GANGGUAN SISTEM

PERKEMIHAN

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

UROLOGI Tractus urinarius ♀ Tractus genitourinarius ♂

The Urinary System consists :• kidneys• ureters• bladder• urethra

RUANG LINGKUPKelainan Bawaan / KongenitalTraumaRadang / InfeksiBatu Saluran KemihObstruksi Saluran KemihEmergency Urologi (non trauma)Infertilitas pada priaDisfungsi Ereksi (DE)Andropause (Male aging) Keganasan

Urinary tract consist of

Kidney: parenchyma pelvicaliceal

Ureter Bladder urethra

Anatomi Fisiologi

Embryology

PronephrosMesonephrosMetanephros

Ureteric bud

Renal parenchyma

Pelvicalyceal systemureter

Pronephros

Mesonephros

Metanephros

Mesonepric duct Ureter bud

Epididimis-vas deferens

Renal parenchymal

Pelvicalyceal systemUreter

Kelainan Bawaan / Kongenital

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

Anomalies of the Upper Urinary TractAnomalies of Number A. Agenesis (bilateral or unilateral)

B. Supernumerary Kidney

Anomalies of volume and structure

A. HypoplasiaB. Multicystic kidney C. Polycystic kidney

Anomalies of Ascent A. Ectopic kidneyB. Pelvic kidneyC. Thoracic kidney

Anomalies of Form and Fusion

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

B. Horseshoe kidney

Anomalies of Rotation A. IncompleteB. ReverseC. Excesive

Anomalies of Renal vasculature

A. Accessory, aberant,a or multiple vesselsB. Renal artery aneurismC. Arteriovenous fistula

A.Agenesis (bilateral or unilateral)B. Supernumerary Kidney

Anomalies of Number

Ascent of Kidney

Anomalies of Ascent A.Ectopic kidneyB.Pelvic kidneyC.Thoracic kidney

Anomalies of Ascent

• Ectopic kidney• Pelvic kidney• Thoracic kidney

Anomalies of Form and Fusion

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

• Horseshoe kidney

Anomalies of Structure (polycystic kidney)

Bilateral kidneyCyst in another organ2 types:Infant and adult typeProgressive renal failureTx: renal transplantation

Anomalies of volume and structure

A.HypoplasiaB.Multicystic kidney C.Polycystic kidney

Anomalies of Structure (Simple Cyst)

Tx marsupialitation if:• Bleeding• Infection• Very huge cyst will

obstruct PCS

Anomalies of volume and structure

A.HypoplasiaB.Multicystic kidney C.Polycystic kidney

Anomalies of Pelvio-ureteric System

Normal Ureteral Bud and Metanephric Development

Anomalies of pelvio-ureteric systemAnomalies of Termination Ectopic ureter

Anomalies of Number Duplication Complete or incomplete

Anomalies of Structure Ureterocele

Obstruction Pelvio-ureteric junction.

Embryology of incomplete double system

Incomplete double system

Y-type ureter:• Asymptomatic• Yo-yo phenomena

V-type ureter:• Asymptomatic• VUR

Embryology of complete double system

Complete double system

Ectopic ureter

Normal orificium ureter

Weighert-Meyer’s Law:Upper pole ureter more distal than lower pole

Ureterocele with ectopic

ureteric

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

Pieloureteric Junction Obstruction

UPJ stenosisAberrant vessel obstruct UPJ

TRAUMA

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

GINJALPaling sering

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

Mudah cidera ginjal patologis Hidronefrosis Kista ginjal Tumor ginjal TBC ginjal

MEKANISME TRAUMA GINJAL

Dikutip dari Smith’s General Urology

GRADE TRAUMA GINJAL

• DIAGNOSISTraumaHematuriaJejas/Massa pada pinggangNyeriTanda perdarahan/syok

• PENCITRAAN– USG– IVU– CT-scan

PENANGANAN

• Tusuk/tembak Eksplorasi laparotomi

• Tumpul :–Konservatif–Operatif

• Renorafi• Partial/total nefrektomi• Penyambungan vaskuler

KOMPLIKASI• SEGERA: Perdarahan, Ekstravasasi urin

– Urinoma– Abses perirenal– Fistula renokutan– Sepsis

• LAMBAT :HipertensiHidronefrosisAV ShuntBatuPNC

URETERIATROGENIK

»Op. Endourologi»Op. Kebidanan»Op. Digestive

» Terjerat» Crushing robek/putus» Devaskularisasi nekrosis

DISTAL

• Diagnosis– Durante operationum– Pasca bedah

• Pencitraan– Retrogade pyelografi– IVU

Dikutip dari Smith’s General Urology

Stab wound of right ureter

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

KANDUNG KEMIH¤ JENIS TRAUMA:

» IATROGENIK TUR terutama buli-buli Litotripsi

» TAJAM : Tembak, tusuk» TUMPUL: Fr. Pelvis (90%)

¤ SPONTAN : Patologis¤ RISIKO : - VU penuh

- patologis

MEKANISME

Dikutip dari Smith’s General Urology

KLASIFIKASI

• KONTUSIO

• RUPTUR– Intra peritoneal 25 – 45%– Ekstra peritonel 45 – 60%– Intra & ekstra 2 – 12%

KLINIS

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

DIAGNOSIS

• KLINIS• RÖ : SISTOGRAFI

PERIVESIKAL DI SELA-SELA USUS

EKSTRAPERITONEUM INTRAPERITONEUM

– NEGATIF PALSU

Robekan kecil

• TEST BULI-BULI• SISTOSKOPI

Dikutip dari Smith’s General Urology

Extraperitoneal bladder rupture

Intraperitoneal bladder rupture

PENANGANAN

• KONTUSIO : Kateter 7 – 10 hari• INTRAPERITONEUM :

Laparotomi/eksplorasi– Jahit– Pasang drain– Sistostomi– Kateter uretra

• EKSTRAPERITONEUM :– Kateterisasi – Jahit – pasang kateter

KOMPLIKASI

• SEPSIS• ABSES PERIVESIKAL• KELUHAN MIKSI• PERITONITIS

URETRA

Dikutip dari Smith’s General Urology

Trauma Urethra

• Trauma urethra posterior– Urethra pars prostatika– Urethra pars

membranosa

• Trauma urethra anterior– Urethra pars bulbosa– Urethra pars

pendulosa

Uretra Anterior• IATROGENIK• STRADDLE INJURY– KLINIS :

• Trauma• Perdarahan per uretram• Miksi (+)/(-)• Hematoma

– Perineum seperti kupu-kupu– Scrotum/penis

– DIAGNOSIS :• Klinis• Uretrografi

– Ekstravasasi kontras

STRADDLE INJURY

Dikutip dari Smith’s General Urology

Dikutip dari Smith’s General Urology

Ruptur bulbar (anterior) urethra following straddle injury

PENANGANAN

• KONTUSIO : – Terapi (-)– Follow up 4 – 6 bulan

• GOLDEN PERIOD ( < 6 – 8 jam) HEMATOMA MINIMAL– Primary repair : pasang kateter dan sistostomi

• HEMATOMA LUAS :– Multipel insisi– Sistostomi– Late repair

KOMPLIKASI

• STRIKTURA URETRA

• FISTULA URETEROKUTAN

Uretra Posterior

• FR. PELVIS / SIMFISIS PUBIS MERUSAK PELVIC RING– ROBEKAN URETRA POSTERIOR

• Ligan Prostatomembranacea robek• Hematoma yang luas dalam cavum ret2ii

VU dan Prostat terdorong ke cranial

“ FLOATING PROSTATE”

INJURY OF POSTERIOR URETHRAL

Dikutip dari Smith’s General Urology

KLASIFIKASI (Colapinto – McCollum)

1) Uretra posterior utuh, stretchingo Uretrogram : memanjang, ekstravasasi(-)

2) Uretra posterior putus, diafragma uretra anterior utuho Uretrogram : ekstravasasi kontras terbatas

di atas diafragma uretra anterior

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

Dikutip dari Smith’s General Urology

Ruptur prostatomembranous urethra

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

DIAGNOSIS:– KLINIS– RÖ : URETROGRAFI

Dikutip dari Smith’s General Urology

Repair of urethral injury

PENANGANAN

• ATASI SYOK• SISTOSTOMI TERBUKA• LATE REPAIR• P.E.R

KOMPLIKASI• STRIKTUR• GANGGUAN EREKSI• INKONTINENTIA

Catatan:

Pada setiap kecurigaan ruptur uretra TIDAK BOLEH dilakukan

kateterisasi !!

PENIS• TRAUMA TUMPUL• TRAUMA TAJAM (AMPUTASI PENIS /

REPLANTASI)• FRAKTUR PENIS

– Robekan T. Albuginea– dalam keadaan ereksi– bengkok dan hematoma

• STRANGULASI/TERJERAT– Karet– Cincin Logam

SCROTUM• TRAUMA TAJAM • TRAUMA TUMPUL • LUKA BAKAR• CRUSHING• AVULSI

Infeksi Saluran Kemih

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

What are the causes the UTI ?

Normal urine : sterile, contains fluid,

salt, waste product,

free of bacteria,

viruses, fungi.

DEFINISI

• Infeksi Saluran Kemih atau bakteriuria adalah didapatkannya mikro-organisme sebanyak 102 CFU/mL → 104

CFU/mL• Kriteria bakteriuria: ≥ 104 CFU/mL

Infection– when microorganisms, usually bacteria from

the digestive tract, to the opening of the urethra and begin multiply. (Escherichia coli)

– first bacteria growing in the urethra Urethritis bacteria move to the bladderCystitis, bacteria go up the ureters

Ureteritis infect the kidney Pyelonephritis

Chlamydia and Mycoplasma UTI in

male and female, limited in the

urethra and reproductive

system, sexually transmitted,

require treatment both partner

Common urinary bacterial pathogens

(Escherichia Coli, Streptococcus

Faecalis, Proteus spp,

Pseudomonas spp, Klebsiella spp)

Who is at risk ?–abnormality of urinary tract,

obstructs the flow of urine (kidney stone)

–enlarged prostate gland slow the flow of urine

–from catheter ( urinary retention, unconscious, critically ill, nervous system disorder / lost bladder control

–Diabetes –changes in immune system,

disorder suppresses the immune system infant,

– infant, born with abnomalities urinary tract (corrected by surgery)

–rarely seen in young men and boys– in women UTIs gradually increases

by age

–women more UTIs then men (the urethra is short, bacteria quick access to the bladder, near the anus and vagina /sources bacteria, sexual intercourse)

–women use a diaphragm more develop UTIs than other forms of birth control

–women whose partners use condom with spermicidal foam

What are the symptoms of UTI ?– not everyone with UTI has

symptoms– symptoms (frequent urge to urinate

and painful, burning in the area

bladder and urethra during urination,

feel uncomfortable pressure ebove

the pubic bone, fullness in the

rectum)

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

– UTIs in children is not

characteristic : irritable, is not

eating normally, unexplained

fever, incontinence, loose bowel,

is not thriving – change in urinary pattern

Features of UTIs–UTIs in adults is common,

particularly in women –Cystistis produces symptoms,

frequency, dysuria, urgency –Pyelonephritis typically present with

loin pain, fever, malaise–UTIs less common in men

urethral extra length prevent colony bacteria the bladder

How is UTI diagnosis ?–urine test for bacteria or pus

(midstream urine in sterile container)–urinalysis test is examined for white,

and red blood cells and –Chlamydia, Mycoplasma can

detected by special bacterial cultures

– If an infection does not clear up with treatment order IVP ( gives images the bladder, ureters, kidneys

–Recurrent UTI recommend USG internal organ, cystoscopy (see the bladder by cystoscope from the urethra)

How is UTI treated ?–with antibacterial drugs (the chois and

the length of treatment depend urine test, the offending bacteria)

–Quinolones : ofloxacin (Floxin), norfloxacin (Noroxin), ciprofloxacin

(Cipro ) and trovafloxin (Trovan)–UTI can be cured 1 – 2 days

treatment doctor ask to take antibiotics for a week or two week to ensure the infection has been cured

–Single dose treatment is not recommended (kidney infection, diabetes, structural anatomy, prostate infections)

– infection caused by Mycoplasma, Chlamydia, longer treatment is also needed treated with (tetracycline, trimethroprin, sulfamethoxazole / TMP,SMZ, doxocycline)

–urinalysis help to confirm UT is infection free

–note : symptoms may disappear, before the infections is fully cleared

–severe ill patients (kidney

infections hospitalized) until they can take fluid and drugs on their own

–2 weeks theraphy with TMP/SMZ as effective 6 weeks, on kidney infections

–various drugs is available to relieve the pain in UTI

–a heating pad also help–drinking water helps cleanse the

urinary tract from bacteria–ovoid drinking coffee, alcohol, spicy

foods

Uncomplicated urinary infections usually responds to 3 days course of antibiotic

EPIDEMIOLOGI UTI OK KATETERISASI

• Lebih dari 25% pasien yang dirawat di RS menggunakan kateter

• Risiko bakteriuria pd kateterisasi tunggal (single catheterization) adalah 1 – 2%

(Sedor & Mulholland, 1999)• Penggunaan kateter menetap (indwelling

catheter) kemungkinan terjadinya bakteriuria adalah 3 – 10% (dengan rerata 5%) → setelah 30 hari

Faktor Risiko Timbulnya ISK Karena Kateterisasi

Faktor Risiko relatifLama kateterisasi > 6 hari 5,1-6,8

Wanita 2,5-3,7

Pemasangan kateter di luar kamar operasi 2,0-5,3

Tindakan urologi 2,0-4,0

Terdapat infeksi di tempat lain 2,3-2,4

Diabetes 2,2-2,3

Malnutrisi 2,4

Azotemia (kreatinin > 2,0 mg/dl) 2,1-2,6

Kateter ureter 2,5

Monitor produksi urine 2,0

Terapi antimikroba 0,1-0,4

(dikutip dari Maki & Tambyah, 2001)

Etiopatogenesis dan Perjalanan Penyakit

≥ 30%

< 4%

Kateterisasi

Bakteriuria

Bakteriemia

Sepsis

Kematian(dikutip dari Saint &

Lipsky,1999)

12,3%

Cara Mikro-organisme Memasuki Saluran Kemih pada Pemakaian Kateter Menetap

(dikutip dari Maki & Tambyah, 2001)

Pencegahan ISK yang Berhubungan dengan Kateterisasi

• Indikasi pemasangan kateter menetap pada pasien yang menjalani rawat inap di rumah sakit

Obstruksi infravesikal (Bladder outlet obstruction) Pemasangan sementara untuk mengatasi retensi urine Dipasang dalam jangka waktu lama karena terdapat kontraindikasi tindakan pembedahan

Inkontinensia urine tanpa obstruksi Terdapat luka pada daerah perineum dan sakral Permintaan pasien

Monitor produksi urine Pada pasien kritis Pasien tidak mampu mengumpulkan urine

Selama pembedahan yang lama dengan pembiusan umum atau regional

Pencegahan• Pemasangan kateter sistostomi (suprapubik)

pada pria• Penggunaan kateter kondom• Antibiotika (??)• Higiene pada saat memasang dan selama

kateter terpasang• Sistem pengaliran tertutup (closed drainage

system)

Morbiditas Kateterisasi

• Faktor risiko berkembangnya bakteriuria menjadi bakteriemia

Pria

Infeksi yang disebabkan oleh Serratia marcescens

Penyakit traktus urinarius lain yang tidak terinfeksi (nefrolitiasis, BPH)

Terdapat kateter uretra menetap

Rangkuman

• Pemakaian kateter ISK/Bakteriuria

• Bakteriuria akan berkembang menjadi bakteriemia, yang menyebabkan morbiditas maupun mortalitas

• Pembentukan biofilm kuman sulit diberantas dengan antibiotika

ProfileDr Yuda Handaya SpB FInaCS,FMAS

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

PROFESSIONAL QUALIFICATIONSSpecialist of General Surgery, University of Gadjah Mada, IndonesiaPROFESSIONAL  LICENSUREIndonesian Medical Council No : 34.1.1.101.1.06.005789