Trauma, Malignancy, Congenital

Abnormalities of Urogenital System

Karunia Valeriani Japar
FK UPH 2014
HEMATURIA
 Tergantung Lokasi
• Spt air cucian daging  biasanya dari bladder/
urethra
• Dysmorphic red cell  GN
• Muddy brown cast / tubular  Tubule defect
• Clotting  above bladder
MALIGNANCY
 Bladder Cancer
• Etiology
a) Rokok
b) Petrolium product
c) Infeksi oleh schistosoma haematobium
d) Cyclophosphamide
e) High Vitamin A consumption
f) Bladder Diverticula
 Pembagian
• Transitional Cell Carcinoma
1. High grade cancer (stadium 3 dan 4)
- lebih sering
- Biasanya karena Tp 53 dan Rb gene
- dari basement membrane akan invasi ke detrussor
muscle dan akan metastasis
2. Low grade cancer (stadium 1 dan 2)  biasanya krna FGF dan
tyrosine kinase)

• Squamous Cell Carcinoma

- berasal dari bladder urothelium
- no distant metastasis
- agresif

• Rare form (adenocarcinoma, rhabdosarcoma, small cell carcinoma)

 Manifestasi Klinis
• Painless gross hematuria
• Red flag sign of malignancy
• Flank and bony pain (menandakan metastasis)
• Lower extremity edema (obstruksi v.iliaca)
• Irritative LUTS
 Diagnosis
• Biopsy  GOLD STANDART dengan cystoscopy
• CT scan with contrast ( jgn lupa cek ureum
creatinine sblmnya)
• Urinalysis
Staging
 Staging
• Stage 4a  invasi seminal vesicle dan uterus
• Stage 4b  invasi pelvic wall dan abdominal
wall
• N1  invade regional lymph Node
• M1  metastasis
 Treatment
• Low grade BTA  Transurethral Resection of
Bladder Tumor (TURBT)+ Intravesical therapy
(kasih vaksin BCG)

• High grade  radical cystoprostatectomy +

chemo/ radio (cisplatin)
RENAL CELL CARCINOMA
 Etiology
• Merokok
• Obesity
• Hypertension
• Long term use of NSAIDs
• Renal cystic disease
 Pathophysiology
• Terjadi kerusakan chromosome 3
• Yang mempengaruhi chr 3:
a) VHL (von hippel lindau disease) 
tumorsupressor
b) TSC (Tuberculous sclerosing complex) 
tumor supressor
c) MET  oncogene
 Jenis
• Clear cell (60%)
kena di TKP
• Papillary tumor (5-15%)
kena di TKP
• Chromophobe tumor (5-10%)
kena di DCT dan CD
• Oncocytic (5-10%)
kena di Cortex CD
• Collecting tubule dan bellini (<1%)
kena di medulla CD
 Manifestasi Klinis
• Hematuria (plum colour)
• Abdominal pain/ flank pain
• Abdominal mass
• Red flag sign of malignancy
• Varicocele
 Diagnosis
• Biopsy
• CT can uro/ renal
• Rontgen Thorax  coin lesion
• urinalysis
Staging
 Treatment
• Grad 1 & 2  radical nephrectomy
• Grade 3 & 4  cytokine therapy (IL 2), anti
VEGF
NEPHROBLASTOMA/ WILM’S
TUMOR
• Cancer of kidney that affects children under 5
y.o
• Mutation of WT 1 gene
• Associated with WAGR syndrome (wilm’s
tumor, aniridia, gonadoblastoma, mental
retardation) dan deny-drash syndrome (renal
failure, abigious genitalia dan wilm’s tumor)
• POKOKNYA ANAK KECIL PERUT MEMBESAR
SECARA PROGRESIF
PROSTATE CANCER
Staging
 Treatment
• Radical Prstatectomy
• Radiation therapy
• External beam radiation therapy
• Brachytherapy
• Antiandrogen
TRAUMA
 Proteksi Ginjal
– Otot lumbar, vertebral bodies, ribs, viscera lain di
anterior
– Fraktur ribs dan prosesus transversus vertebra
dapat menciderai parenkim ginjal
– Sering pada kecelakaan mobil dan olahraga
– Sering pada laki-laki
– Ginjal dengan kondisi seperti hidronefrosis atau
keganasan rentan terhadap trauma ringan
 Trauma Ginjal
• Luka tusuk/ tembak
• Luka tumpul
• Iatrogenic dari operasi
• Trauma pedikel
Grading
» Grade 1 (the most common)—Renal contusion or bruising of
the renal parenchyma. Microscopic hematuria is common,
but gross hematuria rarely occurs.
» Grade 2—Renal parenchymal laceration into the renal
cortex. Perirenal hematoma is usually small.
» Grade 3—Renal parenchymal laceration extending through
the cortex and into the renal medulla. Bleeding can be
significant in the presence of large retroperitoneal
hematoma.
» Grade 4—Renal parenchymal laceration (single or multiple)
extending into the renal collecting system; also main renal
artery thrombosis from blunt trauma, segmental renal vein,
or both; or artery injury with contained bleeding.
» Grade 5—Multiple Grade 4 parenchymal lacerations, renal
pedicle avulsion, or both; main renal vein or artery injury
from penetrating trauma; main renal artery or vein
thrombosis.
 Klinis
– Nyeri: lokal flank atau di seluruh abdomen
– Kateterisasi dapat melihat adanya hematuria
– Retoperitoneal bleeding menyebabkan distensi abdomen, ileus,nusea
dan vomiting
– Shock: large blood loos bisa karena heavy retroperitoneal bleeding
– Echimosis di flank / upper quadrants abdomen
– Difuse abdominal tendernes karena acute abdomen menandakan
darah di peritoneal cavity
– Palpable mass: large retroperitoneal hematoma / urinary extravasation
– Distended abdomen,
 Pemeriksaan Penunjang
• CT scan with contrast
• Urogram buat luka tumpul, klo ga keliatan
boleh pake arteriography
 Late Findings
– Urinoma
» persistent urinary extravasation and late complications of
a large perinephric renal mass and, eventually,
hydronephrosis and abscess formation.
– Hydronephrosis
» Large hematomas in the retroperitoneum and associated
urinary extravasation may result in perinephric fibrosis
engulfing the ureteropelvic junction, causing
hydronephrosis
– Arterio venous vistula
» Karena penetrating injury, tapi jarang
– Renal vascula hypertension
» Karena penurunan aliran darah ke ginjal
 Treament
• Resusitasi
• Supportive
• Surgery
 Bladder Injury
• Paling sering gara2 pelvic fracture
• Ato ga iatrogenic pas lagi operasi bladder/
gynecology
 Klinis
• Heavy bleading karena fraktur pelvis dapat
menyebabkan perdarahan dan syok
• Venous disruption of pelvic vessels
• Tenderness suprapubic dan lower abdomen
• Akut abdomen menandakan intraperitoneal rupture
• Rectal examination: batas tidak jelas karena large pelvic
hematoma
• # Grade 1 : Hematoma : kontusio, hematoma intramural
• Laserasi : tidak mengenai seluruh ketebalan dinding
• # Grade 2 : Laserasi : Laserasi ekstraperitoneal < 2 cm.
• # Grade 3 : Laserasi : Laserasi ekstraperitoneal 2 cm atau
• intraperitoneal < 2 cm.
• # Grade 4 : Laserasi : Laserasi intraperitoneal 2 cm.
• # Grade 5 : Laserasi : Laserasi ekstraperitoneal atau
intraperitoneal
• yang mengenai bladder neck atau muara
• ureter
 Penunjang
• CT scan
• Cystography
• Urinalysis for hematuria

• Nanti kalo ga ada ekstravasasi urine yang

terlihat di imaging  pear shape/ teardrop
shape
 Treatment
• Supportive
• Surgery
 Posterior Urethra Injury
a) Bagian tersering injury: membranous urethra
b) Klinis :
- Blood at the urethral meatus Suprapubic
tenderness jika ada pelvic fracture
- A large developing pelvic hematoma may be
palpated
- Rectal examination may reveal a large pelvic
hematoma with the prostate displaced
superiorly (floating prostate)
 Anterior Urethra Injury
• Etiology
– Straddle injury may cause laceration or contusion
of the urethra.
– Self-instrumentation or iatrogenic instrumentation
may cause partial disruption.
• It is limited only by Colles' fascia
• BUTTERFLY HEMATOMA
• Pasien mengeluh ada meatal bleeding
Diagnosis Treatment
• Urethrogram • Supportive : resusitasi dll
• CT uro • Surgery
• Xray of pelvic for pelvic
fracture
• Urinalysis
 Komplikasi Urethral Injury

• striktur (perlu dilatasi berkala)

• disfungsi ereksi
• inkontinensia
CONGENITAL ANOMALY
 Potter Syndrome
• Cardiovascular malformations
• Skeletal malformations
• Ophthalmologic malformation
• Features of Eagle-Barrett (prune belly) :deficient
abdominal wall, undescended testes, dilated
ureters, and a renal pelvis
• Pulmonary hypoplasia
• Potter facies: Affected infants have a flattened
nose, recessed chin, prominent epicanthal folds,
and low-set abnormal ears.
 Cryptorchid / undescended testis
• Most common genital abnormalities
• Etiology:
a) Family history
b) Disrupsi testosterone dan DHEA
c) Unattach gubernaculum = menahan testis
dan scrotum bersama
d) Menurunnya intraabdominal pressure
e) Premature
 Klinis
• Bisa terpalpasi
• Non palpable testis
• Infertilitas kalau ga diobati
 Diagnosis
• Cek testosterone, LH, FSH, GnRH
Diagnosis Treatment
• Cek testosterone • Surgery setelah 1 taun
• LH • testosterone
• FSH
• GnRH
 Hypospadia
• Congenital defect pada kehamilan week 8-20
• Tidak menutupnya genital tubercle
• Pembagian
a) Anterior
b) Middle
c) Posterior
• Klinis:
a) Urethral meatus di ventral penis
b) Chordae (bengkok)
 Varicocele
• Sumbatan pada plexus pampiniform
• Biasanya di sebelah kiri karena drainase ke
v.renalis
• Gejala
a) Infertilitas
b) Scrotal pain
c) Bengkak
d) Abnormal sperm quality
Diagnosis Treatment
• Transiluminasi test • Surgery
negative untuk hydrocele
(positive untuk hydrocele)
 Hydrocele
• Biasanya asymptomatic
• Disebabkan oleh persistent processus vaginalis
• Resiko: lahir sungsang/ BBLR
• Types:
a) Communicable (di anak2)
b) Non communicable (dewasa karena filariasis)
• Treatment: surgery klo symptomatic