"A Man can't make a mistake can't make anything"

Saturday, 15 June 2013


Case  report


Name                           : Mr. M
Age                              :  62years
Gender                         :  Man
Religion                       :  Islam
Address                       :  Arjawinangun

II.     ANAMNESIS (Autoanamnesis  and Alloanamnesis)
Main complaint                 : Can not urinate
Additional complaints      : Pain when urinating
                                          Sometimes bloody piss
History Disease Now:
Patients come to hospitals with complaints Arjawinangun could not urinate since ± 2 days SMRs. The patient began to feel the disturbance BAK since ± 2 months SMRs. When you wish to urinat patient should wait longer straining and new urine out. Clear yellow urine with poor stream but not branched and sometimes stops then out again and sometimes blood-tinged miksion. After sometimes there dripping urine and his bladder patients often feel incomplete. Low back pain, leg pain, a sense of twisting, bladder stones, pubic pain threshold when urinating, fever, raised lump in the groin and rectal bleeding accompanied denied. Patients also denies decreased appetite and weight loss dramatically over bladder disorders arise. smoothly.
Past history of disease:
- Diabetes history indisputably
- History of high blood pressure is recognized
Family history of disease:
No family member who suffers from the same disease as the patient


Generalists status

General situation         : Looks sick are

Awareness                   : Compos mentis

Vital signs                   : N       : 86 x / min

                                    RR       : 24 x / min

                                    S          : 36.5 º C

                                    TD       : 160/90 mmHg

Head                                       : Normocephal.

Eyes                            : Conjunctiva: Ananemis

                                    Sclera: Anikterik


Cast                             : Inspection: cardiac Iktus not visible

                                    Palpation: no palpable cardiac Iktus

                                    Percussion: Dim, limit of normal heart

                                    Auscultation: I-II regular BJ, BJ additional (-)

Pulmo                          : Inspection: Symmetrical, under static and dynamic conditions.

         Palpation: Vocal fremitus on the right and left hemithorax symmetrical palpable.

                                    Percussion: Sonor on both hemithorax.

                                    Auscultation: Vesicular + / + N, crackles - / -, wheezing - / -

Abdomen                    : Inspection: Flat

         Palpation: Supple, NT / NK / NL -/-/-, liver and spleen not palpable enlarged

                                    Percussion: Timpani in the entire field abdomen

                                    Auscultation: normal BU

Extremities                  : Upper: Edema - / -, cyanosis - / -

Bottom                        : Edema - / -, cyanosis - / -

Urologist status
                                       Right Kidney                        Left Kidney
Massa                             -                                           -
Ballotement                    -                                           -
Tenderness                     -                                           -
Pain tap                           -                                           -

Supra symphysis region
VU: no palpable
Tenderness: -

rectal toucher
- Tonus sphincter ani: Good
- Ampulla recti: No collapse
- Rectal mucosa: Palpable slippery
- Prostate: Prominent, consistency hard, uneven surface, nodules (+), tenderness (+),
- Handscoon: Slime (-), Blood (-), feces (-)
          Full Blood Lab
                        Leukosit                       :   11.000  mm³
Hb                   :   10,2 gr%/dl
Ht                    :   22,5gr%/dl
Plt                    :  457 mm³


Prostate cancer
Benign Prostate Hiperplasia (BPH)

-          Medikamentosa:
Cefoperazoniv 2x1 amp
Tramadol iv 2x1 amp
Ranitidin  iv 2 x1 amp
Amlodipin 1 x 10 mg
-          Prostatektomiradikaldenganpemeriksaan PA

-   Quo ad vitam           : dubia ad bonam
-   Quo ad functionam   :  ad malam


A.    Anatomy and physiology
The prostate is a gland found only in males. It is located in front of the rectum and below the urinary bladder. The size of the prostate varies with age. In younger men, it is about the size of a walnut, but it can be much larger in older men.
The prostate is an organ consisting of components glands, stroma and muscular. This gland begins to grow at the age of 12 weeks gestation due to the effect of androgen hormones are derived from fetus testis. The prostate is a derivative of urogenital sinus of embryonic tissue.  Prostate gland lies side of inferior fur jar, wrap in front of the rectum and posterior urethra. The average size of the prostate in older men 4 x 3 x 2.5 cm and weighs approximately 20 grams.
The prostate's job is to make some of the fluid that protects and nourishes sperm cells in semen, making the semen more liquid. Just behind the prostate are glands called seminal vesicles that make most of the fluid for semen. The urethra, which is the tube that carries urine and semen out of the body through the penis, goes through the center of the prostate.
The prostate starts to develop before birth. It grows rapidly during puberty, fueled by male hormones (called androgens) in the body. The main androgen, testosterone, is made in the testicles. The enzyme 5-alpha reductase converts testosterone into dihydrotestosterone (DHT). DHT is the main hormone that signals the prostate to grow. The prostate usually stays at about the same size or grows slowly in adults, as long as male hormones are present

B.     Defined
Prostate cancer is cancer that develops in the prostate, a gland in the male reproductive system. This occurs when prostate cells mutate and begin to grow out of control. These cells may spread from the prostate metastasis to other parts of the body, especially the bones and lymph nodes. Prostate cancer may cause pain, difficulty in urinating, erectile dysfunction and other symptoms.

C.    Epidemiology
Other than skin cancer, prostate cancer is the most common cancer in American men. The latest American Cancer Society estimates for prostate cancer in the United States are for 2012:
· About 241,740 new cases of prostate cancer will be diagnosed
· About 28,170 men will die of prostate cancer
About 1 man in 6 will be diagnosed with prostate cancer during his lifetime. Prostate cancer occurs mainly in older men. Nearly two thirds are diagnosed in men aged 65 or older, and it is rare before age 40. The average age at the time of diagnosis is about 67.

Possible pre-cancerous conditions of the prostate
Some doctors believe that prostate cancer starts out as a pre-cancerous condition, although this is not yet known for sure.

-          Prostatic intraepithelial neoplasia (PIN)

In this condition, there are changes in how the prostate gland cells look under the microscope, but the abnormal cells don't look like they are growing into other parts of the prostate (like cancer cells would). Based on how abnormal the patterns of cells look,
they are classified as:
· Low-grade PIN: the patterns of prostate cells appear almost normal
· High-grade PIN: the patterns of cells look more abnormal
PIN begins to appear in the prostates of some men as early as their 20s. Almost half of all men have PIN by the time they reach 50. Many men begin to develop low-grade PIN at an early age but do not necessarily develop prostate cancer. The importance of low-grade PIN in relation to prostate cancer is still unclear. If a finding of low-grade PIN is reported on a prostate biopsy, the follow-up for patients is usually the same as if nothing abnormal was seen.
-          Proliferative inflammatory atrophy (PIA)

This is another finding that may be noted on a prostate biopsy. In PIA, the prostate cells look smaller than normal, and there are signs of inflammation in the area. PIA is not cancer, but researchers believe that PIA may sometimes lead to high-grade PIN, or perhaps to prostate cancer directly.

D.    Etiology
Until now still not known for certain causes of prostate ca: but some hypothesis states that prostatic hyperplasia is closely related to the hypothesis that some suspected as the cause of ca mammmae are:
1. A change in the balance between testosterone and estrogen in the elderly.
2. The role of a growth factor (growth factor) as a driver of growth in the prostate gland stroma.
3. Increased long-life cells of the prostate due to reduced cell death
4. Stem cell theory explains that the abnormal proliferation of stem cells leading to the production of stromal cells and epithelial prostate gland as being excessive.

E.     Risk factors
-          Age
Prostate cancer is very rare in men younger than 40, but the chance of having prostate cancer rises rapidly after age 50. Almost 2 out of 3 prostate cancers are found in men over the age of 65.
-          Race/ethnicity
-          Nationality
Prostate cancer is most common in North America, northwestern Europe, Australia, and on Caribbean islands. It is less common in Asia, Africa, Central America, and South America.
-          Family history
-          Genes

Some inherited gene changes raise the risk for more than one type of cancer. For example, inherited mutations of the BRCA1 or BRCA2 genes are the reason that breast and ovarian cancers are much more common in some families. Mutations in these genes may also increase prostate cancer risk in some men, but they account for a very small percentage of prostate cancer cases.
-          Smoking
Most studies have not found a link between smoking and the risk of developing prostate cancer. Some recent research has linked smoking to a possible small increase in the risk of death from prostate cancer, but this is a new finding that will need to be confirmed by other studies.
-          Inflammation of the prostate
Some studies have suggested that prostatitis (inflammation of the prostate gland) may be linked to an increased risk of prostate cancer, but other studies have not found such a link. Inflammation is often seen in samples of prostate tissue that also contain cancer. The link between the two is not yet clear, but this is an active area of research
-          Sexually transmitted infections
Researchers have looked to see if sexually transmitted infections (like gonorrhea or chlamydia) might increase the risk of prostate cancer, possibly by leading to inflammation of the prostate. So far, studies have not agreed, and no firm conclusions have been reached.
-          Vasectomy
Some earlier studies had suggested that men who have had a vasectomy (minor surgery to make men infertile) – especially those younger than 35 at the time of the procedure – may have a slightly increased risk for prostate cancer. But most recent studies have not found any increased risk among men who have had this operation. Fear of an increased risk of prostate cancer should not be a reason to avoid a vasectomy.

F.     Pathophysiology
Causes of Prostate Ca until now not known with certainty, but several hypotheses states that are closely related to Prostate Ca hypothesis suspected as the cause of Ca breast is a change in the balance between testosterone and estrogen in the elderly, this will interfere with the process of cell differentiation and proliferation . This disrupted cell differentiation that causes cancer cells, another cause that is the factor of excessive stromal growth and increased longevity of prostate cells due to reduced cell death that results in a change in the genetic material. Changes prolife causing stromal cell production and prostate gland epithelial cells become excessive, causing Ca Prostate (Price)
Cancer will cause constriction of lumen of the prostatic urethra and will inhibit the flow of urine. This situation led to an emphasis intraavesikal, to be able to dispense urine, the bladder must be able to contract strongly against the prisoner. Continuous contraction causes anatomic changes of the bladder detrusor hypertrophy form, trabeculation, selula formation, Sakula, and divetikel. Detrusor muscle thickening phase is called phase compensation.
Structural changes in the bladder is felt by the patient as a complaint on the lower urinary tract or lower urinary track symptoms (LUTS) formerly known as symptoms - symptoms prostatismus, by increasing retention urethra, detrusor muscle into dekompensaasi phase and ultimately unable to again to contract resulting in urinary retention. Intravesikal higher pressure will be forwarded to all parts of the bladder into the ureter or vesico-ureteric reflux occurs. This situation if continued will result in hydroureter, hydronephrosis, and even eventually be able to fall into kidney failure.
Continuous development of tumors that can occur directly to the expansion of the urethra, bladder neck and bladder semmininalis. Prostate Ca can also spread via the hematogenous the pelvic bones of the lumbar vertebrae, femur and ribs. Organ metastases are the liver and lung.
Pathologic process is the accumulation of collagen and elastin tissue between smooth muscle contraction resulting in muscle weakness. In addition there is degeneration of the nerve cells that innervate smooth muscle. This can result in hypersensitivity post-functional, neurotransmitter imbalance, and decreased sensory input, so the unstable detrusor muscle. Because abnormal bladder muscle function, then an increase in residual urine causing hydronephrosis and upper urinary tract dysfunction.

G.    Grading prostate cancer
Pathologists grade prostate cancers according to the Gleason system. This system assigns
a Gleason grade, using numbers from 1 to 5 based on how much the cells in the cancerous tissue look like normal prostate tissue.
· If the cancerous tissue looks much like normal prostate tissue, a grade of 1 is assigned.
· If the cancer cells and their growth patterns look very abnormal, it is called a grade 5 tumor.
· Grades 2 through 4 have features in between these extremes.
Today, most biopsies are grade 3 or higher, and grades 1 and 2 are not often used. Since prostate cancers often have areas with different grades, a grade is assigned to the 2 areas that make up most of the cancer. These 2 grades are added together to yield the Gleason score (also called the Gleason sum) between 2 and 10.
There are some exceptions to this rule. If the highest grade takes up most (95% or more) of the biopsy, the grade for that area is counted twice as the Gleason score. Also, if 3 grades are present in a biopsy core, the highest grade is always included in the Gleason score, even if most of the core is taken up by areas of cancer with lower grades.
· Cancers with a Gleason score of 6 or less are often called well-differentiated or lowgrade.
· Cancers with a Gleason score of 7 may be called moderately differentiated or intermediate-grade.
· Cancers with Gleason scores of 8 to 10 may be called poorly differentiated or highgrade.
The higher the Gleason score, the more likely it is that your cancer will grow and spread quickly.

H.   Signs and symptoms of prostate cancer
Early prostate cancer usually causes no symptoms. Some advanced prostate cancers can slow or weaken your urinary stream or make you need to urinate more often, especially at night. But non-cancerous diseases of the prostate, such as benign prostatic hyperplasia (BPH) cause these symptoms more often.
If the prostate cancer is advanced, you might have blood in your urine (hematuria) or trouble getting an erection (impotence). Advanced prostate cancer commonly spreads to the bones, which can cause pain in the hips, back (spine), chest (ribs), or other areas. Cancer that has spread to the spine can also press on the spinal nerves, causing weakness or numbness in the legs or feet, or even loss of bladder or bowel control. Other diseases can also cause many of these same symptoms. It is important to tell your doctor if you have any of these problems so that the cause can be found and treated, if needed.

I.       Diagnosis
Most prostate cancers are first found during screening with a prostate-specific antigen (PSA) blood test and or a digital rectal exam (DRE). (See "Can prostate cancer be found early?") Early prostate cancers usually do not cause symptoms, but more advanced cancers are sometimes first found because of symptoms they cause. Whether cancer is suspected based on screening tests or symptoms, the actual diagnosis can only be made with a prostate biopsy.

Imaging tests
If you are found to have prostate cancer, your doctor will use your digital rectal exam (DRE) results, prostate-specific antigen (PSA) level, and Gleason score to figure out how likely it is that the cancer has spread outside your prostate. This information is used to decide which other tests (if any) need to be done to look for possible cancer spread in the body. Men with a normal DRE result, a low PSA, and a low Gleason score may not need any other tests because the chance that the cancer has spread is so low.
Transrectal ultrasound (TRUS)

Transrectal ultrasound (TRUS) uses sound waves to make an image of the prostate on a video screen. For this test, a small probe that gives off sound waves is placed into the rectum. The sound waves enter the prostate and create echoes that are picked up by the probe. A computer turns the pattern of echoes into a black and white image of the prostate.

Bone scan

If prostate cancer spreads to distant sites, it often goes to the bones first. (Even when prostate cancer spreads to the bone, it is still prostate cancer, not bone cancer.) A bone scan can help show whether cancer has reached the bones.

Computed tomography (CT)
The CT scan (also known as a CAT scan) is a special kind of x-ray test that gives detailed, cross-sectional images of your body. Instead of taking one picture, like a standard x-ray, a CT scanner takes many pictures of the part of your body being studied as it rotates around you. A computer then combines these pictures into images of slices of the part of your body being studied. Unlike a regular x-ray, a CT scan creates detailed images of the soft tissues in the body. This test can sometimes help tell if prostate cancer has spread into nearby lymph nodes. If your prostate cancer has come back after treatment, the CT scan can often tell whether it
is growing into other organs or structures in your pelvis.
On the other hand, CT scans rarely provide useful information about newly diagnosed prostate cancers that are likely to be confined to the prostate based on other findings (DRE result, PSA level, and Gleason score). CT scans are not as useful as magnetic resonance imaging (MRI) for looking at the prostate gland itself.
Magnetic resonance imaging (MRI)

MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed by the body and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. Like a CT scan, a contrast material might be injected, but this is done less often. Because the scanners use magnets, people with pacemakers, certain heart valves, or other medical implants may not be able to get an MRI.
MRI scans can be helpful in looking at prostate cancer. They can produce a very clear picture of the prostate and show whether the cancer has spread outside the prostate into the seminal vesicles or other nearby structures. This information can be very important for your doctors in planning your treatment. But like CT scans, MRI scans may not provide useful information about newly diagnosed prostate cancers that are likely to be confined to the prostate based on other factors.

Lymph node biopsy

In a lymph node biopsy, also known as lymph node dissection or lymphadenectomy, one or more lymph nodes are removed to see if they contain cancer cells. This is sometimes done to find out whether the cancer has spread from the prostate to nearby lymph nodes. If cancer cells are found in a lymph node, surgery is not likely to cure the cancer, so other treatment options are considered

Surgical biopsy

The surgeon may remove lymph nodes through an incision in the lower part of your abdomen. This is often done in the same operation as the radical prostatectomy. (See the section, "Surgery for prostate cancer" for information about radical prostatectomy.) If there is more than a very small chance that the cancer might have spread (based on factors such as a high PSA level or a high Gleason score), the surgeon may remove some lymph nodes before attempting to remove the prostate gland.

J.      Penatalaksanaan
Modern methods of detection and treatment mean that many prostate cancers are now found earlier and can be treated more effectively. If you are diagnosed this year, your outlook may be better than the numbers reported above. Depending on the situation, the treatment options for men with prostate cancer may include:
· Expectant management (watchful waiting) or active surveillance
· Surgery
· Radiation therapy
· Cryosurgery (cryotherapy)
· Hormone therapy
· Chemotherapy
· Vaccine treatment
These treatments are generally used one at a time, although in some cases they may be combined.

Some drugs may help reduce the risk of prostate cancer.
5-alpha reductase inhibitors
5-alpha reductase is the enzyme in the body that changes testosterone into dihydrotestosterone (DHT), the main hormone that causes the prostate to grow. Drugs called 5-alpha reductase inhibitors block the enzyme and prevent the formation of DHT.
Two 5-alpha reductase inhibitors are already in use to treat benign prostatic hyperplasia (BPH), a non-cancerous growth of the prostate:
· Finasteride (Proscar®)
· Dutasteride (Avodart®)

Surgery for prostate cancer
Surgery is a common choice to try to cure prostate cancer if it is not thought to have spread outside the gland (stage T1 or T2 cancers). The main type of surgery for prostate cancer is known as a radical prostatectomy. In this operation, the surgeon removes the entire prostate gland plus some of the tissue around it, including the seminal vesicles. A radical prostatectomy can be done in different ways.

Open approaches to prostatectomy
In the more traditional approach to doing a prostatectomy, the surgeon operates through a single long incision to remove the prostate and nearby tissues. This is sometimes referred to as an open approach.

Radical retropubic prostatectomy

For this operation, the surgeon makes a skin incision in your lower abdomen, from the belly button down to the pubic bone. You will be either under general anesthesia (asleep) or be given spinal or epidural anesthesia (numbing the lower half of the body) along with sedation during the surgery.
If there is a reasonable chance the cancer may have spread to the lymph nodes (based on your PSA level, DRE, and biopsy results), the surgeon may remove lymph nodes from around the prostate at this time. The nodes are usually sent to the pathology lab to see if they have cancer cells (it takes a few days to get results), but in some cases the nodes may be looked at right away. If this is done during surgery and any of the nodes have cancer cells, which means the cancer has spread, the surgeon may not continue with the surgery. This is because it is unlikely that the cancer can be cured with surgery, and removing the prostate could still lead to serious side effects.

Radical perineal prostatectomy

In this operation, the surgeon makes the incision in the skin between the anus and scrotum (the perineum), as shown in the picture above. This approach is used less often because the nerves cannot easily be spared and lymph nodes can't be removed. But it is often a shorter operation and might be an option if you don't want the nerve-sparing procedure and you don't require lymph node removal, and is often easier to recover from.
It also might be used if you have other medical conditions that make retropubic surgery difficult for you. It can be just as curative as the retropubic approach if done correctly. The perineal operation usually takes less time than the retropubic operation, and may result in less pain afterward.
Laparoscopic radical prostatectomy

For a laparoscopic radical prostatectomy (LRP), the surgeon makes several small incisions, through which special long instruments are inserted to remove the prostate. One of the instruments has a small video camera on the end, which lets the surgeon see inside the abdomen.
Laparoscopic prostatectomy has some advantages over the usual open radical prostatectomy, including less blood loss and pain, shorter hospital stays (usually no more than a day), and faster recovery times (although the catheter will be needed for about the same amount of time).
Surgical risks

The risks with any type of radical prostatectomy are much like those of any major surgery, including risks from anesthesia. Among the most serious, there is a small risk of heart attack, stroke, blood clots in the legs that may travel to your lungs, and infection at the incision site.
If lymph nodes are removed, a collection of lymph fluid (called a lymphocele) can form and may need to be drained.
Because there are many blood vessels near the prostate gland, another risk is bleeding during and after the surgery. You may need blood transfusions, which carry their own small risk. Rarely, part of the intestine might be cut during surgery, which could lead to infections in the abdomen and might require more surgery to correct. In extremely rare cases, people die because of complications of this operation. Your risk depends, in part, on your overall health, your age, and the skill of your surgical team.

Side effects

The major possible side effects of radical prostatectomy are urinary incontinence (being unable to control urine) and impotence (being unable to have erections). It should be noted that these side effects can also occur with other forms of treatment for prostate cancer, although they are described here in more detail
-          Urinary incontinence
-          Impotence (erectile dysfunction)
-          Changes in orgasm
-          Loss of fertility
-          Lymphedema
-          Change in penis length
-          Inguinal hernia

K.  The AJCC TNM staging system
The TNM system for prostate cancer is based on 5 key pieces of information:
· The extent of the primary tumor (T category)
· Whether the cancer has spread to nearby lymph nodes (N category)
· The absence or presence of distant metastasis (M category)
· The PSA level at the time of diagnosis
· The Gleason score, based on the prostate biopsy (or surgery)
T categories (clinical)
There are 4 categories for describing the local extent of a prostate tumor, ranging from T1 to T4. Most of these have subcategories as well.
T1: Your doctor can't feel the tumor or see it with imaging such as transrectal ultrasound.
· T1a: Cancer is found incidentally (by accident) during a transurethral resection of the prostate (TURP) that was done for benign prostatic hyperplasia (BPH). Cancer is in no more than 5% of the tissue removed.
· T1b: Cancer is found during a TURP but is in more than 5% of the tissue removed.
· T1c: Cancer is found by needle biopsy that was done because of an increased PSA.
T2: Your doctor can feel the cancer with a digital rectal exam (DRE) or see it with imaging such as transrectal ultrasound, but it still appears to be confined to the prostate gland.
· T2a: The cancer is in one half or less of only one side (left or right) of your prostate.
· T2b: The cancer is in more than half of only one side (left or right) of your prostate.
· T2c: The cancer is in both sides of your prostate.
T3: The cancer has begun to grow and spread outside your prostate and may have spread into the seminal vesicles.
· T3a: The cancer extends outside the prostate but not to the seminal vesicles.
· T3b: The cancer has spread to the seminal vesicles.
T4: The cancer has grown into tissues next to your prostate (other than the seminal vesicles), such as the urethral sphincter (muscle that helps control urination), the rectum, the bladder, and/or the wall of the pelvis.
N categories
N categories describe whether the cancer has spread to nearby (regional) lymph nodes.
NX: Nearby lymph nodes were not assessed.
N0: The cancer has not spread to any nearby lymph nodes.
N1: The cancer has spread to one or more nearby lymph nodes in the pelvis.
M categories
M categories describe whether the cancer has spread to distant parts of the body. The most common sites of prostate cancer spread are to the bones and to distant lymph nodes, although it can also spread to other organs, such as the lungs and liver.
M0: The cancer has not spread past nearby lymph nodes.
M1: The cancer has spread beyond the nearby lymph nodes.
· M1a: The cancer has spread to distant (outside of the pelvis) lymph nodes.
· M1b: The cancer has spread to the bones.
· M1c: The cancer has spread to other organs such as lungs, liver, or brain (with or without spread to the bones).

L.     Prognosis
Survival rates are often used by doctors as a standard way of discussing a person's prognosis (outlook). Some patients with cancer may want to know the survival statistics for people in similar situations, while others may not find the numbers helpful, or may even not want to know them. If you would rather not read the survival rates, skip to the next section.
The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Of course, many of these people live much longer than 5 years (and many are cured).
Five-year relative survival rates, such as the numbers below, assume that some people will die of other causes and compare the observed survival with that expected for people without the cancer. This is a better way to see the impact of the cancer on survival.
According to the most recent data, when including all men with prostate cancer:
· The relative 5-year survival rate is nearly 100%
· The relative 10-year survival rate is 98%
· The 15-year relative survival rate is 91%
Keep in mind that 5-year survival rates are based on patients diagnosed and first treated more than 5 years ago, and 10-year survival rates are based on patients diagnosed more than 10 years ago.


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herry setya yudha utama ,surgeon, dokter spesialis bedah, in www.dokterbedahherryyudha.com

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