striktur urethra baru
DESCRIPTION
BedaTRANSCRIPT
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SABTU, 29 DESEMBER 2012
STRIKTUR URETHRA
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ANATOMI URETRA
• Urethra dimulai dari leher buli-buli sampai meatus uretra eksterna
• Panjang :sekitar 20 cm pada priasekitar 4 cm pada wanita
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A. Melalui uretra pars bulbosaB. Melalui uretra pars pendulosaC. Melalui uretra pada bagian koronal penisD. Melalui fossa navicularis
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ANATOMI URETRA PRIA
• Dibagi 2 :A. Anterior :
pars bulbosa pars pendulosa 15 cmfossa naviculare : 2.5 cm
B. Posterior :pars prostatica : 3 cmpars membranacea : 2 cm
• Epitel pelapis uretra anterior : epitel skuamousuretra posterior : epitel transisional
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• Striktur uretra adalah penyempitan lumen uretra karena fibrosis pada dindingnya
• Penyempitan atau penyumbatan dari lumen uretra sebagai akibat dari pembentukan jaringan fibrotik (jaringan parut) pada uretra dan / atau pada daerah peri uretra
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PENYEBAB
• Infeksi :uretritis GOinfeksi ikutan akibat kateter indwelling
• Trauma :iatrogenik :
kateterisasikaliberasireseksi transuretratindakan-tindakan endourogi lain
eksterna :patah tulang panggulstraddle injury
• Kongenital/keganasan
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STRADDLE INJURY
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PATAH TULANG PANGGUL
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PATOGENESA
Infeksi
Trauma
Lesi epitel uretraputusnya kontinuitas uretra
Proses keradanganReaksi Fibrosis / kolagen
Jaringan fibrotik
Penyempitan lumen uretra
Penyumbatan lumen uretra
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JENIS STRIKTUR URETRA
A. Lipatan mukosa / mucosal foldB. Kontriksi iris / iris constriktionC. Fibrosis minimalD. SpongiofibrosisE. Inflamasi dan fibrosis sampai jaringan corpus spongiosumF. Striktur dengan komplikasi fistel. Dapat terbentuk abses, fistel kearah kulit dan rektum
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GEJALA KLINIS
• Kesukaran kencing (hesitansi)• Harus mengejan• Nyeri saat miksi (disuria)• Pancaran melemah (weak flow)• Pancaran bercabang• Menetes sampai retensi urine• Pembengkakan / nanah di perineum• Kadang bercak darah di celana dalam (hematuria)• Bila sistemik : febris, warna urine keruh
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GEJALA KLINIS
• Waktu miksi lama• Double voiding• Terminal dribling• Kencing tidak puas karena masih ada sisa kencing
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PEMERIKSAAN DAN DIAGNOSIS
• Anamnesa :uretritis, trauma dg kerusakan pada panggul, straddle injury, instrumentasi uretra, pemakaian kateter, kelainan sejak lahir
• Inspeksi :meatus eksternus yang sempit, pembengkakan serta fistel di daerah penis, skrotum, perineum, suprapubik
• Palpasi :teraba jaringan parut sepanjang perjalanan uretra anterior pada ventral penis; muara fistel mengeluarkan nanah bila dipijat
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PEMERIKSAAN FISIK
• Colok dubur• Palpasi uretra : indurasi (+) • Distensi pada Vesica Urinaria• Kalibrasi dengan kateter lunak akan ditemukan
hambatan• Kepastian diagnosa :
uretrografiuretroskopi
• Bila sudah sistostomi bipolar uretro-sistografi• Kadang terdapat fistula uretrokutan
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PEMERIKSAAN FISIK
1. Kalibrasi dengan kateter no 16 tak dapat masuk ke buli, tertahan di tempat striktur
2. Ukur panjang kateter yang dapat masuk3. X foto :
- uretrogram retrograd - Bipoler uretro sistogram
5. Endourologi : Uretroskopi
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PEMERIKSAAN FISIK
• Dapat ditunjang uroflowmetri• Pada kasus-kasus individual tertentu : dapat
dilakukan FPA-IVP, USG(pada striktur yang lama, dapat terjadi perubahan sekunder pada kelenjar prostat; batu, perkapuran, abses prostat, epididimitis, fibrosis epididimis
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SYMPTOMS
Urethral strictureHesitancy in starting urinationLessened force and size of the stream, Terminal dribblingHematuriaCloudy urine (infection)Occasionally acute urinary retention.
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SIGNS
Normal urine flow rate : 20–25 mL/s (male)25–30 mL/s (female)
Flow rate < 15 mL/s suspicion Flow rate < 10 mL/s obstruction or weak
detrusor functionFlow rate 3–5 mL/s
atonic neurogenic (neuropathic) bladder
urethral stricture or prostatic obstruction
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PEMERIKSAAN PENUNJANG
Pemeriksaan LaboratoriumAnemia :
- chronic infection - uremia advanced bilateral
hydronephrosisLeukocytosis : acute infectionMicroscopic hematuria : infection or stonePus cells and bacteria
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PEMERIKSAAN PENUNJANG
RadiologiA plain film of the abdomen Retrograde urethrocystography Sonography
INSTRUMENTAL EXAMINATIONCatheterCystoscopy and panendoscopy
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URETROGRAFI
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DIAGNOSIS BANDING
• Disfungsi leher buli• Hipersensitif dari buli• Overaktif buli• Striktur uretra• Kontraktilitas yang rendah dari destrusor.
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PENATALAKSANAAN
• Tergantung :lokalisasipanjang / pendeknya strikturkeadaan darurat : retensio urine
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Clinical Outcome and Quality of Life Assessment in Patients Treated With Perineal Urethrostomy for Anterior Urethral Stricture Disease Guido Barbaglia, Michele De Angelisb, Giuseppe Romanob, Massimo Lazzeric, ,
http://www.sciencedirect.com/science/article/pii/S0022534709008970#
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URETHRAL DILATION
• Periodic Urethral Dilation• Tujuannya adalah meregangkan jaringan parut
tanpa mebimbulkan jaringan parut tambahan.• Dapat sebagai terapi kuratif pada pasien dengan
striktur terbatas pada epitel, tidak ada keterlibatan korpus spongiosum.
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INTERNAL URETHROTOMY
• incising the stricture transurethrally using endoscopic equipment.
• The incision allows for release of scar tissue. • Success depends on the epithelialization process
finishing before wound contraction significantly reduces the urethral lumen caliber.
• The incision is made under direct vision at the 12 o'clock position,
• Complications • Recurrence of stricture, which is the most common
complication, • bleeding, or extravasation of irrigation fluid into perispongial
tissues, thus increasing the fibrotic response.
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PERMANENT URETHRAL STENTS
• Permanent urethral stents are placed endoscopically.
• Most successful in short-length strictures in the bulbous urethra.
• Complications occur when a stent is placed distal to the bulbous urethra, causing pain while sitting or during intercourse. Other complications involve migration of the stent.
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URETHROPLASTY
Pemilihan tehnik tergantung dari faktor – faktor yaitu :• Panjang dan lokasi dari striktur. • Riwayat operasi sebelumnya dan derajat dari
scarnya.• kondisi dari uretranya.• Partial atau total stenosis• tersedianya jaringan tissue untuk melakukan
graft atau pedikel flaps.
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OPEN RECONSTRUCTION
Primary repair
• Primary repair involves complete excision of the fibrotic urethral segment with reanastomosis.
• Complete excision of the area of fibrosis, tension-free anastomosis, and widely patent anastomosis.
• Primary repair is typically used for stricture lengths of 1-2 cm.
• Morey et al (2004) reported on a series of patients who underwent excision with anastomosis for strictures up to 5 cm.[5]Younger patients have more compliant tissue, thus allowing for greater stretch and more ambitious attempts at primary repair. The repair is left stented with a small silicone catheter in the urethra. The bladder is drained with a suprapubic catheter.
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TISSUE-TRANSFER TECHNIQUES
• Success depends on the blood supply of local tissues at the site of placement.
• The urethra is exposed through a penile or perineal incision.
• The urethrotomy is made to open the area of the stricture. The tissue graft is harvested from the desired non–hair-bearing location. For example, bladder, buccal, or rectal mucosa are potential options.
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• Full-thickness skin graft: Non–hair-bearing skin should be used. It is most successful in the area of the bulbar urethra.
• Split-thickness skin graft: The split-thickness skin graft is not preferred with a single-stage repair because of the contraction characteristics of the graft. • It is typically reserved for use in patients for whom
multiple procedures have failed and in whom local skin is insufficient for further reconstruction. It is conducted as a 2-stage procedure.
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Mukosa bukal sebagai graft • Dari bagian dalam
pipi• Bukan dari bibir
bagian bawah
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URETHROPLASTY, DUA TAHAP DENGAN MUKOSA BUCCAL
Semua jaringan scar diambil, graft menggunakan mukosa bukal
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End-to-end urethroplasty: 1. Ruptur uretra komplit 2.Striktur yang pendek pada pars bulbosa/membranacea
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Free graft sebagai patch :1. ventral2. dorsal
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INTERNAL URETHROTOMY, BLIND (OTIS)
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DIRECT VISION INTERNAL URETHROTOMY DVIU
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PATIENT AND METHODE
• Studi retrospektif dan video urodynamic mengidentifikasi wanita dengan striktur uretra antara 1999 dan 2004 pada satu institusi oleh seorang ahli bedah.
• Striktur uretra pada wanita didefinisikan sebagai penyempitan anatomis yang tetap antara bladder neck dan uretra distal dengan gagal masuknya kateter 14 F, dan diagnosis dikonfirmasi dengan sistouretroskopi dan atau urodinamik.
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• Wanita dengan riwayat radioterapi eksternal pada area pelvis karena keganasan uretra dan buli (dibuktikan dengan hasil biopsi) dieksklusikan.
• Sistoskopi inisial dilakukan dilatasi uretra dengan sonde sampai dengan ≥ 30 F biopsi uretra.
• Dipasang kateter dan dilepas setelah 7 hari
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• Setelah periode kateterisasi, dilakukan clean intermittent self-catheterization (CISC) setidaknya sekali sehari dan dimonitor setiap 3-6 bulan.
• Pada tiap follow up uretra dikateterisasi untuk mengeksklusikan rekurensi.
• American Urological Association (AUA) symptom score pada bulan pertama dan 3 bulan pertama follow up.
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RESULT
• 7 wanita ditemukan dengan dx strikture uretra, dilakukan follow up selama rata-rata 21 bulan (6-34) bulan.
• Dilakukan CISC setiap hari beberapa dikurangi secara bertahap menjadi tiap minggu.
• Tidak ada pasien yang mengalami rekurensi dan tidak ada seorang pun yang memerlukan rekonstruksi uretra.
• AUA symtomp score berkurang menjadi rata-rata 10,1.• Tidak ditemukan komplikasi akibat kateterisasi.
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CONCLUSION
• Striktur uretra pada wanita sangat jarang terjadi dan efektif dilakukan CISC dan dapat mencegah rekonstruksi uretra.
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TERIMA KASIH