urolitiasis dan uropati obstruktif,mth
TRANSCRIPT
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Rujukan:Smith’s General Urology, Tanagho EA & Mc.Aninch JW (eds.), Lange Medical Books / McGraw- Hill, 15th ed., 2000(Campbell’s Urology, Walsh PC et al. (eds.), WB Saunders Co., 7th ed., 1998)
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UROLITIASIS
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1. Epidemiologi faktor intrinsik faktor ekstrinsik
2. Etiologi3. Patofisiologi4. Klinis5. Evaluasi medis6. Terapi medis7. Terapi bedah/invasif minimal
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1. EPIDEMIOLOGIIntrinsik:* heriditer* umur & genderEkstrinsik* geografi* iklim dan musim* cairan masuk* diit* pekerjaan
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2. ETIOLOGI
Faktor risiko
Kristaluria: yang abnormal: kristal sistin dan struvit
Sosio-ekonomik: negara-negara industri Diit: perubahan diit, terutama asam
lemak, protein hewani, masukan natrium >>
Pekerjaan: dokter & pekerja kantoran (white-collar worker)
IklimRiwayat keluargaObat-obatan
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3. PATOFISIOLOGIBatu kalsium oksalatBatu hiperkalsemikHiperoksaluriaHiperurikosuriaHipositraturiaHipomagnesuriaKelainan metabolik multipelRenal tubular acidosisBatu asam uratBatu infeksi (struvite)Batu sistinBatu lain-lain
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4. KLINISEpisode akut: Keluhan: kolik renal/ureterterjadi krn obstruksi oleh batu di: kaliks, UPJ,
pelvic brim, pelvis posterior, UVJtiba2, wkt santai, penjalaran khas (ke pinggang,
genitalia, + kd2 frekuensi, urgensimual, muntah, ileus, diareDD: app.itis, kolitis, salpingitis
Gejala: pend.sulit mencari posisi yg.enak, gelisahT/N dpt.meningkat, kd2 demam
Fisik:nyeri tekan lumbal atau pd tempat batu
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4. KLINIS
UrinalisisUrinalisis:hematuria mikroskopik/makroskopikleukosituria / piuria(kristaluria)(bakteriuria)
Darah:Darah:Hb, leko, LED, faal ginjal: BUN, Skreat,
As.urat
Radiologis:Radiologis:Foto polos abdomen (BOF)IVP / IVUUSGCT scan, Renogram (radio-isotop)
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5. EVALUASI MEDISPENILAIAN RISIKO
episode pertama
Ax keluarga BSKAx keluarga BSK
Penyakit tulang / GIPenyakit tulang / GI
GoutGout
ISK kronisISK kronis
NefrokalsinosisNefrokalsinosis
Tidak Ya
Evaluasi sederhana Evaluasi ekstensif
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5. EVALUASI MEDIS
Kunjungan pertama
episode pertama episode berulang
tanpa risiko dg.risiko evaluasi ekstensif
evaluasi sederhana
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5. EVALUASI MEDISEVALUASI SEDERHANA
Ax: Kebiasaan / diitObat2 provokator batuKehilangan cairanISKLab:Analisis batuDarah lengkap, faal ginjal, as.urat, Ca, P,
K, Urinalisis & biakanRadiologis:Foto polos abdomen / USG/ IVP
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5. EVALUASI MEDISEVALUASI EKSTENSIF
Mendeteksi kelainan metabolik, disamping pemeriksaan pada evaluasi sederhana.
Ada beberapa macam cara, kebanyakan masih eksperimental.
Prinsip:koleksi urin 24 jam dan analisis metabolit
urin yang lebih teliti dengan cara khusus (a.l. diit khusus dan analisis faktor risiko yang ada)
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6. TERAPI MEDIS
2 TUJUAN:Tx episode akut: simtomatik: analgetik
(antiprostaglandin = NSAID)prevensi kekambuhan & pembentukan
batu baru
Jarang sekali Tx medis berguna untuk mengobati BSK yang sudah ada; sebagian besar perlu tindakan (kecuali batu asam urat)
Angka kekambuhan: 7% dalam 1 tahun50% dalam 10 tahun
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6. TERAPI MEDIS
1. Observasi (konservatif):syaratbatu ureter sama atau lebih kecil dari 4-5
mmtidak ada obstruksitidak ada episode bakteriemia atau
urosepsiskolik tidak mengganggu penderita2. Hidrasi (& diuretika)3. Olah raga4. Obat pelarut: alkalinisasi atau asidifikasi5. Bila perlu: analgetika (serangan kolik)6. Follow-up (kontrol) teratur
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6. PRINSIP TERAPI MEDIS
Diit jangka panjang untuk semua penderita dg. episode berulang atau episode pertama dg. risiko
1. Masukan cairan banyak2. Restriksi garam (natrium)3. Restriksi oksalat4. Diit rendah purin5. Restriksi kalsium (moderat) pada
hiperkalsiuria(hanya bila densitas tulang normal)
6. Follow-up / kontrol teratur
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7. TERAPI MEDIS
Antibiotika hanya diberikan pada:
1. Bila ada tanda bakteriemia atau urosepsis, tetapi harus segera direncanakan tindakan urgen
2. Bila akan dilakukan tindakan / instrumentasi atau pembedahan
3. Bila sudah pasti bebas batu, tetapi masih ada infeksi, karena dapat terbentuk batu infeksi (struvit)
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7. TERAPI BEDAH / INVASIF MINIMAL
1. BEDAH TERBUKA
2. BEDAH INVASIF MINIMAL
endoskopik: sistoskopi, ureterorenoskopi (URS), renoskopi (PNL)
litotripsi intrakorporeal: mekanik, ultrasonik, laser, elektrohidraulik, pneumatik
litotripsi ekstrakorkorporeal (ESWL):piezoelektrik, elektrohidraulik, elektromagnetikTERGANTUNG INDIKASI & RISIKO
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7. TERAPI BEDAH / INVASIF MINIMAL
Indikasi tindakan segera / urgen:
1. Bila ada bakteriemia atau urosepsis2. Profesi tertentu tidak melihat besar batu,
tetapi lebih bersifat preventif:pilotpekerja / insinyur konstruksidokter spesialis bedah
(serangan kolik membahayakan orang lain atau diri sendiri)
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Batu saluran kemih (BSK)
• Klinis• Efek obstruksi ureter pada faal ginjal
obstruksi ureter
fungsi ekskresi ginjal
redistribusi RBF dari nefron medulla ke korteks
GFR & RPF
fungsi glomerulus dan tubulus
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Algoritma Tindakan Batu Saluran Kemih< 5 mm: bila 2 minggu tetap, perlu tindakan:Batu kaliks, pielum, ureter 1/3 prox.:
ESWL/URS/PNL/terbukaBatu ureter 1/3 tengah:
URS/terbukaBatu ureter 1/3 distal:
ESWL/URS/terbuka
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Algoritma Tindakan Batu Saluran KemihESWL EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY
indikasi:batu ginjal < 2 cm batu ureter (non impacted)
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EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL)
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Algoritma Tindakan Batu Saluran KemihPNL
(PCN, PCNL) PERCUTANEOUS NEPHROLITHOTOMY
indikasi luas, termasuk:batu ginjal dan ureter prox.batu staghornbatu residif
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(PCN, PCNL) PERCUTANEOUS NEPHROLITHOTOMY
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Batu sal.kemih DMS-2001 26
Algoritma Tindakan Batu Saluran KemihURS (+ TUL)URETERORENOSCOPY (+ TRANSURETERAL LITHOTRIPSY)
indikasi:batu ureter proximal, tengah dan distalstein-strasse (post ESWL)
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URETERORENOSCOPY (URS)
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Batu sal.kemih DMS-2001 28
Algoritma Tindakan Batu Saluran KemihPilihan antara ESWL, URS, PNL dan bedah
terbuka:besar, letak, sistem pcs-u kemungkinan bersihstatus medikkeinginan dan kemampuan penderita
(terjangkau, etika)
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Uropati obstruksi = Obstructive uropathy (urinary tract obstruction) terhambatnya aliran urine -> perubahan
struktural & fungsional, bahkan menyebabkan disfungsi renal / kerusakan parenkim ginjal (nephropati obstruksi = obstructive nephropathy)
Pendahuluan
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“hydronephrosis” / hidronefrosis =hydro (Yunani hydor, “air”), nephros (Yunani, “ginjal”), dan osis (“kondisi”) dan secara umum : dilatasi dari pelvis renalis dan
kaliks akibat dari obstruksi aliran urine.
Pendahuluan
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dilatasi dari pelvis renalis dan kaliks dapat terjadi tanpa obstruksi, -> “hidronefrosis” => menggambarkan adanya dilatasi dari pelvis renalis dan kaliks dan tidak menyebutkan penyebab dari dilatasi itu.
Istilah uropati obstruksi >< hidronefrosis sebaiknya tidak digunakan untuk saling menggantikan
Pendahuluan
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ACUTE OBSTRUCTION
ETIOLOGY
StoneSloughed renal papillaeBlood clotAcute retroperitoneal pathologyAccidental ureteric ligation
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ACUTE OBSTRUCTION
PATHOPHYSIOLOGY
Intrarenal pressure
Renal blood flow (RBF)
Glomerular filtration rate (GFR)
Tubular function
Obstructive atrophy
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SYMPTOMS & SIGNSAsymptomatic (incidental)Symptoms:
Acute or chronicUni or bi-lateral In or ex-trinsicComplete or partial
Flank painNausea, vomiting, fever, chilling, anuria
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INTRA RENAL PRESSURETime Coll.syst.pressure RBF
Phase I 0 – 90 min. ↑↑ ↑↑
Phase II 90 min – 4 h ↔ ↓↓(remains elevated) (to below
control)
Phase III 4 – 18 h ↓↓ ↓↓ (to resting)
(cont.decreased)
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BIOMECHANICS OF URETERIC OBSTRUCTIONLaw of Laplace
relationship between intraluminal pressure, volume & tension in the wall of a compliant homogeneous sphere under equilibrium conditions
P.Л.R² = T.{Л.(R+e)²-R²} Simplified: P.R² = T.(2.R.e.+e² )
Assuming e is constant & that e² << R, elimination of e² yields:
P.R.= C.T
Or: Tension X wall thicknessPressure = ------------------------------
Radius
P = intraluminal pressureR = radius of the spheree = wall thicknessT = wall tensionЛ = 22/7 or 3.14
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UPPER TRACT OBSTRUCTIONINVESTIGATION1. IVP2. USG3. RADIONUCLIDE (RENOGRAM)4. CT
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UPPER TRACT OBSTRUCTION
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UPPER TRACT OBSTRUCTIONINVESTIGATION1. IVP2. USG3. RADIONUCLIDE (RENOGRAM)4. CT
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UPPER TRACT OBSTRUCTION
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UPPER TRACT OBSTRUCTIONINVESTIGATION1. IVP2. USG3. RADIONUCLIDE (RENOGRAM)4. CT
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Figure : The effect of obstruction on the renogram curve. A, mild obstruction; b, moderate obstruction;c, high-grade obstruction.
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UNEQUIVOCAL CHRONIC OBSTRUCTIONPathophysiology
Obstruction high i.r.press. fall (N range)
RBF declines pre obst.level after 3-4 h declining to the new, reduced level
GFR falls progressive
Tubular function affected hypotonic
Urinary osmolality & Na content increased
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UNEQUIVOCAL CHRONIC OBSTRUCTION
Primary mega ureterRetrocaval ureterRetroperitoneal fibrosisUrothelial tumorUreteric stoneUreteric stricture
CongenitalTuberculosisBilharzialIatrogenicRadiation
Retroiliac ureter
Ovarian vein syndromeEndometriosisExtrinsic obstruction
Bowel malignancies (e.g. colon)Pelvic malignancies (e.g.cervix)
PregnancyUreteroceleBladder cancerMalacoplakiaBPHProstate CaProcidentiaPelvic lipomatosisUrethral stricturePhimosis
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EQUIVOCAL CHRONIC OBSTRUCTION
UPJ stenosisPrimary megaureterVUJ stenosisUrinary diversionApparent ureteric stricturePregnancyInfective dilatationDuplication
Previous surgery:ureterolithotomyre-implantationpyelopasty
Previous endourology:ureteroscopybasketry
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UPPER TRACT OBSTRUCTION
Indications of emergency drainageTypes of urinary drainageConsiderations in:
type of the procedure timing
Case presentation
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UPPER TRACT OBSTRUCTIONTypes of emergency drainage
External: Nephrostomy
Open Percutaneous (PNS)
Internal Double-J stenting
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UPPER TRACT OBSTRUCTION
Considerations in:type of the procedure
Degree of dilatation Patient condition --- positioning Local or general/regional anesthesia Drainage only or definitive treatment
timing
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UPPER TRACT OBSTRUCTION
Indications of emergency drainageObstructive anuriaUrosepsis caused by
Pyonephrosis Infected Hydronephrosis
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04/10/23
CONCLUSIONUpper Tract Obstruction may be acute or chronic,
uni or bilateral, unequivocal or equivocalUnequivocal diagnosed by imaging techniqueEquivocal obstruction requires functional and
urodynamic assessmentEmergency drainage is indicated when there are
obstructive anuria and pyonephrosisHemodialysis is needed if indicated and should be
discussed appropriately
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