KEMENTERIAN KESEHATAN RI

DIREKTORAT JENDERAL BINA UPAYA KESEHATAN

RSUP dr. SOERADJI TIRTONEGORO
Jalan Dr. Rt. SoeradjiTirtonegoroNomor 1
KLATEN

RINCIAN KEWENANGAN KLINIS STAF MEDIS

Unit Kerja KSM Urologi

NamaDokter dr. Raden Fenditya Agung Nugroho, Sp.U
Spesialis Urologi
Konsultan
Tempat, TanggalLahir Yogyakarta, 20 Maret 1981
Jabatan Anggota KSM Urologi
Pangkat / Golongan BLU

PelatihanBersertifikat

STR KonsilKedokteran 3411106419001108

Saya menyatakan bahwa saya kompeten untuk menangani kasus-kasus yang saya minta di
bidang spesialisasi saya, termasuk melayani konsultasi dari dokter-dokter lain.
Saya juga menyatakan kompeten untuk melakukan prosedur teknis seperti yang tercantum di
bawah ini sebagai bagian dari kewenangan klinis (clinical privilege) berdasarkan status
kesehatan saat ini, pendidikan, dan /atau pelatihan yang telah saya jalani, serta pengalaman
yang saya miliki.

KETERANGAN KODE PENGISIAN

Kode untuk Pemohon:
1. Kompeten sepenuhnya
2. Memerlukan supervisi
3. Tidak dimintakan kewenangannya
karena di luar kompetensi
4. Tidak dimintakan kewenangannya
karena fasilitas tidak tersedia
Kode untuk Rekomendasi:
1. Disetujui berwenangpenuh
2. Disetujui di bawah supervisi
3. Tidak disetujui karena bukan
kompetensinya
4. Tidak disetujui karena fasilitas tidak
tersedia

Page 1 of 14
Sub Komite Kredensial Komite Medik RSST
 Kewenangan Klinis Rekomendasi
No
Jenis Kewenangan Klinis yang dimintakan Sub Komite
.
Kredensial
I OPERASI TERBUKA
A ADRENAL/RETROPERINEAL
1 Adrenalectomy (abdominothoracal)
2 Adrenalectomy

B OPERATIONS ON KIDNEY
1 Nephrotomy and nephrostomy
Nephrotomy. Deroofing/unroofing cysta.
2
Pyeionephrolithotom
3 Nephrostomy
Percutaneous nephrostomy without
4 fragmentation
Bivalve/anatropic nephrolithotomy
5 Percutaneous nephrostomy with fragmentation
6 Pyelotomy and pyelostomy
7 Pyelotomy. Pyelolithotomy
Pyelostomy
8
Extended pyelolithotomy
Diagnostic procedures on kidney.
9
Pyelocalicotomy
10 Nephroscopy
Pyeloscopy. Diseksi kelenjar getah bening
11
pelvis per laparoskopi
Closed (percutaneous)(needle) biopsy of
12
kidney
13 Open biopsy of kidney
14 Other diagnostic procedures on kidney
Local excision or destruction of lesion or tissue
15
of kidney
16 Marsupialization of kidney lesio
17 Open ablation of renal lesion or tissu
18 Percutaneous ablation of renal lesion or tissu
19 Laparoscopic ablation of renal lesion or tissu
Other and unspecified ablation of renal lesion
20
or tissue
Other local excision or destruction of lesion or
21
tissue of kidney
Partial nephrectomy: Calycectomy, Wedge
22
resection of kidney
23 Complete nephrectomy
Nephroureterectomy. Nephroureterectomy with
24 bladder cuff, Total nephrectomy (unilat)

Nephrectomy of remaining kidney. Removal of

25
solitary kidney

Page 2 of 14
Sub Komite Kredensial Komite Medik RSST
 Kewenangan Klinis Rekomendasi
No
Jenis Kewenangan Klinis yang dimintakan Sub Komite
.
Kredensial
Removal of transplated or rejected kidney.
26
Radical Nephrectomy
27 Bilat nephrectomy
28 Transplant of kidney
29 Renal autotransplantation
Other kidney transplantation. Recipient
30
transplantation
Nephropexy. Fixation or suspension of
31
movable (floating) kidney
32 Other repair of kidney
33 Suture laceration of kidney/renoraphy
34 Closure of nephrostomy and pyelostomy
35 Closure of other fistula of kidney
36 Reduction of torsion of renal pedicle
Symphysiotomy for horseshoe kidney. Koreksi
37
horseshoe kidney
Anastomosis of kidney:
38 Nephropyeioureterostomy, Pyeloureterovesical
anastomosis, Ureterocalyceal anastomosis
Correction of ureteropelvic junction.
39
Pyeloplasty
40 Other operation on kidney
Decapsulation of kidney. Capsulectomy of
41 kidney. Decortication of kidney
Nephrectomy for donor transplant
Percutaneous aspiration of kidney (pelvis).
Aspiration of renal cyst.
42
Renipuncture. Punksi dan sklerosing kista
ginjal
43 Replacement of nephrostomy tube
44 Replacement of pyelostomy tube
45 Local perfusion of kidney
Other injection of therapeutic substance into
46 kidney
Injection to renal cyst
Implantation or replacement of mechanical
47
kidney
48 Removal of mechanical kidne
49 Recontruction of renovascular

C OPERATION ON URETER
Transurethral removal of obstruction from
ureter and renal pelvis
1 Removal of: blood clot, calculus, foreign body.
From ureter or renal pelvis without incision.
URS

Page 3 of 14
Sub Komite Kredensial Komite Medik RSST
 Kewenangan Klinis Rekomendasi
No
Jenis Kewenangan Klinis yang dimintakan Sub Komite
.
Kredensial
Ureteral meatotomy
Ureterotomy
Incision of ureter for: drainage, exploration,
2
removal of calculus
Ureterolithotomy
3 Ureterolithotomy proximal
4 Ureterolithotomy distal
5 Diagnostic procedures on ureter
6 Ureteroscopy
7 Closed percutaneous biopsy of ureter
8 Closed endoscopic biopsy of ureter
9 Open biopsy of ureter
Endoscopy of ileal conduit: cystoscopy,
10
looposcopy
11 Other diagnostic procedures on ureter
12 Ureterectomy
13 Ureterectomy, NOS
Partial ureterectomy. Excision of lesion of
14 ureter. Shortening of ureter with
reimplantation. Reimplantasi ureter bilat
15 Total ureterectomy
Cutaneous uretero-ileostomy 56.5 71
16
Formation
Formation of cutaneous uretero-ileostomy.
17
Ileal conduit (Bricker)
18 Revision of cutaneous uretero-ileostomy
19 Other external urinary diversio
Formation of other cutaneous ureterostomy.
20 Anastomosis of ureter to skin.
Ureterostomy NOS. Ureterokutaneostomi
Revision of other cutaneous ureterostomy
21
Revision of ureterostomy stoma
22 Other anastomosis or bypass of ureter
23 Urinary diversion to intestine
24 Revision of ureterointestinal anastomosis
25 Nephrocystanastomosis, NOS
Ureteroneocystostomy. Replacement of ureter
with bladder flap
26
Ureterovesical anastomosis. Reimplantasi
ureter unilateral Psoas Hitch/ Boari flap
Transuretero-ureterostomy. Uretero-
27
ureterostomy
28 Other. Anastomosis end to end ureter
29 Repair of ureter
30 Lysis of intraluminal adhesions of ureter
31 Suture of laceration

Page 4 of 14
Sub Komite Kredensial Komite Medik RSST
 Kewenangan Klinis Rekomendasi
No
Jenis Kewenangan Klinis yang dimintakan Sub Komite
.
Kredensial
32 Closure of ureterostomy
33 Closure of other fistula of ureter
34 Ureteropexy
35 Removal of ligature from ureter
36 Other repair of ureter. Tailoring ureter
37 Other operations on ureter
38 Dilation of uretral meatus
39 Implantation of electronic ureteral stimulator
40 Replacement of electronic ureteral stimulator
41 Removal of electronic ureteral stimulator
42 Ligation of ureter
43 Removal DJ stent

D OPERATIONS ON URINARY BLADDER

Transurethral clearance of bladder
Drainage of bladder without incision
1 Removal of (blood clots, calculus, foreign
body) from bladder without incision
Lithotripsi batu buli
2 Cystostomy
3 Percutaneous aspiration of bladder
Lysis of intraluminal adhesions with incision
4
into bladder
Percutaneous cystostomy
5 Closed cystostomy, percutaneos suprapubic
cystostomy
Other suprapubic cystostomy. Railroading
6
ruptur uretra
Other cystostomy. Lithopalaksi. Sectio alta/
7
vesikolithotomi
8 Vesicostomy
9 Revision or closure of vesicostomy
10 Diagnostic procedures on bladder
Cystoscopy through artificial stoma. Sistoskopi
11
ODS
12 Other cystoscopy. Transurethral cystoscopy
Closed (transurethral) biopsy of bladder. TUR
13
tumor buli
14 Open biopsy of bladder
15 Other diagnostic procedures on bladder
Transurethral excision/destruction of bladder
16
tissue
17 Transurethral lysis of intraluminal adhesions
Other transurethral excision/destruction of
18 lesion/tissue of bladder
Endoscopic resection of bladder lesion

Page 5 of 14
Sub Komite Kredensial Komite Medik RSST
 Kewenangan Klinis Rekomendasi
No
Jenis Kewenangan Klinis yang dimintakan Sub Komite
.
Kredensial
19 Other excision/destruction of bladder tissue
Excision of urachus. Excision of urachal
20
sinus of bladder
Open excision/destruction of other
lesion/tissue of bladder
21 Endometrectomy of bladder. Suprapubic
excision of bladder lesion
Diverticulectomy of bladder
Partial cystectomy. Excision of bladder
22 dome, trigonectomy, wedge resection of
bladder. Reduction of cystosplasty
Total cystectomy. Total cystectomy with
23 urethrectomy
Radical cystectomy
24 Radical cystectomy
25 Other total cystectomy
26 Other repair of urinary bladder
27 Suture of laceration of bladder
28 Closure of cystostomy
Repair of fistula involving bladder and
intestine
Fistulectomy: (rectovesicovaginal,
29
vesicosigmoidovaginal)
Repair fistel enterovesika. Repair fistel
vesikorektal
Cystourethroplasty and plastic repair of
bladder neck
30
Plication of sphincter of urinary bladder
Rekonsiruction/V-Y plasty of bladder neck
31 Repair of bladder extrophy
Reconstruction of urinary bladder
Anastomosis of bladder with isolated segment
32 of ileum, augmentation of bladder,
replacement of bladder with ileum/sigmoid
(closed ileal bladder)
Other anastomosis of bladder
33 Anastomosis of bladder to intestine NOS,
cystocolic anastomosis
34 Other repair of bladder. Neobladder
35 Other operations on bladder
Sphincterotomy of bladder. Division of bladder
36
neck
37 Dilation of bladder neck
Control of (post operative) hemorrhage of
38
bladder
39 Insertion of indwelling urinary catheter

Page 6 of 14
Sub Komite Kredensial Komite Medik RSST
 Kewenangan Klinis Rekomendasi
No
Jenis Kewenangan Klinis yang dimintakan Sub Komite
.
Kredensial
40 Replacement of indwelling urinary catheter
41 Implantation of electronic bladder stimulator
42 Replacement of electronic bladder stimulator
43 Removal of electronic bladder stimulator

OTHER OPERATION ON URINARY

E
TRACT
1 Dissection of retroperitoneal tissue
Retroperitoneal dissection, NOS
2
Limfadeneklomi retroperitoneal/ RPLND
Ureterolysis with freeing/repositioning of
3
ureter for retroperitoneal fibrosis
Other lysis of perirenal/periureteral adhesions
4
Ureterolysis
Laparoscopic lysis of perirenal/periureteral
5
adhesions
Other incision of perirenal/periureteral tissue
6 Exploration of perinephric area. Incision of
perirenal abscess
7 Incision of perivesical tissue
8 Other lysis of perivesical adhesions
9 Laparoscopic lysis of perivesical adhesions
Other incision of perivesical tissue
Exploration of perivesical tissue. Incision of
10
hematoma of space of Retzius.
Retropubic exploration
Diagnostic procedures on perirenal and
11
perivesical tissue
12 Biopsy of perirenal or perivesical tissue
Other diagnostic procedures on perirenal
13
tissue, perivesical tissue and retroperitoneum
14 Plication of urethrovesical junction
Suprapubic sling operation. MMK7 sling
15
uretra
16 Retropubic urethral suspension
17 Paraurethral suspension
18 Other repair of urinary stress incontinence
Levator muscle operation for urethrovesical
19
suspension
Injection of implant into urethra and/or bladder
neck Collagen implant. Collagen implant.
20 Endoscopic injection of implantFat implant.
Polylel implant

21 Anterior urethropexy, repair of stress

incontinence NOS, tudor "rabbit

Page 7 of 14
Sub Komite Kredensial Komite Medik RSST
 Kewenangan Klinis Rekomendasi
No
Jenis Kewenangan Klinis yang dimintakan Sub Komite
.
Kredensial
ear"urethropexy
Ureteral catheterization. Drainage of kidney by
catheter
22 Insertion of ureteral stent/DJ stent.
Ureterovesical orifice dilation Drainage
periureter. Insersi ureter kateter for RPG
23 Other operations on urinary system
24 Excision of perirenal or perivesical tissue
Other operations on perirenal or perivesical
25
tissue
Replacement of ureterostomy tube: Change,
26
reinsertion
27 Replacement of cystostomy tube
Ultrasonic fragmentation of urinary stones.
28
Shattered urinary stones
29 Ureterosigmoidostomy (Coffey)

OPERATIONS ON PROSTATE AND

F
SEMINAL VESICLES
Incision of prostate. Drainage of prostatic
1
abscess. Prostatolithotomy
Diagnostic procedures on prostate and seminal
2 vesicles
Biopsi prostat
Closed (percutaneous) (neddle) biopsy of
3
prostate
4 Open biopsy of prostate
Closed (percutaneous) biopsy of seminal
5 vesicles
Needle biopsy of seminal vesicles
6 Open biopsy of seminal vesicles
7 Biopsy of periprostatic tissue
Other diagnostic procedures on prostate and
8
periprostatic tissue
Other diagnostic procedures on seminal
9
vesicles
10 Transurethral prostatectomy
Transurethral (ultrasound) guided laser induced
11
prostatectomy (TULIP) TRUS
Other transurethral prostatectomy:
Excision of median bar by transurethral
apparoach, TEVAP, transurethral enucleative
12
procedures, transurethral prostatectomy NOS,
TURP, TUIP, BNl, TVP, TMP

13 Suprapubic prostatectomy. Transvesical

Page 8 of 14
Sub Komite Kredensial Komite Medik RSST
 Kewenangan Klinis Rekomendasi
No
Jenis Kewenangan Klinis yang dimintakan Sub Komite
.
Kredensial
prostatectomy
14 Retropubic prostatectomy
15 Radical prostatectomy. Prostatovesiculectomy
16 Other prostatectomy
Local excision of lesion of prostate. Open
17
prostatectomy
18 Perineal
19 Operations on seminal vesicles
20 Percutaneous aspiration of seminal vesicles
21 Incision of seminal vesicles
Excision of seminal vesicles
22 Excision of Mullerian duct cyst,
spermatocystectomy
23 Other operations on seminal vesicles
24 Incision/excision of periprostatic tissue
Incision of periprostatic tissue. Drainage of
25
periprostatic tissue
Excision of periprostatic tissue
26
Excision of lesion of periprostatic tissue
27 Other operations on prostate
28 Percutaneous aspiration of prostate
29 Injection into prostate
30 Repair of prostate
Control of (postoperative) hemorrhage of
prostate
31
Coagulation of prostetic bed
Cystoscopy for control of prostatic hemorrhage
Transurethral balloon dilation of the prostatic
32
urethra
Transurethral destruction of prostate tissue by
microwave thermotherapy
33
Transurethral microwave thermotherapy
(TUMT) of prostate
Other transurethral destruction of prostate
tissue by other Thennotherapy. Radiofrequency
thermotherapy
34
Transurethral needle ablation (TUNA) of
prostate

Masase prostate

OPERATION ON SCROTUM AND

G
TUNICA VAGINALIS
Incision and drainage of scrotum and tunica
1
vaginalis
2 Diagnostic procedures on scrotum and tunica

Page 9 of 14
Sub Komite Kredensial Komite Medik RSST
 Kewenangan Klinis Rekomendasi
No
Jenis Kewenangan Klinis yang dimintakan Sub Komite
.
Kredensial
vaginalis
3 Biopsy of scrotum or tunica vaginalis
Other diagnostic procedures on scrotum and
4
tunica vaginalis
5 Excision of hydrocele (of tunica vaginalis)
Excision/destruction of lesion or tissue of
6 scrotum: fulguration of lesion. reduction of
elephantiasis, partial scrotectomy
7 Repair of scrotum and tunica vaginalis
Suture of laceration of scrotum and tunica
8
vaginalis
9 Repair of scrotal fistula
Other repair of scrotum and tunica vaginalis
10 Reconstruction with rotational or pedicle flaps.
Scrotoplasty
11 Other repair on scrotum and tunica vaginalis
Percutaneous aspiration of tunica vaginalis
12
Aspiration of hydrocele of tunica vaginalis
Excision of lesion of tunica vaginalis other
13
than hydrocele

H OPERATIONS ON TESTIS
Incision of testis. Eksplorasi testis
1
(microsurgery)
2 Diagnostic procedure of testis
3 Closed {percutenous)(needle) biopsy of testis
4 Open biopsy of testis
5 Other diagnostic procedure of testis
Excision/destruction of testicular lesion
6 Excision of appendix testis. Excision of cyst of
Morgagni in the male
7 Unilat orchidectomy
Bilat orchidectomy. Male castration. Radical
8
bilat orchidectomy
Removal of both testis at same operative
episode
9
Bilat orchidectomy NOS. Extended
orchidectomy
Removal of remaining testis
10 Removal of solitary testis. Subcapsular
orchidectomy
11 Orchidopexy (UDT, torsio testis)
12 Repair of testis
13 Suture of laceration of testis
14 Other repair of testis. Testicular graft

Page 10 of 14
Sub Komite Kredensial Komite Medik RSST
 Kewenangan Klinis Rekomendasi
No
Jenis Kewenangan Klinis yang dimintakan Sub Komite
.
Kredensial
15 Insertion of testicular prosthesis
16 Other operations on testis
17 Aspiration of testis
18 Injection of therapeutic substance into testis

OPERATION ON SPERMATIC CORD,

H
EPIDIDYMIS, AND VAS DEFERENS
Diagnostic procedures on spermatic cord,
1
epididymis, and vas deferens
Biopsy of spermatic cord, epididymis, and vas
2
deferens
Other diagnostic procedures on spermatic cord,
3
epididymis, and vas deferens
Excision of varicocele and hydrocele of
spermatic cord
4 High ligation of spermatic vein.
Hydrocelectomy of canal of Nuck
Funicocelectomy. Varicocelectomy (palomo)
Excision of cyst of epididymis.
5
Spennatocelectomy
Excision of other lesion or tissue of spermatic
6 cord and epididymis
Excision of appendix epididymis
7 Epididymectomy
8 Repair of spermatic cord and epididymis
Suture of laceration of spermatic cord and
9
epididymis
10 Reduction of torsion of testis or spermatic cord
11 Transplantation of spermatic cord
12 Other repair of spermatic cord and epididymis
13 Vasotomy. Vasostomy. Vasovasostomy
14 Vasectomy and ligation of vas deferens
15 Male sterilization procedure, NOS
16 (ligation, crushing, division) of vas deferens
17 Ligation of spermatic cord
18 Vasectomy
19 Repair of vas deferens and epididymis
Suture of laceration of vas deferens and
20
epididymis
Reconstruction of surgically divided vas
21
deferens
22 Epididymovasostomy
23 Removal of ligature from vas deferens
24 Removal of valve from vas deferens
25 Other repair of vas deferens and epididymis
26 Other operations on spermatic cord,

Page 11 of 14
Sub Komite Kredensial Komite Medik RSST
 Kewenangan Klinis Rekomendasi
No
Jenis Kewenangan Klinis yang dimintakan Sub Komite
.
Kredensial
epididymis and vas deferens
27 Aspiration of spermatocele
28 Epididymotomy
29 Incision of spermatic cord
30 Lysis of adhesions of spermatic cord
31 Insertion of valve in vas deferens

I OPERATIONS ON PENIS
1 Circumcision (male)
2 Diagnostic procedures on the penis
3 Biopsy of penis
4 Other diagnostic procedures on penis
Local excision/destruction of lesion of penis
5 Eksisi plaque {Peyronie disease). Excisi
webbed penis
6 Amputation of penis
7 Repair and plastic operation on penis
8 Suture of laceration of penis
9 Release of chordae/chordectomy
10 Construction of penis
11 Reconstruction of penis. Eksisi fibroma
Replantation of penis. Reattachment of
12
amputated penis
Other repair of penis. Operasi priapismus
13 (prosedur Winter)
Koreksi priapismus
14 Other operations on male genital organs
15 Dorsal or lateral slit of prepuce
16 Incision of penis
17 Division of penile adhesions
18 Fitting of external prosthetis of penis
Insertion or replacement of non-inflatable
penile prosthesis
19
Insertion of semi-rigid rod prosthesis into shaf^
of penis
20 Removal of internal prosthesis of penis
Insertion or replacement of inflatable penile
prosthesis
21
Insertion of cylinders into shaft of penis and
placement of pump and reservoir
Other operations on penis. Corpora cavemosa-
corpus spongiosum shunt
22
Corpora-saphenous shunt. Irrigation of corpus
cavemosum
23 Dissection of lymp node of inguinal
24 Hidrokelektomi per inguinal/ligasi tinggi

Page 12 of 14
Sub Komite Kredensial Komite Medik RSST
 Kewenangan Klinis Rekomendasi
No
Jenis Kewenangan Klinis yang dimintakan Sub Komite
.
Kredensial
25 Incisi abses perenium
26 Lymphadenectomy ilioinguinal
27 Vasography
28 Dissection of lymp node of pelvis
29 ESWL
30 Laparatomy exploration
31 Operasi Sistokel
32 Insersi catheter Tenckhoff untuk CAPD
33 Uroflowmetri
34 Infiltrasi sitostatika intravesica
35 Chemotherapy

Tanggal: DokterPemohon:

(dr. Raden Fenditya Agung Nugroho, Sp.U)

Page 13 of 14
Sub Komite Kredensial Komite Medik RSST
 Bagian II.Rekomendasi Sub Kredensial Komite Medik

……………………………………………..
Catatan:

Daftar Mitra Bestari

No. Nama Spesialisasi TandaTangan

5
Tanggal:

KetuaKomiteMedik Ketua Sub KomiteKredensial

(dr. Guntur Surya Alam, Sp. B., Sp. BA ) (dr. Fajar Sudarsono, Sp. U)

Page 14 of 14
Sub Komite Kredensial Komite Medik RSST