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Thursday, 16 August 2012

Tehnology Urology CURRENT AFFAIRS / TEHNOLOGI DIBIDANG BEDAH UROLOGI TERKINI


CHAPTER I
INTRODUCTION

Surgery or operation is a treatment that uses all of the follow-invasive way to open or show the body parts that will be addressed. The opening of the body is generally done by making an incision. Once the parts to be handled is displayed, do the corrective action concludes with the closing and sewing.
Urology is the branch of medicine which studies disorders of the urinary tract and genital male and female urinary tract.
In penetalaksanaan urinary tract and genital abnormalities, science and medical aspects of urology explore aspects of the operative.
Some communities do not yet know or are unfamiliar with the doctor of urology (urologist), although these cases are very much urology.
Most of us probably have a complaint:
• urinate so frequently, straining to urinate and not lampias, or dripping at the end of micturition.
• The pain of colic with reddish or bloody urine, pain while urinating
• Urine is cloudy, or had urinary sandy or rocky.
• Frequent urinating or incontinence.
• There is a congenital malformation of the genitals, such as the testes are not one or both sides, the mouth of the urethra is not at the end of the genitalia (hypospadia).
• Abnormalities of erection / erectile dysfunction in a group of sexual dysfunction
• Abnormalities of fertility or infertility in men
The foregoing are some examples of complaints or disorders related to urology. Medical aspects of the intended management of urology urology kelaianan done a preventive or treatment (Medical) that is not surgery, whereas the operative aspects include the start of surgery that is not invasive to the action that is very invasive.
For example: a man in the diagnosis of kidney stones with a stone the size of a small (<0.5 mm) and found no signs of blockage in the radiological treatment may be recommended ekspektatif the waiting for 2 weeks with lots of drinking and exercises, whereas if the rock is quite there may be many choices of action can be started with no or less invasive, such as ESWL (extra-corporal shock wave lithotripsy), PCNL, URS with litotriptor / special stone-breaking or using a laser. Action is the most invasive open surgery.












CHAPTER II
DISCUSSION

I.  Urology
Urology is a surgical specialty that focuses on the urinary tract of men and women, and the male reproductive system. Medical professionals who specialize in the field of urology are called urologists and are trained to diagnose, treat, and manage patients with urological disorders. Included in the urologic organs including the kidney, ureter, bladder, urethra, and male reproductive organs (testis, epididymis, vas deferens, seminal vesicles, prostate and penis).
In men, urinary tract system overlaps with the reproductive system and urinary tract in women unrelated to the reproductive tract. Urology combines management of medical (non-surgical) problems such as infections in the urinary tract and benign prostatic hyperplasia, as well as the management of surgical problems such as cancer surgery, congenital abnormalities, and incontinence due to stress.
Urology is interconnected and in some cases overlapping with, the field of medical oncology, nephrology, gynecology, andrology, pediatric surgery, gastroenterology, and endocrinology.
As a discipline that involves many organs and physiological systems, urology can be broken down into subfields. In the larger centers and especially university hospitals, many urologists sub-specialize in a particular field of urology.
II. LINE SYSTEM MALE urinary and genital
A. KIDNEY

Figure 1: The anatomy of the urinary system
The kidneys are located in the upper abdominal cavity on either side of the Columna vertebral column, behind the peritoneum (retroperitoneal). The top of the kidneys are located on the bottom surface of the diaphragm and covered and protected by the lower ribs. Renal adipose tissue attached to the kidney is useful as a bearing and also enveloped by a membrane of fibrous connective tissue called fascia that helps kidney renal remain in place.
Each kidney has a notch called the hilum on the medial. At the hilum, the renal artery, renal vein into the renal hilum is also the exit ureter. Renal artery is a branch of the abdominal aorta and the renal vein is where the return of blood to the inferior vena cava. Ureters carry urine from the kidneys to the bladder overdo.

2. INTERNAL STRUCTURE OF THE KIDNEY
In the coronal and frontal piece of the kidney, there are three areas that can be distinguished. Lateral and central areas of the network layer, whereas the medial part of the hilum is the cavity. The outermost layer is called the renal cortex, which comprises part of the kidney blood vessels and renal tubules are tortuous. Tissue called the renal inner medulla, which consists of loops of Henle and collecting tubules. In the renal medulla contained a cone-like shape called the renal pyramids. The tip of the pyramid called the apex or papilla.
The third area is the renal pelvis; this section is not the network layer, but rather the cavity formed by the expansion of the ureter within the kidney at the hilum. Chimney forms an extension of the renal pelvis called the calyx, renal papillae surrounding the pyramid. Urine flow from the renal pyramids into the calyx, then into the ureter and renal pelvis.

3. Nephron
Nephron is the structural and functional unit of the kidney. Each kidney has about 1 million nephrons in it. Nephrons associated with blood vessels, that is where urine is formed. Each nephron has two major parts: the corpuscle and the tubular. Each part is divided into several subdivisions.
4. Renal corpuscle
Renal corpuscle comprises a glomerulus surrounded by Bowman's capsule. Glomerulus is a network of capillaries that arise from the afferent arterioles and efferent arterioles ending in. Diameter of efferent arterioles smaller than the afferent arterioles, which helps keep blood pressure in the glomerulus evenly.
Bowman's capsule (glomerular capsule) is stretched and ended up in the tubules; Bowman's capsule surrounds the glomerulus. The inner layer of Bowman's capsula podosit made of cells, which means the foot cell, and the foot is on the surface podosit of the glomerular capillary. Combination of podosit form pores, which makes this part a semipermeable. Outer layer of Bowman's capsule does not have pores and are not permeable. The distance between the inner and outer layers of the renal filtrate contains Bowman's capsule, a liquid formed from the blood passing through the glomerulus which will turn into the urine.

5. The renal tubules
Is a continuation of the renal tubules and Bowman's capsula consists of the following parts: tubular proximalis contortus (the cortex), the loop of Henle (in bagien medulla), and distal convoluted tubules (in the cortex). Distal part of some convoluted tubules which end up in disposal colektivus. Beberara collecting ducts unite to form the papillary dukktus passing urine into the calix.
Cross section of the renal tubules, how thin the walls of the convoluted tubules proximalis. Anatomic characteristics of the support material exchange efficiency, as you can see.
All parts of the renal tubules surrounded by peritubulari capilary, which emerged from the arterioles efferen. Peritubulari capilary direabsorbsi will receive the material by the renal tubules; this explains how the urine can be formed.
6. Renal vascular
Track blood flow through the kidney is a very important part of the formation of urine. Blood from the abdominal aorta into the renal artery, which extends into the kidney into small arteries. The smallest part of the artery appeared to be the afferent arterioles in renal cortex. Of afferent arteriolar blood flow into glomeruli and efferent arterioles to, proceed to peritubulari capillaries, into the vein in the kidney, and went out into the renal vein, and finally end up into the inferior vena cava.
7. Ureter
Each ureter extends from the hilum of the kidney to the bottom rear of the vesica urinary. Such as the kidney, ureter is located in the retroperitoneum. (Behind the peritoneum) in the dorsal abdominal cavity.
Wall of the ureter smooth muscle to contract to push urine periodically to vesica urinary (bladder). Ureter will suppress the lower end to prevent any backflow.

8. VESICA urinary
Vesica urinary muscle is a bag that is under the peritoneal cavity and adjacent to the pubic bone. In women, the vesica in the inferior part of the uterus; in men in the superior part of the prostate gland. Vesica urinary worked as a reservoir of accumulated urine, and contract to dispose of urine.
Part of vesica urinary mucosa is transitional epithelium cells, which can expand without damaging the wall of his self. Vesica on the ground floor there is a triangular area called the trigone, which does not have the rugae as in other parts and can not expand itself. At the corners of the trigone there is a hole, the entrance and the exit of the ureter into the urethra.
Vesica urinary having a typical muscle on his wall, it is the musculus detrusor muscle. These muscles are the muscles that form a ball, when he contracted would be a smaller ball, then the volume will be reduced. Around the exit of the urethra (urethral internal spincter) are formed by an involuntary detrusor muscle fibers.

Figure 2: urinary vesicles
9. The urethra
Carry urine from the urethra to the outside of the urinary vesica. External urethral spincter formed from skeletal muscle of the circular on the bottom floor of the pelvis bone, is under voluntary arrangements, so that we can stop urinating.
Length of the urethra in women is 2.5 to 4 cm and the exit is located in the vagina. In the long male urethra 17 to 20 cm. The initial part of the urethra called the prostatic urethra because of the pars is surrounded by the prostate gland. The next section is called the membranous urethra is the external portion of spincter. The longest part of the urethra called the pars cavernosa (also called spongiosa or penile), this section passes through the tissue cavernosa (erectile) organ penis. Urethra as the semen out as urine.
III. SYSTEM DISORDERS Urology
STONE TRACT
Stones of the urinary tract along the kidney, ureter, bladder and urethra. Symptoms of urinary tract stone disease, among others
low back pain radiating to the front of the abdomen or groin, sometimes with reddish colored urine, or pain at the end of micturition.
A person may suffer from urinary tract stone disease if there is a supporting factor is lack of drinking so that the concentration of stone forming substances in the urine becomes more concentrated, resulting in easy to form stones.
• Factors other causes:
A. Family history of suffering from urinary tract stones.
2. Eating foods that contain lots of calcium or oxalate in excess (chocolate, nuts, soft drinks, tea in the portion of excess).
3. Gout (elevated blood uric acid levels).
4. Had suffered from frequent urinary tract stones or urinary tract infection.
5. Urinary tract obstruction.
Conservative treatment (Watchful Therapy)
Your doctor will recommend conservative treatment only in cases of stones smaller than 4 mm and no other complications. Expected to be out on his own stone through the urinary tract by drinking plenty of water and facilitating drug urination.
BPH (benign prostate hyperplasia)
An enlarged prostate gland (gland that exists only at the bladder neck men) that normally occurs in men aged 50 years or more. Enlargement causes urinary tract obstruction so that urine flow is not smooth or even be unable to urinate at all. At the age of 40s, a man has the possibility of BPH by 25%. The age of 60-70 years, likely to be 50%, and at the age above 70 years the risk will grow to 90%.
Cause
BPH arises because of the influence of hormonal balance, the hormone androgen and estrogen in men.
Symptom
The location of the prostate gland is behind the urinary tract, in the event of the enlargement of this gland can cause the symptoms of urinary obstruction and irritation known as the Lower UrinaryTtract Syndrome (LUTS). Symptoms may include urinary blockage is faltering, not lampias after urination, weak urination beam, and must be managed before straining to urinate. Irritation symptoms may include frequent urination and the urge to urinate is intolerable.
If not immediately treated BPH can be progressive (more severe). The existence of the remaining urine in the bladder can cause retention of bacteria that can ultimately lead to urinary tract infections. If this situation lasts a long time can cause the risk of kidney failure.
Examination of Early Detection of BPH
• Plug the rectum to feel if we enlarged prostate or not.
• Laboratory tests of blood and urine to see if there is infection. To view the kidney function, may be examined levels of urea, creatinine, and blood electrolytes.
• Examination SpecificAantigen Prostate (PSA) for prostate cancer risk early deteski. Men with enlarged prostate may have elevated levels of PSA.
• ultrasonography (USG) Transabdominal (through the abdominal wall) or transrectal (through the anus) to determine the size of the prostate.
• Examination of x-ray photo BNO IVP to see how much blockage happens.
• Biopsy (tissue sampling) of the prostate gland in patients with a significant increase in PSA levels.

Urologic symptoms
Urinary system consists of kidneys, ureter, bladder, and urethra. Key elements in the renal system, a pair of fist-sized organ located below the ribs toward the middle of the back. The kidneys remove excess fluid and waste from the blood in the urine. The kidneys maintain a stable balance of salts and other substances in the blood, and produces a hormone that helps to form red blood cells. Urether carry urine from the kidneys to the bladder, which is located in the lower abdomen. Urine is stored in the bladder and emptied through a narrow canal called the urethra.
As part of the urinary system is not functioning properly, the symptoms can vary dramatically. Symptoms can be mild, moderate or severe, they can exist or not exist. But remember, if the symptoms come and go does not mean disorder or disease disappear. Some of the signs and symptoms that are characteristic of urology such as bladder cancer, kidney cancer, prostate cancer or urinary tract obstruction among others:
• Blood in the urine or semen
• A lump in the abdomen
• Weight loss is a sudden drop and loss of appetite
• Pain in the hip or lower back
• Changes in urination (inability, frequency, pain, less output, incontinence)
• BAK is not smooth and was not satisfied when BAK
• feeling the bladder even after urinating feels peuh
• Difficulty starting urination

IV. TYPES OF MEDICAL TECHNOLOGY SECTOR Urology
A. Endourology is the branch of urology associated with minimally invasive surgical procedures. Endourology performed using a tiny camera and instruments inserted into the urinary tract. Traditionally, transurethral surgery has become the cornerstone endourology. Through the urethra, the entire urinary tract can be seen, enabling prostate surgery, tumor surgery in the urothelium, stone surgery, and simple operations on the urinary tract.
2. Shock Wave Lithotripsy (SWL)
SWL is widely used in the treatment of urinary tract stones. SWL is to break the principle of urinary tract stones using shock waves generated by a machine outside the body. The shock wave generated by a machine outside the body can be focused in the direction of the stone with a variety of ways. Arriving at the rock, shock waves were going to release its energy. It takes a few thousand times the shock waves to break stones up into tiny fragments, in order to get out without causing pain with urination.
Various types of SWL machines can be found at this time. Although the principle works all the same, there are significant differences between old and new generation engines, the ureter stone therapy. In the new generation of more narrow the focus point and is equipped with flouroskopi, making it easier in setting targets / firing position for ureteric stones. This machine is not located in the old generation, so their utilization for the treatment of ureteric stones is very limited. However the new generation engine has also had a weakness that is not as strong as the strength tembaknya a long time, so to hard rock to several times the action.
Complications of SWL for ureteric stone treatment is almost non-existent. SWL but has some limitations, such as when a stone is hard (for example, calcium oxalate monohydrate) is difficult to break and need to be several times the action. Also in obese people might have trouble. The use of SWL for distal ureteral stone therapy in women and children should also be considered seriously. Because there may be damage to the ovaries. Although no data is valid, for women under 40 years should be clearly informed.
3. Ureterorenoscopy (URS)
URS is a specialist action procedure using endoscopic tools measuring less than 3 mm are inserted through the urinary tract stones in the ureter and then solved by the air waves. Broken stone will come out with urine. This action requires anesthesia and hospitalization.
4. PCNL (Percutaneous nephrolithotomy)
PcNL action taken to destroy kidney stones with the aid of an endoscope that is inserted into the kidney so that the stones can be crushed with a stone-breaker. This action requires anesthesia and hospitalization.
5. DJ Stents
DJ stent is an abbreviation of the double J stent. This tool is often used urologist with a shape like two pieces of the letter J. This tool is installed in the ureter, a tail to the system pelvikokaliks kidney and another in the bladder.

Figure 3: DJ stent

Figure 4: RO installation of DJ stent
Function of the object is to facilitate the flow of urine from the kidneys to the bladder, also make it easier carry a urinary tract stone chips. When the end of DJ stent on ureteral peristalsis systematic pelvikokaliks then stopped so that the entire ureter dilatation. (Source peristalsis in renal minoris Calix). Urine from the kidney to flow in the hole between the DJ and DJ stent with a ureteral stent. DJ stent mounted when (DJ stent mounting indications):
A. Connecting the severed ureter.
2. If the current action in the ureter injured URS layer.
3. After surgery URS distal ureter stones, because it was feared the mouth of the ureter is swollen so that urine can come out.
4. Stenosis or narrowing of the ureter. DJ stent in order to function after mounted constriction becomes loose.
5. After URS with ureter stones embedded, so that when completed URS layer in the ureter is not good.
6. Kidney stone surgery are numerous and there is the possibility of residual stones. If not mounted a prolonged urine leak can occur.
7. Kidney stones are large and planned ESWL. If not installed then the stone fragments may cause pain.
8. To secure the urinary tract in patients with cervical cancer.
9. To secure both kidneys when kidney / ureter is blocked and will be treated on 1 side only. Then the other side of the DJ stent installed.
10. In patients with renal failure due to blockage of urine, (can not be made smaller nephrostomy for hydronephrosis).
DJ stent mounting risk:
A. berlubangnya urinary tract.
2. urosepsis tract germ that is circulating in the bloodstream.
3. the emergence of rock in the DJ stent, therefore DJ stent is removed / replaced after a certain time. DJ stent old age varies, and there are generally 2 months to 1 year old. If not given the information, usually 2-month-old DJ stent. DJ suggested stent removed or replaced after 2 months.
4. DJ stent can not be withdrawn. Should this happen it would require open surgery.
6. The urethra Trans Ablatin Needle (TUNA).
Is a therapy for patients with benign prostatic hyperplasia (BPH) or enlarged prostate is blocking the flow of art out of the bladder. Through the urinary tract TUNA equipment will emit radio waves directly into the prostate. Energy from radio waves to destroy the enlarged prostate to the urethra is open again, then return to normal urinary stream.
Excess TUNA Therapy
A. Cure the symptoms of BPH
2. Shorter treatment time
3. Quickly recovers
4. Very few side effects
5. Eliminate the risk of inkontensensia uri.
7. Minimally Invasive Surgery (MIS) Urology
Robot-assisted laparoscopic surgery (or Da Vinci robotic surgery) is a minimally invasive surgical techniques for complex urological surgery. This technique has been used for radical prostatectomy (removal of the prostate gland), neprektomi (kidney removal), and pieloplasti (urethral stricture repair).

Da Vinci robotic surgery is the preferred technique for minimally invasive urologic procedures are complicated.

Figure 5: robotic surgery

The main advantages of robotic surgery include quicker healing of wounds smaller incisions and less pain, less blood loss and need for transfusions, a clearer vision and tissue dissection with greater vision and the use of specialized robotic equipment.
Patients who require radiation therapy, brachytherapy (planting seeds) is a minimally invasive option in which the seeds of permanent radioactive seed rice is inserted through the skin of the perineum (between scrotum and anus) under ultrasound guidance.

Da Vinci is a sophisticated robotic system that mimics the view and the surgeon's hand movements.

Figure 6: ROBOTIC

8. Transurethral resection of the prostate (TURP)
A surgical removal of prostate tissue through the urethra using resektroskop. Surgery without an incision is closed and has no adverse effect on the healing potential.
Transurethral resection of the prostate (TURP) can be used as the criterion standard to reduce the "bladder outlet obstruction (BOO) secondary to BPH". TURP is the most commonly used method in which a block of prostate tissue removed through an instrument inserted through the urethra (urinary tract). Is one of the many types of endoscopic surgery done today is TURP (transurethral resection of the prostate) in which the prostate gland is cut by scraped by using electrical energy.

Figure 7: TURP
Impact of TURP
A. Patterns of perception and governance of healthy living. Onset of changes in health care because of bed rest for 24 hours post-TURP. Complaints of pain due to spasm of the bladder requires the use of appropriate applicable antipasmodik doctor.
2. Nutrition and metabolic patterns of clients who do anasthesi SAB should not eat and drink before flatus
3. Pattern of elimination. On the client can occur hematuri after TURP action. Retention of urine can occur when there is a blood clot on the catheter. While incontinence can occur after the catheter is removed.
4. Patterns of activity and exercise. Activity limitations due to the weak condition of the client and installed traction for 6-24 hours be on the verge of defeat. Performed on the thighs should not be gluing the catheter is still needed flexion during traction.
5. Patterns of sleep and rest. Pain and changes in circumstances since hospitalization can affect sleep patterns and rest.
6. Cognitive and perceptual patterns. System vision, hearing, taste, touch and panghidu not impaired after TURP
7. Patterns of perception and self-concept. Clients can experience anxiety due to lack of knowledge about complications of BPH treatment and post-TURP
8. Patterns of relationships and roles for the client to undergo treatment in hospital, then it can affect both client relationships and roles within the family, workplace, and society.
9. Patterns of sexual reproduction. Action TURP can cause impotence and retrograde ejaculation
Indication of TURP
In general, indications for TURP method is that patients with persistent symptoms of obstruction, progressive due to prostate enlargement, or can not be treated with drug therapy again. TURP is an indication of the symptoms of moderate to severe, the prostate volume of less than 60 grams and the patient is healthy enough to undergo surgery. This operation is performed on an enlarged prostate between 30-60 grams. TURP process should not be more than 1 hour.
Mechanism of TURP
TURP is performed using an instrument called resektoskop with a curved diathermi. Prostate gland tissue layer by layer and sliced ​​through the sheath resektoskop issued. Bleeding were treated by using diathermi, usually done within 30 to 120 minutes, depending on the size of the prostate. Irigan distilled water is used during surgery or isotonic fluid without electrolytes. This procedure is done with regional anesthesia (Block Subarakhnoidal / SAB / Peridural). Once the catheter was placed number Ch. 24 for several days. Commonly used catheters or a branched three channels to prevent spoel the pembuntuan by blood clots. The balloon was developed to fill a physiological saline or distilled water as much as 30-50 ml is used as a tamponade the prostate by means of traction for 6-24 hours. Traction can be done by taping into the thigh with a client or giving weight (0.5 kg) on ​​the catheter through the pulley. Traction can not be longer than 24 hours because it may cause pressure on the urethra causing stenosis skrotal jar - jar because ischemi. After fixation loosened moved traction on the proximal thigh or lower abdomen. Antibiotic prophylaxis was continued several hours or 24-48 hours post surgery. After the urine comes out clear, the catheter can be removed. Catheter is usually removed on days 3-5. For the release of a catheter, antibiotics administered 1 hour before to prevent urosepsis. Usually, the client may either go home after micturition, one or two days after the catheter is removed
9. Surgery with a laser (Laser prostatectomy)
Because of the way the operative (open surgery or TUR P) to remove the enlarged prostate is a bloody operation, while treatment with TUMT and Turf can not give as good results with the operation manner of operation, try to do almost no bleeding.
The use of laser for prostate surgery was first suggested by Sander (1984). To treat prostate ca local still using Nd YAG (Neodymium, Yttrium Aluminium Garnet) Solid state Nd YAG was first introduced in 1964 but was only tested in 1975 a new field of urology for mengablasi jar superficial tumors (Hoffstetter). Pc Phee wrote about the use of the YAG laser irradiation to photo segmental mucosal jar.
YAG laser has a wavelength suitable for the treatment of prostate therefore have a deep enough penetration power. At first for the prostate laser is only used for additional treatment after TUR P on prostate ca, which is usually given 3 weeks after TUR P (Shanberg 1985, Mc Nicholas 1990).
Then propose the use of Nd YAG Shenberg to melaser prostate in patients who can not tolerate bleeding when performed TUR. Roth and aretz (1991) pioneered the use of laser Transuretral Ultrasound Guided Laser Induced Prostatectomy (TULIP), which led to the use of ultrasound for prostate can shoot enhanced by using tools pembelok (deflector) laser beam at an angle of 90 degrees so that the laser beam can be directed to direction of an enlarged prostate gland.
Nd YAG has a wavelength of 1064 nm so that the wave is not absorbed by the water like a CO2 laser and has a divergence properties but still have a deep enough penetration power. If the Nd YAG laser is the energy of prostate tissue will turn into thermal energy that can vaporize tissue with no contact with the Nd YAG laser effects the network has a maximum at a depth of 3mm was taken so that the power of C 40 -  mucosa and thermal effects can reach 100 60 watts will cause coagulation at a depth of 3mm and causes a small explosion called the "pop corn effect". Nd YAG is safe for the treatment of prostate because of a rather large blood vessels and blood vessels in the prostate capsule will be retaining heat (heat sink) so it will be spreading the heat out of the prostate.
In 1989, Johnson found a tool that pembelok Nd YAG laser beam by using pembelok of gold that can be deflected 90  affixed to the laser fiber tip, so that the laser beam can be directed into the prostate tissue of the urethra. With this tool pembelok 92% of laser energy can still achieve preostat network. Costello (1992) pioneered the use of this laser ablation of benign prostate enlargement separately via cystoscopy. using a deflected laser 90
The time required for prostate melaser usually about 2-4 minutes for each lobe of the prostate (right lateral lobe, left and medius). At the time of ablation will find pop corn so that it looks through sistoskop effect occurs on the surface ablation of the prostate, prostatic urethra so it will soon will be wider, which is then followed by the effects of ablation will still follow the right cause "laser necrosis" over the following 4-24 weeks later so that the final result will occur in the prostate cavity cavity resembles that occurred after TUR.
Advantages of laser surgery are:
A. Does not cause bleeding that can not happen due to retention of blood clots and does not require a transfusion
2. The technique is simpler
3. Faster operating time
4. The length of stay in hospital is shorter
5. Does not require anticoagulant therapy
6. There is no risk of impotence
7. Minimal risk of retrograde ejaculation
Disadvantages: The use of these lasers still require anesthesia (regional)

reference


1. http://www.cancer.gov/cancertopics/factsheet/Detection/early-prostate # q4
2. American Urological Association Foundation,www.urologyhealth.org , URL: http://www.urologyhealth.org/adult/index.cfm?cat=03&topic=37
3. http://bedahurologi.wordpress.com/2011/10/14/dj-stent/dj-stent1/
4. http://www.ssmh.co.id/index.php?option=content&task=detail&id=12
5. Sjamsuhidajat R, de Jong W. Buku Ajar Ilmu Bedah Edisi revisi, Jakarta : EGC, 1997.
6. Tenggara T. Gambaran Klinis dan Penatalaksanaan Hipertrofi Prostat, Majalah Kedokteran Indonesia volume: 48, Jakarta : IDI, 1998.
7. Reksoprodjo S. Prostat Hipertrofi, Kumpulan Kuliah Ilmu Bedah cetakan pertama, Jakarta : Binarupa Aksara, 1995.
8. Sabiston, David C. Hipertrofi Prostat Benigna, Buku Ajar Bedah bagian 2, Jakarta : EGC, 1994.
9. Katzung, Bertram G. Farmakologi Dasar dan Klinik edisi VI, Jakarta : EGC, 1997.
1. http://www.cancer.gov/cancertopics/factsheet/Detection/early-prostate # q4 
2. American Urological Association Foundation,www.urologyhealth.org , URL: http://www.urologyhealth.org/adult/index.cfm?cat=03&topic=37
3. http://bedahurologi.wordpress.com/2011/10/14/dj-stent/dj-stent1/
4. http://www.ssmh.co.id/index.php?option=content&task=detail&id=12
5. Sjamsuhidajat R, de Jong W. Buku Ajar Ilmu Bedah Edisi revisi, Jakarta : EGC, 1997.
6. Tenggara T. Gambaran Klinis dan Penatalaksanaan Hipertrofi Prostat, Majalah Kedokteran Indonesia volume: 48, Jakarta : IDI, 1998.
7. Reksoprodjo S. Prostat Hipertrofi, Kumpulan Kuliah Ilmu Bedah cetakan pertama, Jakarta : Binarupa Aksara, 1995.
8. Sabiston, David C. Hipertrofi Prostat Benigna, Buku Ajar Bedah bagian 2, Jakarta : EGC, 1994.
9. Katzung, Bertram G. Farmakologi Dasar dan Klinik edisi VI, Jakarta : EGC, 1997.


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