1. GANGGUAN SISTEM PERKEMIHAN dr A. Yuda Handaya SpB,FInAC,FMAS Bagian Bedah RSUD Kabupaten Malang

4. ureters

5. bladder

7. Trauma

8. Radang / Infeksi

9. Batu Saluran Kemih

10. Obstruksi Saluran Kemih

11. Emergency Urologi (non trauma)

12. Infertilitas pada pria

13. Disfungsi Ereksi (DE)

14. Andropause (Male aging)

16. Anatomi Fisiologi

17. Embryology Pronephros Mesonephros Metanephros Renal parenchyma Pelvicalyceal system ureter Ureteric bud

18. Pronephros Mesonephros Metanephros Mesonepric duct Ureter bud Epididimis-vas deferens

20. Kelainan Bawaan / Kongenital dr A. Yuda Handaya SpB,FInAC,FMAS Bagian Bedah RSUD Kabupaten Malang

21. Anomalies of the Upper Urinary Tract

22. Anomalies of Number

23. Ascent of Kidney

25. Pelvic kidney

28. Infection

30. Normal Ureteral Bud and Metanephric Development

31. Anomalies of pelvio-ureteric system

32. Embryology of incomplete double system

36. Complete double system Weighert-Meyer’s Law: Upper pole ureter more distal than lower pole Normal orificium ureter Ectopic ureter

37. Ureterocele with ectopic ureteric A big ureterocele will obstruct bladder neck Filling defect on cystogram phase of IVP.

38. Pieloureteric Junction Obstruction Aberrant vessel obstruct UPJ UPJ stenosis

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

40. GINJAL Paling sering Trauma tumpul, tajam / tembak Langsung Tak langsung (deselerasi) Mudah cideraginjal patologis Hidronefrosis Kista ginjal Tumor ginjal TBC ginjal

41. MEKANISME TRAUMA GINJAL Dikutip dari Smith’s General Urology

42. GRADE TRAUMA GINJAL

43. DIAGNOSIS Trauma Hematuria Jejas/Massa pada pinggang Nyeri Tanda perdarahan/syok PENCITRAAN USG IVU CT-scan

44. PENANGANAN Tusuk/tembak Eksplorasi laparotomi Tumpul : Konservatif Operatif Renorafi Partial/total nefrektomi Penyambungan vaskuler

46. Hidronefrosis

47. AV Shunt

48. Batu

50. Op. Kebidanan

51. Op. Digestive

52. Terjerat

53. Crushing  robek/putus

54. Devaskularisasi nekrosisDISTAL

55. Diagnosis Durante operationum Pasca bedah Pencitraan Retrogade pyelografi IVU

56. Stab wound of right ureter Dikutip dari Smith’s General Urology

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

60. TUMPUL : Fr. Pelvis (90%)

61. SPONTAN: Patologis

62. RISIKO : - VU penuh - patologis

63. MEKANISME Dikutip dari Smith’s General Urology

64. KLASIFIKASI KONTUSIO RUPTUR Intra peritoneal 25 – 45% Ekstra peritonel 45 – 60% Intra & ekstra 2 – 12%

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

66. DIAGNOSIS KLINIS RÖ : SISTOGRAFI PERIVESIKAL DI SELA-SELA USUS EKSTRAPERITONEUM INTRAPERITONEUM NEGATIF PALSU Robekan kecil TEST BULI-BULI SISTOSKOPI

67. Extraperitoneal bladder rupture Intraperitoneal bladder rupture Dikutip dari Smith’s General Urology

68. PENANGANAN KONTUSIO : Kateter 7 – 10 hari INTRAPERITONEUM : Laparotomi/eksplorasi Jahit Pasang drain Sistostomi Kateter uretra EKSTRAPERITONEUM : Kateterisasi Jahit – pasang kateter

69. KOMPLIKASI SEPSIS ABSES PERIVESIKAL KELUHAN MIKSI PERITONITIS

70. URETRA Dikutip dari Smith’s General Urology

71. Trauma Urethra Trauma urethra posterior Urethra pars prostatika Urethra pars membranosa Trauma urethra anterior Urethra pars bulbosa Urethra pars pendulosa

72. Uretra Anterior IATROGENIK STRADDLE INJURY KLINIS : Trauma Perdarahan per uretram Miksi (+)/(-) Hematoma Perineum  seperti kupu-kupu Scrotum/penis DIAGNOSIS : Klinis Uretrografi Ekstravasasi kontras

73. STRADDLE INJURY Dikutip dari Smith’s General Urology

74. Ruptur bulbar (anterior) urethra following straddle injury Dikutip dari Smith’s General Urology

75. 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

76. KOMPLIKASI STRIKTURA URETRA FISTULA URETEROKUTAN

77. 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”

78. INJURY OF POSTERIOR URETHRAL Dikutip dari Smith’s General Urology

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

81. Repair of urethral injury Dikutip dari Smith’s General Urology

82. 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 !!

83. PENIS TRAUMA TUMPUL TRAUMA TAJAM (AMPUTASI PENIS / REPLANTASI) FRAKTUR PENIS Robekan T. Albuginea dalam keadaan ereksi bengkok dan hematoma STRANGULASI/TERJERAT Karet Cincin Logam

84. SCROTUM TRAUMA TAJAM TRAUMA TUMPUL LUKA BAKAR CRUSHING AVULSI

85. Infeksi Saluran Kemih dr A. Yuda Handaya SpB,FInAC,FMAS Bagian Bedah RSUD Kabupaten Malang

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

87. DEFINISI Infeksi Saluran Kemih atau bakteriuria adalah didapatkannya mikro-organisme sebanyak 102 CFU/mL -> 104 CFU/mL Kriteria bakteriuria: ≥ 104 CFU/mL

88. 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 thebladderCystitis, bacteria go up the ureters  Ureteritis  infect the kidney  Pyelonephritis

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

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

91. 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

92. 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

93. 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

94. 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)

95. 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

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

97. 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

98. 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

99. 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)

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

101. 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)

102. 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

103. 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

104. 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

105. 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

106. Faktor Risiko Timbulnya ISK Karena Kateterisasi (dikutip dari Maki & Tambyah, 2001)

107. Etiopatogenesis dan Perjalanan Penyakit Kateterisasi Bakteriuria Bakteriemia Sepsis Kematian (dikutip dari Saint & Lipsky,1999) < 4% ≥ 30% 12,3%

108. Cara Mikro-organisme Memasuki Saluran Kemih pada Pemakaian Kateter Menetap (dikutip dari Maki & Tambyah, 2001)

109. Pencegahan ISK yang Berhubungan dengan Kateterisasi Indikasi pemasangan kateter menetap pada pasien yang menjalani rawat inap di rumah sakit

110. 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)

111. Morbiditas Kateterisasi Faktor risiko berkembangnya bakteriuria menjadi bakteriemia

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

113. Profile Dr Yuda Handaya SpB FInaCS,FMAS Contact Person Jl. Bromo 98-100 Kepanjen,Kabupaten Malang,JawaTimur,Indonesia Phn/sms/mms 0341-7304141; 08175404141 ; 08122966805 Fax 0341-394979 email : yudahandaya@yahoo.com PROFESSIONAL QUALIFICATIONS Specialist of General Surgery, University of GadjahMada, Indonesia PROFESSIONAL LICENSURE Indonesian Medical Council No : 34.1.1.101.1.06.005789

114. Thank You