an m iqbal ardani 2th
74 19-Oct-17 an katharine 3,7th
75 26-Oct-17 an galang 10 th sidotopo
76 13-Nov-17 an achmad zidan al khalifi 3 th lamongan
77 13-Nov-17 an m fakri setia
muhammad harijuddin
78 16-Nov-17 9th sugihwaras nganjuk
mubarok
79 16-Nov-17 an. Muhammad faqih 21 bulan sidoarjo
80 16-Nov-17 an fahmi 11 thn nganjuk
81 20-Nov-17 margarheta ditri hardini 13 th dorok 2/2 manggis puncu
82 23-Nov-17 alrafaeyza dirgantara 2 th wadungasih buduran
83 23-Nov-17 moch rizky hendrawan 2th garuda 123 betro sedati
84 4-Dec-17 an m rafa azka putra 21 bulan bojonegoro
85 11-Dec-17 Muhammad kevin 5 th probolinggo
86 11-Dec-17 reza kurniawan 11th gresik 39 asrama brimob
87 21-Dec-17 An M Yoga kurniawan 8 th Pakal. Surabaya
88 21-Dec-17 An Sifan 16 bln
89 21-Dec-17 An M Anif S 11 th
90 ilham syafaat 14th lakar santri RT 2/4
91 28-Dec-17 Marshendi PE 11 th Jember
92 28-Dec-17 Ahmad M. AU 3 th Bojonegoro

93 28-Dec-17 An Wahyu A Sampang
94 28-Dec-17 An M. F. Ilhamsyah Surabyaa
95 4-Jan-18 an yoga adhitya 7th lamongan
96 4-Jan-18 an eko hardinata 10th gresik
97 4-Jan-18 an m alif n arsarin 7th surabaya wonosari
98 4-Jan-18 an akbar fadilah 12th gresik
99 4-Jan-18 an axel brandon 7th sidoarjo
100 11-Jan-18 an. Abdullah 2 th Jombang
101 11-Jan-18 an Umar M 1 th Kupang
102 11-Jan-18 an Tri Egi 11 th Tuban
103 11-Jan-18 an Adinda 3 th Sidoarjo
104 15-Jan-18 an ahmad FA. gresik
105 15-Jan-18 an M. Adam bangil

106 15-Jan-18 an Bayu suraya gresik
107 15-Jan-18 an nur habib gresik
0852 03871110 -
Undecencus testis bilateral +
085645509298 - 12203926
Hipospadia scrotal
081230903399
81334334129 12334250 UDT D/S+phimosis
hipospadia mid shaft post

85646236825 12254596
chordectomy urethroplasty
087856760791/
12415314 hipospadia scrotum
085646428091

chordectomy + uretroplasty ec
82331456948 10775492 hipospadia scrotalis + scrotum
bifidum + post orchidectomy S +
klienefelter syndrome
082132208142/ fistel uretrocutan post

12259714
081332618211 chordectomy + urethroplasty
hipospadia perineal post
085336483583/ chordectomy 3x - uretroplasty +
12411398
085749993811 fistel uretrokutan + meatal
stenosis + UDT D/S
epispadia + dianthesis simphisis

82245502431 12451400
pubis
82245502431 12451400 epispadia

O85228635046 10786027
vesicolitotomi + uretrolitotomi
Fistula subcutan scrotum +

81333931877 12080092 Post sigmoidostomy + post
repair buli + post herniotomy
Hipospadia penil post

O8573609095 12018251
chordectomy + uretroplasty
O87853663999 12228226 recurrent UDT S

Hipospadia penoscrotal +
O81277892114 12475524
Chordae berat
Hipospadia scrotalis + Post

O85257807804 12380403 chordectomy + transposisi
scrotum
Hipospadia penoscrotal post

O82301212805 12413242
chordectomy
81233689485 12480511 Hipospadia Subcoronal + chordae
083831988005 / Epispadia + Repair Epispadia

12397898
083831988007 Urethroplasty
Hipospadia post chordectomy+

85232405822 12300126
ureteroplasty
USD/ UDT(s)+ Hil(s)+

81230402922 12480740
Hipospadia Penoscrotal
087855571663/
12564017 Hipospadia + Chordae
087862229086
Striktur urethra total pars bulbosa

O81274162695 12628291
+ riwayat open
Hipospadia scrotalis + scrotum

85604111798 12465466
bifidum + Chordae
Hipospadia + Korde + Skrotum

85707804180 12555697
Bifidum + Mikrotestis
85230772195/0852 hypospadia coronal post

12355153
30024691 chordectomy uretroplasty
087849388286/085 hypospadia distal post

12562320
648751314 uretroplasty-chordectomy
Hypospadia penoscrotal +chordae
85655247052 12414784
berat+scrotum bifidum
81233029611 12568725 Hypospadia penile distal+chordae
Hipospadia penoscrotal +
O81333689686 12225433
hipospadia
Hipospadia penil diuctal +

O81233029611 12568723
Chordae
hipospadia skrotum + Chordae
82334190202 12568758 berat +hidrokel testis D
82311931042 12546529 Congenital penile contractile
Hipospadia subcoronal + UDT

83849035692 12242236 D + down syndrom
085335989754/0 Hiposapadia penoscrotal +
12572205
85102675447 chordae
Hipospadia scrotal + UDT D +

81335097294 12553778 DSD
083857006300 12499151 UDT S + Cornela
Hipospadia phenoscrotal +
082141575501/0 post chordectomy 2x +
12216485
85257920773 uretroplasty +post johanssen
procedure I
Hipospadia Phenoscrotal +
85645400817 12528019 Chordae berat + UDT D/S +
Developmental delay
retractile testis D + hidrocele S

085784551554/0 + phimosis + hidrocephalus
12497313
85755020205 post VN shunt + paraplasia
post eksisi cele
81363100827/0838 hipospadia penoscrotal+chordae

12605207
47176527 berat
hipospadia penoscrotal+retractile
82334119454 12587482 testis+ scrotum bifidum+chordae
berat
081331385330/085
12604847 UDT bilateral +retractile testis S
63099521
Batu ureter distal S + HN berat

89679173043 12478432 S + hidroureter S
085233114398/0 HN berat S + Hidroureter S

12604720
823303802770 Susp. UPJ stenosis
Trauma ureter prox D gr IV +

82338295053 12566456 post opensistektomi
085330914111/085 incompleted sirkumsision+meatal

12610817
330645463 stenosis
085234012929/085 Hypospadia midshaft penile +

12610254
331059664 chordae
87754289460 12590408 UDT D/S
87754289460 12590408 UDT D/S
cripple hypospadia + korde

85224558767 12239625 postkordektomi 2x + uretroplasty
085736766171/081 Hypospadia phenoscrotal +

12537488
548262289 chordae
85748513671 12410620 UDT S

085736766171/08 Hypospadia phenoscrotal +
12537488
1548262289 chordae
85748513671 12410620 UDT S
Batu ureter 1/3 tengah D + batu

085784546775/081
12613337 ureter 1/3 distal D + HN sedang
380214400
D
0812721312/0857 post rechordectomy+ hipospadia

12355580
55691416 subcoronal
085784546775/08 Batu ureter 1/3 tengah D + batu

12613337
1380214400 ureter 1/3 distal D + HN sedang D
hipospadia penoscrotal +
085903627639/ 12580088 chordee + CHD + Scrotum
085338521185 bifidum
085606311133/08 Hipospadia Midshaft

12615442
5607556944 penile+Chordae post sirkumsisi
Hypospadia scrotalis + Chordae

81217211551 12567266 berat+Scrotum Bifidum
0851050918180/0 12607970 Hypospadia + Chordectomy+UDT

85731148300 D/S
082244859015/08 12617917 Hypospadia Midshaft

52335579211
085648448888/08 hypospadia post uretroplasty +

12612029
1220448888 fistel uretrocutan+chordae
085707840033/08 UDT D/S + Hypospadia

12617912
5649433429 phenoscrotal+Chordae
hypospadia
081357839277/08 12615177 phenoscrotal+scrotum
2140885131 bifidum+post orchidopexy D/S
082237738828/08 phimosis + riwayat kejang

12616141
7854550207 demam
hypospadia
85790493836 12618637 phenoscrotal+chordae
085733747095/ fistula urethrocutan post

10603607
08121785449 urethroplasty BMG
082257300999/ UDT D/S + Phymosis + burried

12517770
085257032596 penis +
082231845656/08 hypospadia
12620281
2333047400 phenoscrotal+chordae berat
083830644969/ 12450481 UDT S+ retractile testis D

085234788402
081331470996/ VUR gr IIS + Susp UVJ Stenosis D +

12619475
082131038335 HN Berat D/S
081362794438/ 12624926 hipospadia penoscrotal +

081334000920 chordee + scrotum bifidum
85735992018 12626598 webbed penis + retractile testis D
081554208326/ hiposadia penoscrotal + chordee

12620161
085607781299 + scrotum bifidum
scrotum bifidum + chordee +
85785837090 12384965 retractil testis S + dev delay +
mikrocephali
082299834224/ phimosis + CMV + dev.delay + riw
12625470
08175195303 kejang demam
hipospadia skrotalis + chordee

82139689100 12466561 berat post cordectomy + scrotum
bifidum post transposisi scrotum
Ectopic ureter D + ectopic upper

81330049729 12620491 moity ren D
89628929262/ hipospadia penoscrotal +

12628403
085730427551 chordee
congenital penile curvature +

085730022772/ 12627596 parameatal cyst + high scrotal D +
085107134252 retractile testis S
phymosis + spina bifida + VP

85332500744 12480340 shunt
85258303574 12631076 UDT D/S (palpable) + phimosis
hhidronefrosisberat D +
hidroureter proksimal D +
83856275814 12454950 stenosis uretra D + batu pole
bawah ren D
O83119728378 12637528 hipospadia coronal + chordae
UDT S + multiple kongenital

O8224447000 12624302 anomali
O81938486947 12635590 chordae
85645132242 10745001 scrotum bifidum + chordectomy +
multiple congenital anomaly
O85859350355 12637870 chordae
O85284188249 12523149 chordectomy + urethoplasty
O82301955951 12632030 UDT D/S
85330429780/ 12573109 hipospadia penil distal

085733754213
85755125113 / 12637481 hipospadia penoscrotal
085746580670
81231258787 12573109 webbed penis
085101522292/ 12637844 hipospadia penile distal

085236110323
85331333300/ 12639329 UDT sin

08123290467
HN Berat (S) + HN Sedang (D)
081216565119 12621467 susp UPJ
Bt Buli + Stenosis ureter D/S
082144374833/0 12621214 +HN ringan D/S +phimosis post
82146517827 RPG URS D/S
085812604825/0 12637742 chorde post chordectomy
8507587292
urethroplasty
complete double system S +
85746752460 12641169 dilatasi ureter S
hipospadia skrotalis + chordae
085649977414 12629610 scrotum
085336088481/0 12643408 hipospadia
85859801002
85730163881 12499500 hipospadia penoscrotal
81357560735 12642092 hipospadia subkoronal
Tindakan Status Update 21 Jan 2018 Keterangan
1. Laparoscopy Dx Orchidopexy D/S + 2. sudah masuk Soetomo,

Hipospadia - evaluasi ulang menunggu jadwal
laparoscopy diagnosis+orchidopexy Askes III tidak diangkat
re-do urethroplasty ASKES II/III bersedia operasi
panendoskopy + tes ereksi k/p re chordectomy +

urethroplasty
Repair fistel uretrokutan BPJS III bersedia operasi
repair fistel uretrocutan SPM bersedia operasi
laparoskopi diagnostik k/p orchidopexy -> repair

fistel
repair epispadia BPJS III tidak diangkat
repair epispadia BPJS kelas III tidak diangkat
sistokopi k/p repair fistel BPJS kelas II bersedia operasi
Explore fistulektomy bersedia dioperasi
Re-uretroplasty BPJS III bersedia dioperasi
Re-Laparoskopic dx k/p orchidopexy S BPJS kelas III bersedia operasi

Re-chordectomy + re uretroplasty BPJS III bersedia operasi
Uretroplasty BPJS III bersedia operasi
uretroplasty BPJS III bersedia operasi
chordectomy + urethroplasty BPJS kelas I bersedia operasi
Repair Epispadia Umum bersedia operasi
Repair Fistel Uretrocutan BPJS II bersedia operasi
Urethrocytoscopy dgn GA Jamkesmas tidak diangkat
Chordectomy + Uretroplasty BPJS III bersedia operasi
end to end anastomose urethra BPJS III bersedia operasi
Chordectomy + uretroplasty BPJS III bersedia operasi
Chordectomy + Uretroplasty BPJS II bersedia operasi
re-do uretroplasty test ereksi k/p chordectomy BPJS II bersedia operasi
redo chordectomy-uretroplasty bersedia operasi

tahap I chordectomy+yahap II Uretroplasty BPJS III bersedia operasi
Chordectomy+uretroplasty BPJS II bersedia operasi
Chordectomy + urethroplasty BPJS II bersedia operasi
choerdectomy-uretroplasty BPJS II bersedia operasi

chordectomy uretroplasty k/p 2 tahap + BPJS III Bersedia Operasi
hidrokeloktomy inguinal D
tes ereksi k/p chordectomy BPJS III Bersedia Operasi
orchidopexy D + laparoscopy diagnostic D + BPJS III Bersedia Operasi

sirkumsisi
chordectomy urethroplasty BPJS III Bersedia Operasi
Laparoscopy diagnostic D + chordectomy BPJS III Bersedia Operasi

uretroplasty - transposisi scrotal
Orcidopexy S BPJS I Bersedia Operasi
urethroplasty BPJS III Bersedia Operasi
Analisis kromosom + orchidopexy + BPJS II Bersedia Operasi

uretroplasty
Hidrokelektomy S + Orchidectomy D + BPJS III Bersedia Operasi

sirkumsisi
Chordectomy+uretroplasty BPJS III bersedia operasi

orchidopexy D/S I+ II Chordaectomy + III
uretroplasty
orchidopexy D/S BPJS III bersedia operasi
RPG S + ureterolithotomy distal S BPJS III Bersedia Operasi
RPG S + Pyelopasty S BPJS Bersedia Operasi
repair ruptur dg segmen ileum BPJS III Bersedia Operasi

(rekonstruksi)
re sirkumsisi BPJS III bersedia operasi
Orchidopeksi D/S bersedia operasi
Orchidopeksi D/S Bersedia operasi
chordaectomy+uretroplasty BPJS II Bersedia operasi
laparosscopy diagnostic + orchidopexy

BPJS III bersediacoperasi
S+sirkumsisi
chordaectomy+uretroplasty BPJS II Bersedia operasi
laparosscopy diagnostic + orchidopexy BPJS III Bersedia operasi

S+sirkumsisi
Laparoskopy ureterolitotomy D (transperitoneal) BPJS III bersedia operasi
chordectomy + uretroplasty BPJSIII bersedia operasi
Bersedia operasi
Laparoskopy ureterolitotomy D (transperitoneal) BPJS III (urgent)
Chordectomy + uretroplasty Bersedia Operasi
chordectomy+scrotuloplasty+uretroplasty BPJS III Bersedia Operasi
laparoskopi diagnostik+orchidopexy D/s, diskusi BPJS III Bersedia Operasi

ulang rechordectomy, uretroplasty
Chordectomy-uretroplasty BPJS III Bersedia Operasi
chordectomy+repair+fistel uretrocutan BPJS III Bersedia Operasi
OrchidopexyD/S+Chordectomy+uretroplasty BPJS I Bersedia Operasi

chordectomy uretroplasty BPJS I Bersedia Operasi
sirkumsisi dengan GA (ODC) BPJS III Bersedia Operasi
chordectomy+urethroplasty BPJS III Bersedia Operasi
re-do urethroplasty BPJS III bersedia operasi
orchidopexy D/S Urgent BPJS III bersedia operasi
sedang mengurus
chordectomy+uretroplasty Bersedia Operasi
BPJS
orchidopexy D/S BPJS III bersedia operasi
RPG D/S + neoimplantasi D/S BPJS II bersedia operasi
cjordectomy - urethroplasty 1 tahap + JAMKESMAS bersedia operasi

scrotoplasty
rekonstruksi penis + orchidopexy D BPJS III bersedia operasi
chordectomy + scrotoplasty + urethroplasty BPJS III bersedia operasi
chordectomy + scrotoplasty + urethroplasty BPJS III bersedia operasi

sirkumsisi dgn GA BPJS III bersedia operasi
urethroplasty BPJS III bersedia operasi
sistoskopi RPG D k/p neoimplantasi ureter D BPJS III bersedia operasi
chordectomy + urethroplasty BPJS II bersedia operasi
orchidopexy D/S + chordectomy + eksisi kista BPJS II bersedia operasi
Sirkumsisi dgn GA BPJS II bersedia operasi
orchidopexy D/S + sirkumsisi BPJS III bersedia operasi
URS D BPJS II bersedia operasi
Chordectomy + urethoplasty BPJS II bersedia operasi
Orchidopexy S BPJS I bersedia operasi
Chordectomy + urethoplasty BPJS I bersedia operasi

chordectomy + urethroplasty bpjs iii bersedia operasi
chordectomy kalo perlu urethroplasty BPJS III bersedia operasi
release webbed penis bpjs iii bersedia operasi
chordectomy urethroplasty bpjs ii bersedia operasi
urgent laparoskopik diagnostik + bpjs i bersedia operasi

orchidopexy sin
RPG D/S K/P Open BPJS III bersedia operasi
AFF DJ Stent D/S dengan GA BPJS II bersedia operasi
sistoskopi -RPG S + neoimplantasi ureter BPJS II bersedia operasi
chordectomy + urethroplasty JKN bersedia operasi

chordectomy + urethroplasty KIS bersedia operasi
No. Tanggal Nama Usia Alamat
1 6-Jun-14 Tn. Kristovel Mavolly 39 th Sudirman 23 Kupang
2 14-Jul-14 Ny. Darmisih 72 th Jl. Wiyung IV/06 Surabaya
Jokotole II/4 Pamekasan

3 23-Dec-14 Ny. Nurhasanah 42 th
Madura
4 12-Jan-15 Ny asminarti 52th jojoran 2/41
5 19-Feb-15 NY darsih 54th tuban
6 9-Feb-16 Ny. Nur hasanah 36 th Kowel Pamekasan
7 22-Feb-16 Ny. Rumilah 50 th tropodo 1 barat
Kapas Gading Madya 4 / 19

8 21-Apr-16 Ny. Tatik 37
Surabaya
Lebak timur asli gg masjid

9 30-May-16 Ny. Istiyah 57 th
IA/19 SBY
Bandu Urip Kidul 8F/22

10 23-Aug-16 Ny. Minorsih 53th
Surabaya
11 2-Nov-16 Ny.Wartini 69th Margo Rukun
12 7-Nov-16 Ny.Devi Amil 55th Kramat Jagu Taman
13 19-Nov-16 Ny. Sri Ayoh Pajaran Utara muri Sidoarjo

Pakis Gunung 2/50A
14 16-Feb-17 Nn. Rewina 23 th
Surabaya
15 20-Feb-17 Ny Bibit wahyuni 48 th Satria sidoarjo
16 28-Feb-17 Ny. Uswatun Hasanah 24 th Gumuk probolinggo
17 4-May-17 Ny. Sulistian 53 th
18 4-May-17 Ny. Tities Patriawaty 67 th Kupang
19 5-May-17 Ny nurul Muchayah 45 th Petemon Surabaya
20 15-May-17 Ny. Sumariyah 45 th Lamongan
21 16-Jun-17 Ny. Suparti 62 th Madiun
Kembang kuning keramat

22 20-Jun-17 Ny. Supeni 63 th 2/34 SBY
KRT Nangala 12 Amban

23 7-Jul-17 Ny. Watminah 44 th
Papua Barat
24 13-Jul-17 Ny. Sri Ani 51 th Mojokerto
25 14-Jul-17 Ny. Supiah 27 th Surabaya
26 17-Jul-17 Ny. Sumiati 48 th

28 1-Aug-17 Ny. Enik Choiriyah 56 th karang tembok 2/5
29 1-Aug-17 tn deni budi 56 th Kr tembok
30 7-Aug-17 Ny. Maridah 50 th Banyuatos Sampang
31 7-Aug-17 Ny Masideh 50 th Banyuates Sampang
32 10-Aug-17 Ny Sri Susilowati 53 th pasuruan
33 10-Aug-17 Ny. Sumiyatun 37 th bangkalan
34 15-Aug-17 Ny. Astutik 38 th Kediri
35 18-Aug-17 Ny. Lailatul F 31 th HalmaheraPasuruan
Jl. Ikan Hiu gang 4/37

36 21-Aug-17 Ny. Misnah 44th
Probolinggo
28-Aug-17 NTT/ Astana Ampel No. 34

37 Ny. Solfiana
Surabaya
38 29-Aug-17 Ny. Irianti Balong Bendo Krian

40 Ny. Srini 68 th
Surabaya
Hayam Wuruk I Kaliwates

42 12-Sep-17 Nn. Nadiyah 20 th
Jember
43 14-Sep-17 Ny. Bonatin 49 th Banyuwangi
44 15-Sep-17 Ny. Sri Suhartini 61 th Lamongan
45 26-Sep-17 Ny. Dwi Yuniarti 40 th Bojonegoro
46 5-Oct-17 Ny. Srinah 50 th Banyuwangi
48 24-Oct-17 Nn. Maghfiroh 22th Nganjuk
49 2-Nov-17 ny sri wahyuni 55th lempung maly
50 20-Nov-17 ny maryati sulistyani 39th Surabaya
51 21-Nov-17 Ny sugiarti 46th sby
52 24-Nov-17 Ny mujianah 66th genting tombak dalam
53 28-Nov-17 Ny marniyah 46th

54 5-Dec-17 nandes sulis 33th tanah merah utara
55 5-Dec-17 ny tio swan nio 63th sby
56 11-Dec-17 ny sugianti 39th gemblangan surabaya
58 12-Dec-17 ny kustining 47th tesan 10/5 babat lamongan
59 15-Dec-17 Ny. Kasiyati 49th puri mojokerto
60 18-Dec-17 Ny. Nur Khayati 29th Kec Bancan Kab tuban
61 22-Dec-17 Ny Elisa T. Setiawati 65 th
62 22-Dec-17 Ny Sukman 62 th Porong. Sidoarjo
63 22-Dec-17 Faidaturahma 23 th Lamongan
64 28-Dec-17 Ny Endang S 47 Kandangan, gunung tamsi

65 28-Dec-17 Ny Wijiyanti 51 Palangkaraya
66 29-Dec-17 Ny Tri suhartini 65 lamongan
67 29-Dec-17 Ny Tutik Lestari 54 Surabaya
68 4-Jan-18 ny lipan jungkluh 59 th surabaya
69 12-Jan-18 ny Musyarafah mojokerto

70 15-Jan-18 ny Sulikah 52 Kupang
No. Telepon No. RM
81337237999 12333438
85815678256 12586893
85257210108 12382139
82336066212 12300652
85335980903 12386250
87850680718 12466173
O83849100013
12461853
85231487987 1232330
81938097244 11052256
82245645402 12536036
85852051092 12535833
85707846103 12538775
085258414029/085850538200 12526576
85234763135 12559145
85213957334 12560754
85730307012
81249007306 12553870
81217703606 12233556
83857500707 / 85732373889 12577000
89603387235 12590046
83854957194 638826
81344241823 12597486
085101227001/085103463832 12583747
87852746708 12595837
085755290476/083845170742 12507967
082141036048/081337330860 12590207
81357962239 10118528
81357962239 10118528
085259879467/085257830645 12595035
085259879467/085257830645 12595035
82301504297 12605932
085845809363/085852806715 12595085
085784982784/085749037049 12439198
85706987266 12608473
81336159703 12607321
81330165994 12602123
81233709623 12525541
O85790633636 12529321
81330231288 10183291
81252580762/085731295893 12612059
85102177010 12594165
82140015228/08785256776 12404200
085655365957/081615034628 12606917
82331529905 12203582
082337600778/0823344868929 12606652
082332374626/082388451261 12554370
085755498883/ 085655998323 12533308
81331928768 10273425
08175040314/ 087852819088 12620457
81913220058 12618311
081344395380/ 083830523636 12617117
087806806347/ 085940461651 12622398

081233105333/ 081931565000 12622003
81357978632 12621306
081235154449/ 081235108090 12570055
83830095613/ 085707793796 12593877
8151532759 12485474
085748704230 / 085853269090 12632864
853321343999 12635525
O82247209727 12234221
O81364641990 12500146
O85755981100 12597921
O81357312725 12636557
O85250014187 12631883
O85645479259 12606917
O85331291544 12165979
85230051855 12636325
085707725270/085608607590 12438783
085239126352/081339005390 12640942
O85859350355 12637870
O85284188249 12523149
O81939393681 12637895
O82301955951 12632030
Diagnosis Tindakan
Batu ureter 1/3 medial + HN grade II

RPG+URS k/p
D+Hidroureter D
Ca cx IIB+HN ringan D/S pro kemoradiasi DJ stent D/S k/p internal stenting S k/p URS S
Epispadia + Repair Epispadia

URS S+ ESWL S
Urethroplasty
batu ren S pole tengah + DM + HT + ISK PNL S

Batu staghorn + batu pyelum S + HN sedang
RPG D/S + pasang DJ stent S
berat S
Multiple batu opaque pole tengah bawah D + HN

pyelonefrolitotomy D k/p reseksi pole bawah D
D gr IV + Batu Pyelum D
susp. Stenosis ureter distal S dd batu non opaque

RPG -URS D k/p neoimplantasi ureter
ureter distal D + HN gr III D + hidroureter D
Batu Pole Atas Ren S + HN ringan S Pro PNL S
BT ureter Prox D + HN gr IV D RPG D --> URS D k/p open uretrolitotomy prox D
Caranculus Uteri Residif Sistoskopi K/P Eksisi Carunculae
Batu Renal D PCNL D
Batu Pyelum D + HN gr II D + Batu

PNL D
Multiple
Batu ren D pole bawah + batu ren S PNL D

HN sedang S post
RPG-URS S k/p Open
heminefrectomyureteroplasty
Sistoskopi +colcup biopsi KP URS S + sistectomi

TCC Buli T2NxMo ;post TURBT
radical
batu ren D pole bawah + HN gr I Ren D PNL D
Tumor ginjal kanan T4NxMo Radical nephrectomy D
Fistula vesicovagina + Susp. Uretrovagina Sistoskopi + RPG S + k/p URS S + Explor coper
+ HN sedang S
Batu multiple renal D pole tengah + Btu

multiple renal pole atas S + batu uereter RPG D/S + URS D + k/p DJ stent S + PNL D + PNL
distal D + HN ringan S + CKD st IV + HT st S
II
Ca Renal Dx CT2aMxMo Radikal Nefrektomy Dx
Fistula vesicovagina post TAH-BSO + Repair fistula vesikovagina transvaginal

sistoskopi
Batu ren S Multipel pole bawah +s. Batu

uretra D 1/3 Proximal dd stenosis ureter+AKI PNL S-konsul anestesi setelah MRS
dd Ackd +post open Ren S+post CABG+post
repair
Batu ureter 1/ proximal D+batu multipel pole
bawah Ren D+Batu sekunder pole atas + 1. URS D dorong batu+PNL D 2. diskusi ulang
Batu multipel Ren S+HN grade II
Batu pyelum S + UPJ Stenosis S + UPJ

PNL S
Stenosis S + HN Grade II/III S
Batu pyelum D + Batu Multipel Sekunder

Pole Bawah D + HN grade Sedang D + RPG D + PNL D
MR ringan
susp. Ca Blader TxNxMo + fistel
rectovesica + HN ringan D + Efusi Pleura Cistoscopy berseme narskoss, onko uro
rekonstruksi urologi
D
fistel vesicovagina + Ca cervix IVB
PNL D
metastatic paru infiltrasi buli rectum
Fistel vesicovagina + Ca cervix IVB Uretrocutaneustomy D/S k/p open nefrostomy

metastatic paru infiltrasi buli rectum per lumbectomy
Fistula vesicovagina + Ca cervix III b +

ureterpcutaneostomi D/S k/p open nefrostomi
mestastae ureter
Batu UVJ S+Batu sekunder pole atas

+bawah S +HN berat S
Batu upj S + batu skunder pole atas

bawah rsn S + HN berat S + Contracted PNL S
Ren D + HT stage II + Asidosis metabolic
teregulasi + Oligouri + Anemia
Batu Pyelum S PNL S
Batu multiple ren D + DJ Stent in situ D + PNL D

Post ESWL 2x
Susp.Fistel retrogram dd Fistel

vesicovagina + HN ringan - sedang S + Sistoskopi + tes methylen blue + RPG S k/p Neo
stenosis ureter distal S + non visualized implantasi Ureter S
Ren S + post kistictomy ovarii D/S
Batu ureter proximal D + HN grade III D

URS dorong batu + PNL D
+Hydroureter proximal D
Batu ureter proximal D + batu Ren S

URS D +PNL S
+HN Sedang Bilateral + GERD
Bt staghorn S+Bt sekunder pole atas D+HN

Bivalve Nephrolitotomi S
grade III S
Bt Ureter 1/3 Proximal D+Bt Multiple Ren D

URS+PNL D k/p Bivalve nephrolitotomi
pole bawah HN sedang D +Ca cx IIIB
Striktur uretra parsial pars bulbosa + post

Pre end to end anastomosis urethra
end to end anastomose
TCC Buli Ct2cN0M0 post TURB Sistoskopi k/p Biopsi

Batu pyelum S + HN grade II S PNL S
Ca rectosigmoid residif + HN Sedang D+

RPG D + DJ Stent D/S
hydroureter S + Colostomi status
Ca-cx IIIB + HN sedang S prokemoradiasi Pasang DJ Stent D/S
Ca-cx IIIB pro ER-AFL+ HN ringan D+HN

Pasang DJ Stent D/S
sedang S+Nonvisualized REN S
Batu Ren D Multiple + Batu Ren S Pole

PNL D/S
bawah+HN Grade II D +post ESWL
Batu Staghorn D/S+HN Ringan D+HN Berat

PNL D/S
S
Cacx IIb post kemoradiasi + HN ringan

ganti DJ Stent D coba pasang DJ Stent S
S+HN Berat D+DJ Stent D insitu
batu ureter prox D + HN berat D + tumor

RPG-URS dorong batu -> PNL D k/p open
parathyroid S
HN sedang D + batu pole bawah ren D + HN

sedang S + susp stenosis ureter S + contacted RPG - URS D/S + ESWL
ren D/S + riw open ren D + riw PJK
ca cervix std IIIB on chemo + HN sedang D

pasang Djstent D/S
+ HN ringan S + DVT
batu ren D pole atas + local ectasis ren D PNL D upper pole puncture
batu pyelum S + batu pole atas S + Susp UPJ

RPG S+ PNL S atau open pyeloplasty S
stenosis S + Hnringan S + DM
single kidney S post nephrectomy D + Batu

staghorn S + batu ren S pole bawah + DJ Aff DJ Stent S + PNL S
stent S + post RPG URS S + Riw. Aka
HN berat + hidroureter D RPG D k/p neoimplantasi ureter
batu pyelum S + Batu pole bawah ren S +

PNL S
HN gr I S
tumor adrenal kanan + HHD + DMT2 laparoscopic adrenalectomy kanan

cystadenoma ovarium S post TAH -BSO + aff DJ stent D + PCNL D
CML
ca cervix Iib post ERAFC 25x + kemoterapi

DJ stent D/s k/p internal stenting D k/p UCS D
3x + HN sedang S
Ca Cervix IIIB Pro ERAFC + HN gr III D DJ stent D/S
sistoskopi + eksplorasi + repair fistula

fistula vesikouterine
vesikouterina
Ca ovarium IIIa pot complete surgical

staging + susp residual mass + non Pasang DJ stent D
visualized ren D + HN sedang D +
hidroureter D
Ca cervix III b +HN ringan S + pot radiasi Pasang DJ stent D/S

35x
Ca ovarium post post SVD + progresive DJ stent S

dissease + HN berat S + metastase paru
Batu pyelum dextra + batu sekunder pole URS D. Jika lancar/ stenosis (-) --> PCNL D
bawah ren dextra + HN grd I-II D
Ca Cervix III B + kemoterapi DJ stent D/S
Ca cervix IV B + DJ stent D in situ Ganti DJ stent D, coba pasang stent S
Batu pyellum D + batu sekunder pole PNL D
bawah ren D + HN gr III D
batu ureter proksimal dekstra + HN berat RPG URS dx
dx + nefrocalsinosis
Ca Cervix III B + HN Berat D + HN ringan S DJ stent D/S k/p internal stenting S k/p UCS S
batu staghorn S + HN gr I-II Bivalve nephrolitotomy
Hipospadia subcoronal + chordae Chordectomy + urethroplasty
Hipospadia mid shaft + post Repair fistule + redo urethroplasty
chordectomy + urethoplasty
Hipospadia distal chordectomy + urethroplasty
UDT D/S Laparoskopi diagnostik D/S
Status Update 21 jan 2018 Keterangan
BPJS II tidak dapat dihubungi
jamkesmas tidak dapat dihubungi
BPJS II Tidak Bersedia operasi
BPJS Kelas III Bersedia operasi
BPJS kelas II Bersedia operasi
ASKES II tidak dapat dihubungi
BPJS III Tidak diangkat

BPJS III Tidak Aktif
BPJS III Sudah Operasi
BPJS I hp tidak aktif
sudah oprasi di jombang nov

BPJS II 2017
BPJS II sudah oprasi di rsal des 2017
BPJS III Tidak aktif

BPJS I Tidak aktif
bpjs III bersedia operasi
BPJS III tidak aktif
BPJS II bersedia Operasi

BPJS III (urgent) Bersedia Operasi
BPSJ III bersedia operasi

BPJS iii bersedia operasi
BPJS III mandiri bersedia operasi
BPJS II/III Bersedia Operasi

bersedia operasi


No Tanggal Nama Usia Alamat No. Telepon
Tn.
1 6-Jun-14 Kristovel 39 th Sudirman 23 Kupang 81337237999
Mavolly
2 16-Jan-15 M. deni 18 th Gresik 85707560671
3 2-Apr-15 tn rifai 49th 85233435415
sdr. M. 081912498999 /
4 17-Mar-16
Gufron
13 th Surabaya
083830413145
Tn. Eko
5 15-Apr-16
Ari
18 Surabaya 85733133192
Sdr 082143840864/0857
6 26-Apr-16 Syarifuddin 14 th Gresik 48345087
Al-hafidah
7 28-Apr-16 Moch. fajar 18 th Tandes -surabaya 81332655052
8 16-May-16 Tn. Asliani 61 th Nalang Tabalong - KALSEL 082158081901/0853

4941881
9 27-May-16 tn. Misto 51 th Kalidami 4/4d Surabaya ana
Sdr Rifaldi 085731933356/0823

10 27-May-16 14 th Ngaglek Krian
Eko M 37365175
Tn Hafi
12 7-Jun-16 60 th TegalMulyorejo Baru 131 089664421606/0857
Zainuri 31003556
16 1-Jul-16 Anik Bagus 16 TH Semambung Driyorejo 85732710790
19 12-Aug-16 Tn Miyanto 44 th Pucangan Palang tuban 81333149974
Kalibongkor I/26 A
20 19-Aug-16 sdr Sugeng 14 th
Surabaya
81359813011
Panderejo Gempolo
21 23-Aug-16 Tn. Miskon 63 th 85663553300
Pasuruan
Tn.
22 29-Aug-16 54 th Menganti 27 Lobak Santri 85731394364
Nasipan
Tn. Moch Kerbongan Baru 7/39
23 30-Aug-16 43 th 8813514869
Yunus S Surabaya
Tn. 82199002675 /
24 6-Sep-16 Bartholom 68 th Jayapura 085254356061
ous
082139801903 /
Tn. Sena
25 6-Sep-16 43 th Sisingamangaraja 12/6 3539109/
Bambang 08813528754
Sdr. Endah Sememi Jaya 5/63 081336964042/

27 3-Oct-16
Wijayanti
26 th
Surabaya 082390934442
Tn. Dukuh Bulak Banteng 1/6

28 11-Oct-16
Matosan
59 th
Surabaya
85100922514
Tn. 87853508414/878510
30 20-Oct-16
Sadimin
57 th Tengah Sampang
63353
081386984317 /
32 25-Oct-16 Tn. Aghozi 18th Godangan 08563101794
Ani
33 27-Oct-16
Kusanah
16th Kediri 85735424091
34 8-Nov-16 Tn. Misdar 53 th Jombang 85203283271
Perum randi permai

36 6-Dec-16 tn. yacob 61 th 85736982555
Jombang
Tn.
37 15-Dec-16 Rakhmat 26 th Lobo RT7/2 Sidoarjo 82213000308
Eko Nur
Sdr Bagas
38 19-Dec-16
H
15 th Surabaya 85645290354
Tn.
39 20-Dec-16
Muhamad
46 th Pamekasan 87816733446
Tn. Tambak suri selatan

40 17-Jan-17
Rachmad
24 th
2/10surabaya
81289074264
41 17-Jan-17 Tn sutrisno 50 th madiun 81233979515
42 9-Mar-17 Tn. Agus Subagio

51 th 85234354048
43 30-Mar-17 Sdr. Gilang bagus

19 th Pandean kawedanan 81555674103
Zainul tambak osowilangun 10/4

44 16-Jun-17
Arifin
30 th
Surabaya
83830045923
45 20-Jun-17 Tn Iswanto 65 th Surabaya 82140439138
46 26-Jul-17 Tn. Misdi 72 th Simo Ponorogo 85259513002
47 31-Jul-17 Tn. Sapari 57 th Benowo 81314618623

Tn. Abd 8071524/0812302030
48 4-Aug-17
Shomad
67 th Siwalan, Panji, Buduran
38/085606065949
49 8-Aug-17 tn. Sukoili 54 th 82139901345
22-Aug-17 Tn. Abdu 55 th 82338405838

50 Kamal madura
Ghofur
Sumengko, Duduk
51 24-Aug-17 Tn. Musfik 39 th
Sampean, Gresik
81556652695
Tn. 081235175966/08121
52 28-Aug-17
Wariono
45 th Sukodono Sidoarjo
6311365
Tn. Moh. Jalan Basuki Rahmad 081331091011/08224

53 29-Aug-17
Sujadid
35 th
286a Tuban 4250801
Tn. Nur 082141134473/08123

54 31-Aug-17
Salim
Surabaya
5544146
Sdr. Nur Sumberwaru Wringin 08121721312/085755

55 7-Sep-17
wachid
14 th
anom 691416
Tn.
56 11-Sep-17
Massari
75 th Beringinan Talago 85232405188
57 11-Sep-17 Tn. Ridoi 55 th Kemayoran Surabaya 8123236311

Tn. Abdul 085608429952/081
58 18-Sep-17 49 th Jrenggol Sampang
Malik 553362227
Tn. 082257392113/0812
59 18-Sep-17 77 th Juwingan 1/16 Surabaya
Soekadi 1770560
Tn.
085298135864/087
60 25-Sep-17 Slamet 25 th Kebon Agung Pacitan
882592783
Adi
Tn.
61 6-Oct-17 39 th Madura, Sampang 87849969786
Satuhan
tn warih 082334353526/
62 16-Oct-17 25th
triyanto 082244063127
082335919592/
63 19-Oct-17 misnadi 67th situbondo 085230376443
tn 082139039560/
64 25-Oct-17 danistya 24th gresik 085102317770/
suwarno 081332032361
082234958380/
65 27-Oct-17 sugeng 36th banyuwangi 082353395674
66 24-Nov-17 tn syakir 57th bangkalan 81939302440
Tn.
Milkianus 082195080228/
67 24-Nov-17 49th ambon
dominggu 081343561177
s
tn deni 085704917346/
68 30-Nov-17 28th
budi 085704917535
13-Dec-17 tn moch wedoro utara wanu 85706239623

69 72th
iksan sidoarjo
tn mat londalem galis 081931055111/

70 14-Dec-17 66th
nasir bangkalan 087852323727
89678202729/
71 14-Dec-17 sugeng 48th kupang jaya 2/54 081249318816
085232058558/
72 14-Dec-17 paeran 70th girilaya 10/33A 081330630920
aguswant 081937175469/
73 14-Dec-17 40th kejayan warung dowo
o 085749799845
Tn Ridho
74 21-Dec-17 17 th Pamekasan O85233302087
Illah
Jl Gadel tengah III no 19.

75 22-Dec-17 Tn Tarlim 56 th O85101834425
Surabaya
Tn Ahmad
76 2-Jan-18 72 Sidoarjo O85790633636
Subarna
77 3-Jan-18 Tn Sukadi 65 Jombang O81274162695
78 4-Jan-18 Tn M Huri 36 th lamongan 82333806055

79 4-Jan-18 tn hanafi 44th surabaya 85228908161
Tn.
80 10-Jan-18 Sidowungu Menganti 087712883842/083
Muhajir 849244003
Tn. Nur
81 11-Jan-18 Surabaya 085256735818
Wachid
Tn. 085606665152/085
82 12-Jan-18 25 th gresik
Syaihullah 707812169
Tn. Sentot
83 15-Jan-18 45 th Nganjuk 082233783696
Priyo
Ny Kandangan, gunung
28-Dec-17 47 O81357312725
Endang S tamsi
Ny 51 Palangkaraya O85250014187
Wijiyanti
Marshend
28-Dec-17 11 th Jember O85859350355
i PE
Ahmad M.
28-Dec-17 3 th Bojonegoro O85284188249
AU
28-Dec-17 An Wahyu Sampang O81939393681
A F.
An M.
28-Dec-17 Surabyaa O82301955951
Ilhamsyah
No. RM Diagnosis Planning
Batu ureter 1/3 medial + HN grade II

12333438 RPG+URS k/p
D+Hidroureter D
HIpospadia periscrota+chordate+torsio
12380582 Chordectomy+urethroplasty
penis
Epispadia + Repair Epispadia Sistoskopi + litotripsi + RPG D k/p URS S +
12397456
Urethroplasty ESWL S
hipospadia Penil distal post chordectomy

12435950 redo urethroplasty
uretroplasty
Fistel Uretrokutan post chordektomi +

10621906 Repair Fistula
post uretroplasti + repair fistula
12498229 Hipospadia glandular+Chorde Chordectomy+Glanduloplasty
12464908 Hipospadia+varicocele+UDT D Orchidopexy,chordectomy uretroplasty
BPH gr I + LUTS sedang + BT kaliks

12495924 Panendoskopi + BNI K/P TURP, PNL S
inferior S Post open ren S + HT II
batu ren D pole bawah + HT st II +

12477973 PCNL D
ACKD
12182914 Fistel uretrocutan post urethroplasty
Stricture urethra pars membranacea +

12508020 End yo end anastomosis urethra
BPH gr II
Strictur urethra anterior post johensen I

10414639 riwayat hipospodia post chordrectomy- URS pro Uretroplasty
uretroplasty
Pan uretra stricture post johansen I + BT

12474735 Pro Johansen II (MRS setelah bulan 9)
ren D/S
Fistel ureterocutan + Hipospadia +

12383809 Repair fistel ureterocutan
cordectomy + ureteroplasty
Batu Ren S Pole Bawah, Residual

12525474 PNL S (met u/ Residual stone)
Multiple Stone Ren D
BPH Gr I+LUTS Sedang + BT Ren D

12521803 PNL D
Multiple + Delayed Function Renal D
Strictur urethra pars bulbomembranasea
12526984 Pro BMG Uretroplasty
+ Open Sistostomi
Strictur ureter lotous pars pandeculare Open Prostectomi< Pandoscopy + Urethrography

12526435 End to End Anastomosis
12374838 Multiple batu ren S+ HN Sedang S PNL S
12503995 UDT D/S + Hipospadia Perineal Laparoscopy diagnostic + Urethroplasty
Residual sone ren D post nefrolitotomi D

12535588 PNL D
+ HN ringan + DJ stent D
Striktur uretra pars bulbomembranacea +

Pro uretrografi di OK + End to end anastomose
12454325 post repair buli e.c ruptur buli iatragenik
uretra
+ diverticulosis buli
12487351 UDT D Laparoscopy diagnostic k/p Orchidectomy D
12452677 UDT D/S Uretroplasty
12525288 Bladder TCC T4aNXM0 Radikal sistektomi +Bricker procedure
12544251 Post johansen I + post cystostomi Uretroskopi johansen II k/p BMG
Batu pyelum ren (D)+HN St I (D)

12548958 +double system incomplete ren (D) PNL (D) senior
+Batu ren (S) pole bawah
Fistula urethrocutan+post chordectomy +
10837623 Repair fistula+test ereksi k/p chordectomy
urethroplasty+post repair fistula
Striktur uretra pars bulbomembranacea

12534821 Uretroscopy end-to end anastomosa uretra
post open
12560056 Ectopia ren S + Non Visualis ren S RPG S + Laparoskopi nefrektomi S
12545191 Tumor ren D cT1NoMo laparoscopic radical nefrectomy
TURP de obstruksi + subscapular

12548306 Adenoprostat GS (5+4) T4NxMo orchidectomy
stricture uretra parsial post reudalens

12360621 post chordectomy uretroplasty + tahap II brack procedur
repair fistel post johansen 1 +
eksisiretral plate + brackie procedur
striktur uretra pars membrana

12564845 uretroscopy di OK (Oktober 2017)
prostatika+status sistostomi
striktur uretra pars bulbomembranacea +

12221914 panendoscopy K/P uretroplasty+BMG
post Trochar Sistostomi+ BPH grade II
Ca Buli T1/2NxM0 + Simple cyst ren S

12585203 TUBT Staging
+ BPH Gr. II + Elongasi retro + HN St.II
Batu UPC D = Batu pole bawah ren D +

10996129 RPG k/p URS
HN sedang D + batu ren S
bt pole tengah+pole bawah Ren
12603071 PNL D
D+residual+ HN+AKI
12584113 Striktur uretra pars membranosa + End to end anastomosis uretra

LUTS berat + sistostomy striktur
Striktur uretra parsial pars bulbosa + Pan Endoskopi + end to end anastomose
12603219
post Troichart Sistetomy uretra
Striktur uretra pars bulbosa totalis + post

12591157 panendoskopi + end to end anastomose uretra
open sistostomi
Single kidney+ Bt pyelum D+HN berat

12353985 D+DM type II+TB paru post OAT PS RPG D + pyelonephrolithotomy D
ASA II
Batu ren D pole atas tengah+HN grade

12533914 Aff DJ stent D+ PNL D
III D+ DJ stent + Post PNL D
retensio urin ec striktur uretra parsial

125995591 pars bulbomembranacea + sistoskopi+ uretrosistoskopi k/p sachse/TUIP
sistostomi status + HT stg 1
post rechordectomy + hypospadia

12355580 Chordectomy-uretroplasty
subcoronal (riwayat operasi 3x)
Strictur uretra parsial pars pendulare post

12579842 AFF DK + uretrografi
uretroplasty BMG+sistostosmi
12600068 Batu staghorn D/S + DJ Stent insitu D/S Lepas Dj Stent D+Bivalve Nefrotomi S
TCC Buli T4bNxM0+Post TURBT
12608855 2x+Batu Reb Pole bawah D+Riwayat Sistoscopy Biopsi/TURBT
Ureterolitotomi
Bladder Cancer T2NxM0+HT St

18001513 II+HN Grade IV D+HN Grade TURBT
IIIS+Hydroureter D/S

12426374 BVCUG di OK + EEA
bulbomembranacea post EEA
striktur uretra total pars

uretrografi di OK k/p end to end anastomose
12607238 bulbomembranacea+post open
uretra setelah 3 bulan
sistostomi
12431652 hipospadia penile + post chodectomy

repair fistel urethroplasty
urethroplasty +
striktur total urethra pars pendulare

12621260 End to end anastomosic urethra k/p BMG
post TURP + sistostomi statis
123342299 hipospadia midshaft + post

re-urethroplasty k/p BMG
chordectomy + urethroplasty 3x op)
12613862 ca buli TxNxM0 Post TURBT + AKI

re-TURBT
dd ACKD + Anemia
Batu ureter distal D + batu pyelum S

12624056 + batu sekunder ren S + HN gr III URS D + pasang DJ stent S + PNL S
D/S
12630068 batu ren S pole bawah PNL S

12632043 UDT D/S + infertilitas primer laparoscopic diagnostic + orchidopexy D/S
tumor buli TxNxM0 + hidronefrosis

12618569 sedang S + hidroureter S + kista TURBT staging
ginjal D
striktur uretra parsial + retensio urin+

12629003 R/ open prostatectomy + ESBL urethroscopy + urethrosplasty + BMG
(kultur urin)
striktur urethra + post

12563089 Uretrography k/p urethroplasty
urethrolithotomy
adeno ca prostat GS 8 T1cNxM0 post

radikal prostatektomi
TURP + parkinson disease
ruptur uretra pars bulbomembranasea

+ closed degloving regio lumbal +
12595616 EED urethra k/p pubotomy
post pemasangan UDS + post aff ext
fix pubis
Batu pyelum D + Batuj sekunder pole

12636621 bawah pole D + HN berat D RPG k/p URS D +PNL D
+hidroureter D
BPH grd II + retensio urin + batu ren

12555725 VTP - TURP (join orthopedi)
D pole atas + R/ ORIF
Striktur uretra parsial pars bulbosa +

12529321 Pre end to end anastomosis urethra
post end to end anastomose
Striktur urethra total pars bulbosa +
12628291 end to end anastomose urethra
riwayat open
batu ureter proksimal sin + batu

12636359 URS sin dorong batu + PNL sin
pyelum sin + post ekspulsi batu buli
batu pole tengah ureter sin +
12604036 parenchymal kidney disease bilateral PNL sin
+ PJK omi + DM
SCC Penis T2N0M0 partial penektomi
12614206 pro kemoterapi
+ kemoterapi
12630869 BPH grd II + retensio urin VTP - TURP
12639029 Bt. UPJ S + HN Berat S + HT I RPG-URS S + PNL S
Batu Staghorn D + HN Ringan D + bt

12215251 PCNL D
ren pole bawah S + bt UVJ S
Batu pyelum dextra + batu sekunder
12636557 URS D. Jika lancar/ stenosis (-) --> PCNL D
pole bawah ren dextra + HN grd I-II D
12631883 Ca Cervix III B + kemoterapi DJ stent D/S

12637870 Hipospadia subcoronal + chordae Chordectomy + urethroplasty
12523149 Repair fistule + redo urethroplasty
chordectomy + urethoplasty
12637895 Hipospadia distal chordectomy + urethroplasty
12632030 UDT D/S Laparoskopi diagnostik D/S
Kelas Update 21 januari 2018
BPJS I Tidak bersedia Operasi
Jamkesma Tidak diangkat
ASKES I Tidak diangkat
BJPS kelas III Tidak diangkat
Jamkesmas sudah operasi di rs darmo jan 2018
BPJS III sudah oprasi di rs ibnu sina agustus 2016
BPJS Kelas III Tidak aktif
BPJS kelas I Bersedia operasi
Tidak dapat dihubungi
BPJS kelas III Bersedia operasi
BPJS II belum operasi, masih bersedia

BPJS II Tidak diangkat
BPJS I Tidak bisa dihubungi
KIS Tidak bisa dihubungi

Bersedia operasi
BPJS 1 Bersedia operasi


jamkesmas Bersedia operasi

BPJS III Tidak bisa dihubungi

BPJS ? Bersedia operasi
Bersedia operasi
BPJS III
BPJS III
BPJS III
BPJS III
BPJS III
BPJS II
Keterangan

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No Tanggal Nama Usia Alamat

1 4-Sep-14 An Bagas 5 Kebon sari - blitar

2 5-Dec-14 an. Moch Hamzah 7 th petulangan tengah 18 B

4 27-Jul-15 an andika hervin septian 7th dutat jaya pasar 57

5 4-Aug-15 an mas adhi 5th

perum sumber permai

7 8-Jan-16 An M zaibidin 8 bojonegoro

9 3-Mar-16 By Valorian 1 bln Surabaya

10 1-Apr-16 Ny.Samianah 48 Jombang

11 15-Apr-16 Tn. Eko Ari 18 Surabaya

12 28-Jun-16 An Ahmad Wildan 11 TH Janti Wots Kediri

Wonokromo kulon 4/3

16 6-Dec-16 Ny. Samianah 48 th Ampera bareng Jombang

17 19-Dec-16 Sdr Bagas H 15 th Surabaya

18 4-May-17 Ny. Tities Patriawaty 67 th Kupang

15-May-17 Gebangan, Gemarang,

20 24-Jul-17 Ny. Marcelina B. 48 th Kupang

21 1-Aug-17 Ny.Erik Choriyah 56 th Kr tembok

22 15-Aug-17 Ny. Astutik 38 th Kediri

23 10-Oct-17 kanang sudarma 13th kartoharjo

24 18-Dec-17 Ny. Nur Khayati 29th Kec Bancan Kab tuban

3-Jan-18 Tn Sukadi 65 Jombang

28-Dec-17 Ahmad M. AU 3 th Bojonegoro

Fistula subcutan scrotum + Post

083831988005 / Epispadia + Repair Epispadia

85784250555 12489179 Fistelvesica vaginahbufa tah-brot Sistocopy=repaifistel

Fistel Uretrokutan post chordektomi

Fistel Uretrocutan + Urinoma

RPG D/S + repair fistula

Fistula vesicovagina + Susp. Sistoskopi + RPG S + k/p URS

Fistul Urethrocutan + Hipospadia

fistel vesicovagina + Ca cervix

Fistula vesicovagina + Ca cervix ureterpcutaneostomi D/S k/p

Susp.Fistel retrogram dd Fistel

853321343999 sistoskopi + eksplorasi + repair

Hipospadia mid shaft + post Repair fistule + redo

BPJS kelas III bersedia operasi

BPJS I bersedia operasi

BPJS kelas III bersedia operasi

BPJS III bersedia operasi

SPM bersedia operasi

BPJS II bersedia operasi

BPJS kelas II bersedia operasi

Umum bersedia operasi

BPJS II bersedia operasi

Jamkesmas bersedia operasi

BPJS I bersedia operasi

BPJS II bersedia operasi

BPJS II bersedia operasi

BPJS III bersedia operasi

BPJS III bersedia operasi

BPJS I Bersedia Operasi

Umum bersedia operasi

BPJS I Bersedia Operasi

bpjs III bersedia operasi

BPJS II Bersedia operasi

BPJS III bersedia operasi

BPJS II Bersedia Operasi

BPJS III besedia operasi

BPJS III bersedia operasi

3 27-Jul-15 an andika hervin septian 7th dutat jaya pasar 57

Langkah Buntu I/41

6 5-Feb-16 An. Wisnu energik 3 th

7 15-Feb-16 An, Arga Prayoga 11 th Batam