FEMALE UROLOGY

 Dr KADEK BUDI SANTOSA SpU

Kehamilan dan Urolithiasis
UROLOGI FK. UNUD/RSUP SANGLAH DENPASAR
PENYEBAB

 Herediter
 Umur (dekade 3 sampai 5 kehidupan)
 Kurang minum
 Temperature tinggi dan iklim panas
 Makanan (tinggi kalsium, garam, dan daging
merah)
 Pekerjaan ( di tempat yang panas)
 Lokasi geografis
 Kelas sosial ( berhubungan dengan pekerjaan
dan diet)
 Obesitas
Urolithiasis dan Kehamilan

 Nyeri karena urolithiasis merupakan

penyebab non obstetric yang paling sering
menyebabkan wanita hamil harus dirawat
inap

 Insiden relatif dan angka rekurensi

urolithiasis pada wanita hamil adalah 1/1500
Kejadiannya ?

 80-90% wanita hamil dengan batu saluran

kemih umumnya mengalami keluhan
pada trisemester 2 dan 3

 Karena pada fase

ini batu sulit keluar
spontan

 Pada wanita hamil batu ureter dua kali lebih

sering dibandingkan batu ginjal
Diagnosa dan terapi sulit ?

Diagnosis sulit karena tanda dan gejala

urolithiasis bisa ditemukan pada wanita
hamil normal atau sulit dibedakan dengan
kelainan lain seperti Appendicitis,
diverticulitis, atau abrupsi placenta
 Terapi sulit karena adanya efek dari
anestesi, radiasi dan pembedahan
Pathophysiology

 Faktor yang mencetus terbentuknya batu

pada kehamilan

1. Peristalsis ureter menurun

2. Hydronefrosis fisiologis pada kehamilan
3. Infeksi
4. meningkatnya ekskresi kalsium urine
 Faktor yang mencegah
terbentuknya batu pada kehamilan

 Ekskresi dari urolithiasis

inhibitors, seperti citrate, magnesium, dan
glycosaminoglycans
Kenapa tejadi hidronefrosis pada kehamilan?

1. Progesteron menginduksi relaksasi otot

polos ureter dan mengurangi peristalsis
ureter yg menyebabkan hidronefrosis
2. Tekanan ureter akibat membesarnya
uterus
Jenis jenis batu saluran kencing ?
Uric acid stone formation

 Dehydration, hyperuricosuria, and

significantly acidic urine contribute to uric
acid supersaturation and stone formation

 However, during gestation, urine tends to be

more alkaline, probably because of greater
intrinsic purine use and increased urinary
citrate excretion
Calcium oxalate and calcium phosphate stone
formation

 Calcium excretion increases 200-300%

compared with that in healthy patients who
are not pregnant
 However, increased concentration of the
urolithiasis inhibitors present in urine during
gestation and increased urine fluid output
counters the increased risk imposed by any
hypercalciuria
Struvite stones

 Struvite stones form only when the urinary

tract is infected with urea-splitting
organisms (eg, Proteus species)
Symptoms

The most common symptoms of urolithiasis of

pregnancy include the following:
 Flank pain
 Pain radiating to the groin or labia
 Nausea
 Dysuria
 Gross hematuria
Laboratory Studies

1. Urinalisis
2. Urine culture
3. CBC
4. BUN sc
5. Metabolic study
Imaging Studies
RADIASI??

< 5000 millirad [mrd]) has not been associated

with fetal abnormalities or pregnancy loss
1. Ultrasonography – None
2. MRI (< 1.5 T) - None
3. KUB, 1.4 milligray (mGy) - 140 mrd
4. Intravenous urography, 1.7 mGy - 170 mrd
5. Renal tract CT scanning, 80 mGy - 800 mrd
6. Technetium Tc 99m renal scan
USG

 Renal ultrasonography, with or without

Doppler studies, is recommended as the
primary imaging modality in pregnant
women
Intravenous urography (IVU) or IVP
Treatment

1. Medical
The initial management of urolithiasis in pregnancy
should be conservative
 Intravenous hydration
 analgesia
 Bed rest
 Antiemetics
 antibiotics
 Alpha blocker
spontaneous passage of symptomatic calculi in 64-
84% of patients
Contraindicated

Codein
NSAID
Alopurinol
Quinolone
Kapan dilakukan tindakan ?

 Most stones (64-84%) pass spontaneously

with conservative treatment.
 However, if the calculus does not pass, it
may initiate premature labor, produce
intractable pain, cause urosepsis in the
setting of urinary tract infection, or interfere
with the progression of normal labor
Surgical Care

 Surgical intervention is required in 20-30% of

pregnancies complicated by urolithiasis.
 Indications for surgical intervention:
1. Ureteral obstruction associated with increasing
azotemia
2. Obstruction in a solitary kidney
3. Intractable pain despite maximal conservative
measures
4. Urosepsis
5. Renal colic–induced premature labor
unresponsive to tocolytics
Surgical Care

1. Percutaneous nephrostomy tube

2. Ureteral stent placement
3. Ureteroscopy
4. Open surgery
Percutaneous nephrostomy tube
NEFROSTOMI
Ureteral stent placement
Ureterorenoscopy (URS)
Ureterorenoscopy (URS)
Surgical risk

 Venous thromboembolism (VTE) and

pulmonary embolism (PE)
 The increasing size of the gravid uterus
changes the hemodynamics in the lower
extremities
 Aspiration
 Premature delivery
 Fetal risks of anesthesia: Inhalation
anesthetics readily cross the placenta
because of their lipid solubility.
 Teratogenicity>>
Kesimpulan

 Initial management should be Conservative

 Invasive (eg, stent placement, ureteroscopy
with stone manipulation, percutaneous
nephrostomy)
 With appropriate diagnosis and
management, the outcome for both the
mother and baby is excellent
RETENSI URINE
Retensi Urine

 Keadaan dimana px tidak dapat

mengeluarkan urine yang terkumpul
didalam buli-buli shg melampaui kapasitas
maksimal buli-buli
Penyebab

1. Vesika
2. Infra vesika
3. Dissinergi (vesika dan infravesika)
Penyebab

1. Kelemahan detrusor : (vesica)

- cedera sumsum tulang belakang
- kerusakan saraf perifer (DM)
- dilatasi detrusor yang berlebihan dalam
waktu lama, divertikel buli
2. Hambatan jalan keluar : (infravesika)
- Striktur Uretra
- Clot retention
- Batu buli-buli dan uretra
-Retroverted uterus in pregnancy
-pelvic organ prolapsed
- infeksi
-konstipasi
-Obat2an (anti depresan, anti kolinergik, anti
histamin)
3. Disinergi detrusor-spingter (ggn koordinasi) :
(vesika dan infravesika)
- cedera sumsum tulang daerah cauda equina
Urine retention and pregnancy
 Retroverted uterus
Causes

genetic
pelvic surgery
pelvic adhesions
endometriosis, fibroids, pelvic inflammatory
disease, or the labor of childbirth
 Treatment options are rarely needed, and
include exercises, a pessary, manual
repositioning, and surgery
Vaginal delivery and urinary retention
Vaginal delivery and urinary retention

In women, sphincter abnormalities :

1. An anatomic viewpoint, urethral
hypermobility (urethral support defect)
ex prolapsed pelvic organ
2. functional viewpoint, intrinsic sphincteric
insufficiency (ISD)
Vaginal delivery and urinary retention

mechanisms of sphincteric damage and

incontinence:

1. injury to connective tissue

2. vascular damage to the pelvic structures
3. damage to the pelvic nerves or muscles or
both
4. direct injury to the urinary tract during
labor and delivery
 The abnormalities found were most marked
in
1. Multiparas
2. Prolonged second stage of labor
3. Forceps delivery
Pelvic organ Prolapsed

 Prolapsed uteri
 Cystocele
 Rectocele
Penatalaksanaan Retensio urine :

1. Kateter perurethra
2. Trokar sistostomi
3. Open sistostomi
4. Atasi causa
ex repair prolapsed organ
reposisi uteri
1. Kateterisasi per urethra:
Syarat :
 Prinsip aseptik
 Gunakan kateter folley
 Usahakan tidak nyeri  spasme spingter
 Sistim tertutup dan ukur volume urine initial
 Antibiotik profilaksis
2. Sistostomi trokar/tertutup :

Indikasi :
 Kateterisasi perurethra gagal : striktur, batu
uretra yg menancap
 Ada kontraindikasi pemasangan DK : trauma
uretra
Bladder injury
 Bladder
Injury
 Etiologi
1. 86% blunt abdominal trauma
motor vehicle acc
falls from height
crush injury
2. 14% penetrating trauma
PATOFISIOLOGI

 Extraperitoneal (60%):
 Associated with pelvic fracture
 Extravasated urine confine to pelvis

 Intraperitoneal (30%):
 Blunt abdominal trauma ( > children)
 Trauma to distended full bladder
 High mortality
DIAGNOSIS

Imaging
 Cystography
Extraperitoneal injury
flame-shaped collection of contrast extravasation
Intraperitoneal injury
Contrast material outlines loops of bowel
Intraperitoneal bladder rupture
Management
 Intraperitoneal injury
Surgical repair
 Extraperitoneal injury
Nonoperative
by catheter drainage 10 days
Extraperitoneal rupture after 2 weeks of
catheter
Bladder injury and pregnancy
Etiology

Traumatic
 Post surgical
 External trauma
 Radiation therapy
 Advanced pelvic malignant disease
 Infectious or inflammatory
 Foreign body
 Obstetric
Post surgical

 Abdominal hysterectomy
 Vaginal hysterectomy
 Anti-incontinence surgery
 Anterior vaginal wall prolapse surgery (e.g.,
colporrhaphy)
 Vaginal biopsy Bladder biopsy, endoscopic
resection, laser procedures
Obstetric

 Obstructed labor
 Forceps laceration
 Uterine rupture
 Cesarean section injury to bladder
Vesicovaginal fistula
Evaluation and Diagnosis.

Symptoms

 Constant urine drainage per vagina

 Pain is an uncommon
Physical Examination
Speculum
Cystoscopy.
Imaging
cystography
Treatment

 The goal of treatment of VVF is the rapid

cessation of urine leakage with return of
normal and complete urinary and genital
function
Conservative

 Trial of indwelling catheterization and

anticholinergic medication for at least 2 to 3
weeks may be warranted in selected patients
with newly diagnosed VVF as spontaneous
healing may result
Surgical repair ?
Vesicovaginal Fistula Repair
Renal Cyst

 Definition
Round pouches of fluid that form in the kidneys
 Cysts are present in over one third of
patients older than 50 years, and few require
surgical intervention

 Simple cyst/ Noncancerous cyst

Simple cyst

 Thin distinct smooth wall

 Spherical or oval with no internal echoes,
and have good transmission of sound waves
with acoustic enhancement behind the cyst

 Selain itu  CT scan

Curiga tumor ?

 Large cystic components & septation

 Irregular margins
 Solid vascular elements
Kapan dilakukan tindakan ?

1. Pain
2. Infection
3. Obstruction
4. Curiga keganasan
Procedure

1. Needle aspiration and sclerotic agent

2. Decortication
3. Excisi
RENAL CYST EXCISION
TERIMA KASIH