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Ceramah Jogja Djoko Rahardjo Dept of Urology Cipto Mangunkusumo Hospital Univ

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Ceramah Jogja Djoko Rahardjo Dept of Urology Cipto Mangunkusumo Hospital Univ Powered By Docstoc
					                Djoko Rahardjo
Dept. of Urology, Cipto Mangunkusumo Hospital
               Univ. of Indonesia
What is Urolithiasis :
Stone disease in the urinary tract :
     •   Kidney stone
     •   Ureteric stone
     •   Bladder stone
     •   Stone in the urethra
Stone formation process
 • Hypersaturation
 • Lack of inhibitors
 • Metabolic
   Hypercalciuria
   Hyper oxaluria
    hyper uricosuria
 • Infection
   Struvit formation
                       Unstable          Nucleation
                       supersaturation
Ion-activity product

                                                             Formation
                                                             product
                       Metastable        Crystal growth
                       Supersaturation   aggregation

                                                              Solubility
                                                              product
                       Undersaturated    Crystal
                       zone              dissolution




                                                   Urolithiasis - Dr. Djoko Rahardjo
 Inhibitors
• Crystallization inhibitor
• Crystal aggregation
  inhibitor
Important inhibitors
Citrate   K citrat
          Magnesium oxyde
Hypercalciuria
•   Absorptive type 1
•   Absorptive type 2
•   Absorptive type 3
•   Resorptive
•   Renal leak
•   Unknown of origin
   Diagnosis of Urolithiasis
Anamnesis :
• Pain
  – Low pain
  – Colicky pain
  – Dysuria
• Color of Urine
  – Hematuria
  – Cloudy urine   infection
• Fever (sign of infection)
• History of passing stone or
  previous treatment of stone
          Diagnosis
Physical examination
• Palpable enlarged kidney
• Pain or fast percussion
• Palpable stone in the urethra
• Palpable bladder (retention)
    Laboratory Test
• Urinalysis :
  – Present of erythrocyte in the
    sediment
  – Present of WBC
  – Culture
• Blood examination :
  – Hemoglobin
  – WBC court
  – Blood urea
  – Serum creatinine
  – Uric acid
                 Imaging
• Ultrasound of kidney and
   bladder
• Plain X ray
• IVU
• MSCT with or without contrast
Long standing stone
• Infection
                Kidney function
• Obstruction
                Squamous cell
• Metaplasia    carcinoma
Treatment of the stone
Depends on :
 Stone location
 Stone burden
 Kidney function
 Availability of man power
 Availability of instrument
      Renal Colic/Ureter Colic
• Patent pain colic
  – NSAID
  – Morphin
  – Morphin like drugs :
        Tramadol
        Tamadol

• Medical expulsion therapy for stone <
  5mm
  – Alpha blocker
  – Batugin Elixir (?)
        Kidney stone
With huge hydronephrosis or
pyonephrosis :
Percutaneous Nephrostomy is
mandatory
aim to improve kidney function
Kidney stone without enlargement of
         collecting system
    • < 5mm
      – Watchful waiting
      – ESWL
    • 5mm – 20 mm
      – ESWL
      – PcNL
      – if no urologist  open surgery
Kidney stone without enlargement
      of collecting system
     • > 20 mm
       – ESWL + Double J
       – PcNL
       – Open surgery
     • Staghorn stone
       – Open surgery
       – PcNL
       – ESWL (fractional)
  Efficacy of ESWL
Stone size        Stone free rate (%)
< 10 mm                84 (40 – 92)
10 – 20 mm             77 (50 – 85)
ca oxalat monohydrat   38 – 81
cystine                60 – 63
< 15 mm                71
> 20 mm                40
Efficacy of PcNL

Stone size         Stone free rate (%)
• < 20 mm           • 84
• In lower calyx    • much better than
   10 – 20 mm         ESWL
  Retreatment of ESWL
• Maximal 3-5 times
  depends on : type of the machine
• For electrohydrolic intent 4-5 days
• For Piezoelectric ± 2 days
 Staghorn stone

• Open surgery
• Sandwich
   PcNL and ESWL
  Ureter Anatomy
• Narrowing of ureter
  – UPJ
  – Crossing with iliac vessel
  – intramural
• Upper and lower tract
  Treatment of Ureteric stone
        depends on :
• Size
• Location
• Complication
  – Obstruction
  – Infection
  – Kidney function
    Treatment of Ureteric
•
                 stone less than 5mm
    Observation : for stone
  except for :
    Infection
    Intractable pain
    Single kidney
    Transplant kidney
    Reduced kidney function
• MET
       Diuresis 2 liter/24 hours
       NSAID
       Alpha blocker
       Calcium Chanel Blocker
Treatment of Ureteric Stone
            Location          Treatment
 Proximal               ESWL
 < 1 cm                 URS lithotripsy
                        Ureterolithotomy
 > 1 cm                 Ureterolithotomy
                        ESWL
                        PcNL
                       URS + Lithotripsy
Treatment of Ureteric Stone
           Distal
  < 1 cm             URS + Lithotripsy
                     ESWL
                     Ureterolithotomi
  > 1 cm             URS – Lithotripsy
                     Ureterolithotomy
                     ESWL
         Bladder stone
            (adult)
 < 2 cm  lithotripsy
 > 2 cm  Endoscopic
            Holmium YAG
             Pneumatic
            Electrohidrolyc
            Ultrasound

   > 2 cm  Open surgery
Bladder stone in children
   • Open surgery
   • Percutaneous lithotripsy
    Urethral stone
• Holmium Laser
  (Endoscopy)
• Push back  bladder stone
          Sources
• IAUI                  Guidelines
  Penatalaksanaan
   penyakit batu saluran kemih,
  2007
• Pocket Guidelines EAU 2010
Benign Prostate
Hyperplasia:
Pathophysiology, Diagnosis &
Treatment


                  Djoko Rahardjo

               Department of Urology,
          Cipto Mangunkusumo Hospital/
     Faculty of Medicine University of Indonesia
               Overview

• Background


• Diagnosis


• Treatment


                          DR 2009
   Understanding the prostate




n Walnut-shaped gland that forms part of the male
  reproductive system
n Penetrated by the urethra


                                                    DR 2009
What is Benign Prostatic Hyperplasia?

                   Hyperplasia of the periureteral gland


                             Peripheral zone


                                Transition zone

                                         Urethra




                                                   DR 2009
Peripheral zone


   Transition zone

            Urethra




                      DR 2009
               Why Prostate enlarges?
Risk factors:
1. Aging
2. Functioning of the testicles (testosteron)




                                                             DR 2009

Prostate volume reduced by 20 – 30 % after 3 months of treatment
  What is the nature BPH?
BPH is part of the natural aging
process, like getting gray hair or
wearing glasses

BPH cannot be prevented


BPH can be treated

BPH not to develop becoming
Prostate Cancer

                                     DR 2009
    BPH


n Normal Size of the young adult is 15-20 cc.

•   Pathological process start at age 40 years
•   50% in men > 60 years*
•   90% in men > 85 years*
•   90% in men 50-80 years**
•   Second most frequent in urology in Indonesia

                    *AUA practice guidelines committee. J.Urol.2003,170   DR 2009
                   ** MSAM-7 Eur Urol. in press 2004
                BPH Symptoms

Voiding (obstructive)       Storage (irritative or
symptoms                    filling) symptoms
• Hesitancy                 • Urgency
• Weak stream               • Frequency
• Straining to pass urine   • Nocturia
• Prolonged micturition     • Urge incontinence
• Feeling of incomplete
  bladder emptying
• Urinary retention




                                                     DR 2009
               Overview

• Background


• Diagnosis


• Treatment


                          DR 2009
Anamnesis :
1. Keluhan utama
2. keluhan tambahan




                      DR 2009
Total IPSS
   • Mild: 0–7
   • Moderate: 8–19
   • Severe: 20–35


     Obstructive symptoms
     Irritative symptoms
PEMERIKSAAN FISIK
DRE (Digital Rectal Exam)/ pemeriksaan colok dubur




                                     Pemeriksaan fisik :
                                     colok dubur
                                            . Ukuran
                                            . Nodul
                                            . Konsistensi
                                            . Kelembutan




                                                            DR 2009
     Pemeriksaan penunjang lain
• Pemeriksaan PSA (Prostate Specific
  Antigen)
  untuk menyingkirkan dugaan menderita kanker
  prostat
  PSA merupakan suatu protein yang diproduksi
  oleh sel prostat dan seringkali pada kanker
  prostat levelnya meningkat

• Transrectal Ultrasonografi
  jika ada kecenderungan ke arah
  keganasan/ kanker prostat                DR 2009
PEMERIKSAAN PENUNJANG LAIN




                  IVP
                             Cystoscopy




   uroflowmetri                  DR 2009
TRUS



 Hypoechoic lession




                      DR 2009
Derajat BPH & Komplikasi




ringan   sedang     berat

                            DR 2009
               Overview

• Background


• Diagnosis


• Treatment


                          DR 2009
     BPH treatment choice
1.   Watchful waiting

2.   Medical treatment
     - Alpha blocker
     - Androgen suppression
     - Phytotherapy

3.   Surgery
                              DR 2009
        Treatment of BPH
• Watchfull Waiting
  – IPSS < 8
  – Residual urine < 50 cc
  – Q max > 15 cc/ sec
  – Prostate volume < 20 cc
     BPH treatment choice
1.   Watchful waiting

2.   Medical treatment
     - Alpha blocker
     - Androgen suppression
     - Phytotherapy

3.   Surgery
                              DR 2009
         Treatment of BPH
• Indication for medical treatment
  – IPSS > 8
  – Residual urine > 50 cc
  – Q max < 15 cc/ sec
                              Mekanisme kerja α-blockers

                     Nerve ending                                Menghambat alfa 1a
Causes prostatic
relaxation                                                       & 1d pada otot polos
                           Norepinephrine
                                                                 di uretra & prostat
                             (Blockade)
      Harnal


                   α1A α1A α1A    α1A α1A
      α1C    α1B
                                            α1A
α1D                    prostate                                  Relaksasi /
                                                                 menurunkan tekanan
                                                                 uretra d bagian
                                                                 prostat
                       Nerve ending




                              Norepinephrine                     Memperbaiki
       α1D     α1C    α1B α1B α1B α1B α1B         Blood Vessel   gangguan buang air
                     Blood Vessel

               (causes vascular contraction)      = α1B          kecil yg disebabkan
                                                                 oleh BPH          DR 2009
                       Type of Alpha adrenergic receptor




                                               1 dominant in prostate
                                               2 also in blood vessel
                                                    smooth muscle

Lepor E, Saphiro E. J Urol 1984; 132: 1226-9



 Non selective adrenergic blocking agent : blocks 1 and 2 receptors

                Selective adrenergic blocking agent : blocks only 1 receptor
                                                                                DR 2009
Types of  adrenergic blocking agent

          Type    Generic name
 Non selective    - Phenoxybenzamine
1 short acting   - Prazosin
                  - IR Alfuzosin
 1 long acting   - Doxazosin
                  - Terazosin
                  - SR Alfuzosin
                  - XL Alfuzosin
1a long acting   - Tamsulosin IR : Immediate release
                                   SR : Sustained release
   Half Life

       Substance           Half life (hours)
Prazosin (1979 Hedlund)       2–3
       Doxazosin (1995)       22
        Alfuzosin (1998)      3 – 4 (IR)
        Terazosin (1992)      12
     Tamsulosin (1998)        10 - 13
Dosage in Indonesia

• Doxazosin      1-2 mg once a day
• Terazosin      1-2 mg once a day
• Tamsulosin     0,2-0.4 mg once a day
• Alfuzosin XL   10 mg once a day
     BPH treatment choice
1.   Watchful waiting

2.   Medical treatment
     - Alpha blocker
     - Androgen suppression
     - Phytotherapy

3.   Surgery
                              DR 2009
     5  reductase inhibitor




                          5  reductase
                             inhibitor



Prostate volume reduced by 20 – 30 % after 3
months of treatment
                                               DR 2009
     5  reductase Inhibitor

• Finasteride : Iso enzyme type 2
• Dutasteride : Iso enzyme type 1 and 2




                                          DR 2009
• Proscar world wide efficacy and safety study
  (PRO WESS)
• Proscar long-term efficacy and safety study
  (PLESS)
     Proscar :
       • Q max
       • reducing prostate volume
       • reduce incidence of AUR
       • reduce surgical intervention



                    Mc Connell JD et al Engl J Med.1998; 338
                    Marberger MJ        Urol. 1998; 51
                    Roehrborn CG        Eur Urol. 2000; 37     DR 2009
Dutasteride
Dosage 0,5 mg/day

 Symptom Score
 Q max
 Prostate vol
 Incidence of AUR
    Better than finasteride

          Roehrborn DG et al. Urology 2002; 60(3)   DR 2009
          O Leary MP et al. BJU Int 2003; 92
  Side effect of Finasteride
• Reduces libido
• ED
• Reduced ejaculate
• Lowering PSA  should be doubled to
  detect CaP



      MC Connel JD et al. Engl J Med. 1998; 338
                                                              DR 2009
      Kirby RS. Proceeding of AUA 99 th Annual Meeting 2004
           TRIPLE THERAPY

• Since the incidence of overactive bladder in
  BPH patients is about 70 %, anti Muscarinic
  drugs should be considered as an adjuvant
  treatment

• Since nocturia may cause worsening of the
  QOL Anti Muscarinic drug will improve the
  condition

• Pressure flow study will give a better
  indication for triple therapy               DR 2009
Urodynamic of male 70 years old with LUTS




                                            DR 2009
     BPH treatment choice
1.   Watchful waiting

2.   Medical treatment
     - Alpha blocker
     - Androgen suppression
     - Phytotherapy

3.   Surgery
                              DR 2009
 Phytotherapy
Species                  Generic name
  –   Serenoa repens     – Saw palmetto berry
  –   Hypoxis rooperi    – South African star
  –   Pygeum africanum     grass
  –   Urtica dioica      – African plum tree
  –   Secale cereale     – Stinging nettle
  –   Cucurbita pepo     – Rye pollen
  –   Countia            – Pumpkin seed
  –   Pinus              – Cactus flower
  –   Picea              – Pine flower
                         – Spruce
                                                DR 2009
  Mechanism of action of
     Phythotherapy
• Anti inflammation through
  prostaglandin metabolism
• 5 reductase inhibitor
• Inhibition of growth factors production
  (FGF, EGF)


          Lepor H, Leuwe. Campbells Urology, 8 th ed 2002   DR 2009
     BPH treatment choice
1.    Watchful waiting

2.    Medical treatment
     - Alpha blocker
     - Androgen suppression
     - Phytotherapy

3.   Surgery
                              DR 2009
  Absolute indication for
         Surgery
Chronic urinary retention
Gross hematuria
Complicated UTI
Bladder stone
Decrease renal function
Large diverticula
Failure of medical treatment (Relative)
Intravesical protrusion of the prostate > 1.5 cc
 (?)                                          DR 2009
       Open Surgery
• Masih dikerjakan pada volume
  Prostat yang besar (> 80 cc),
  atau belum ada spesialis Urologi
• Memerlukan anastesi
• Perawatan YANG LEBIH LAMA
• Kadang perlu Transfusi darah
• Ada bekas sayatan
ENDOSCOPIC SURGERY

     • TURP
     • TUIP
0THER ENDOSCOPIC
    SURGERY
  • Trans Urethral Enucleation
  • Laser Treatment of the
    Prostate
       Holmium Yag Enucleation
       Holmium Yag Resection
       Green Laser
       KTP Laser
  Conclusion
• BPH patients should be stratified according to
  symptoms score, maximal flow rate, residual
  volume and prostate volume
• Medical treatment should be tailored
  according to the above stratification
• One should remember that the placebo effect
  is there
• Invasive and less invasive treatment should
  be with very strict indication
                                              DR 2009
TERIMA KASIH



               DR 2010

				
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