POLRI DAERAH JAWA TIMUR

BIDANG KEDOKTERAN DAN KESEHATAN

RUMAH SAKIT BHAYANGKARA TK III TULUNGAGUNG

REKOMENDASI RINCIAN KEWENANGAN KLINIS

DOKTER SPESIALIS UROLOGI

Nama :
NRP / NIP / NIK :
Tempat/Tanggal Lahir :
Pendidikan / Jabatan : Dokter Spesialis Urologi

Kewenangan Klinis Yang Diminta Yang Disetujui

Operation On Adrenal
1. Adrenalectomy (abdominothoracal)
2. Adrenalectomy
3. Laparoscopic adrenalectomy
4. Other laparoscopy of the adrenal(s)
Operation on Kidney
1. Nephrotomy
2. Nephrostomy
3. Percutaneous nephrostomy without fragmentation
4. Percutaneous nephrostomy with fragmentation
Pyelotomy and pyelostomy
1. Pyelotomy
2. Pyelostomy
Diagnostic procedure on kidney
1. nephroscopy
2. pyeloscopy
3. closed (percutanous/needle) biopsi of kidney
4. open biopsi of kidney
5. other diagnostic procedure on kidney
Local excision or destruction of lesion or tissue of kidney
1. marsupilasation of kidney lesion
2. open ablation of renal lesion or tissue
3. percutaneous ablation of renal lesion or tissue
4. other and unspecified ablation of renal lesion or tissue
5. other local excision and destruction of renal lesion or
tissue
Patial nephrectomy
1. calycectomy
2. wedge resection of the kidney
Complete nephrectomy
1. nephroureterectomy with bladder cuff
 2. totalnephrectomy (unilateral)
3. nephrectomy of remaining kidney
4. removal and of solitary kidney
5. removal of transplanted or rejected kidney
6. bilateral nephrectomy
Transplant of kidney
1. renal autotransplantation
2. other kidney transplantation
nephropexy
1. fixation or suspension of moveable (floating) kidney
Other repair of kidney
1. suture of laceration of kidney/renorraphy
2. closure of nephrostomy and pyelostomy
3. closure of other fistula of kidney
4. reduction or torsion of renal pedicle
5. symphysiotomy for horseshoe kidney
6. anastomosis of kidney
nephropyeloureterostomy

pyelouertrovesical anastomosis
ureterocalyceal anastomosis
7. corection of ureteropelvic junction
8. repair of kidney, not otherwise specified
Other operations on kidney
1. decapsulation of kidney
capsulectomy of kidney
decortication of kidney
2. percutaneous aspiration of kidney (pelvis)
aspiration of renal cyst
renipuncture
3. replacement of nephrostomy tube
4. replacement of pyelostomy
5. local perfusion of kidney
6. other injection of therapeutic substance into kidney
injecyi into renal cyst
7. implantation or replacement of mechanical kidney
8. removal of mechanical kidney
9. other operations on kidney, not otherwise specified
10. recontruction of renovaskular
11. laparoscopic ablation of renal lesion or tissue
12. laparoscopic radical nephrectomy
13. laparoscopic partial nephrectomy
14. laparoscopic renal cyst deroofing/unroofing
15. laparoscopic living donor nephrectomy
16. laparoscopiccorrestion of ureteropelvic junction
17. laparoscopic pyelotomy
18. laparoscopic pyelolithotomy
 19. other laparoscopy of the renal, perirenal and pyelo-
calyceal system, not otherwise specified
20. retrograde intra-renal surgery with fragmentation
21. retrograde intra-renal surgery without fragmentation
22. endoscopic correction of ureteropelvic junction
Endopyelotomy
Operation on ureter
Transurethral removal of obstruction from ureter and renal
pelvis
1. Removal of :
Blood clot from ureter or renal pelvis without incision

Calculus from ureter or renal pelvis without incision
Foreign body from ureter or renal pelvis without incision
Ureteral meatotomy
1. Incision to ureteral meatus
Ureterotomy
1. Incision of ureter for :
Drainage

Exploration
Removal of calculus
Diagnostic procedures on ureter
1. Ureteroscopy
2. Closed percutaneous biopsy of ureter
3. Closed endoscopic biopsy of ureter
4. Open biopsy of ureter
5. Endoscopy of ileal conduit : cystoscopy, looposcopy
6. Other diagnostic procedure on ureter
Uretectomy
1. Uretectomy, not otherwise specified
2. Partial uretectomy
3. Total uretectomy
Cutaneous uretero-ileostomy
1. Formation of cutaneous uretero-ileostomy
2. Revision of cutaneous uretero-ileostomy
Other external urinary diversion
1. Formation of other cutaneous ureterostomy
2. Revision of other cutaneous ureterostomy
Other anastomosis or bypass of ureter
1. Urinary diversion to intestine
2. Revision of ureterointestinal anastomosis
3. Nephrocystanastomosis, not otherwise specified
4. Ureteroneocystostomy
5. Transureter-ureterostomy
6. Other anastomosis or bypass of ureter, not otherwise
specified
Repair of ureter
1. Lysis of intraluminal adhesions of ureter
2. Suture of laceration of ureter
3. Closure of ureterostomy
4. Closure of other fistula of ureter
 5. Ureteropexy
6. Removal of ligature from ureter
7. Other repair of ureter
Other operations on ureter
Dilation of uretral meatus
Implantation of elektronic ureteral stimulator
Replacement of elektronic ureteral stimulator
Removal of elektronic ureteral stimulator
Ligation of ureter
Other operations on ureter, not otherwise specified
Laparoscopic ureterolithotomy
Laparoscopic ureteral re-implantation
Laparoscopic lysis of adhesions of ureter
Laparoscopic lysis of adhesions of ureter
Other laparoscopy of the ureter, not otherwise specified
Operation on urinary bladder
Transurethral clearence of bladder
1. Drainage of bladder without incision
Removal of :
Blood clots from bladder without incision
Calculus from bladder without incision
Foreign body from bladder without incision
Cystotomy and cystostomy
1. Percutaneous aspiration of bladder
2. Lysis of intraluminal adhesions with incision into bladder
3. Percutaneous cystostomy
4. Other suprapubic cystostomy
5. Other cystostomy
Vesicostomy
1. Vesicostomy
2. Revision or closure of vesicostomy
Diagnostic procedures on bladder
1. Cystoscopy through artificial stoma
2. Other Cystoscopy
3. Closed (transurethral) biopsy of bladder
4. Open biopsy of bladder
5. Other diagnostic procedure on bladder
Transurethral excision or destruction of bladder tissue
1. Transurethral lysis of intraluminal adhesions
2. Other transurethral excision or destruction of lesion or

tissue of bladder
Other excision or destruction of bladder tissue
1. Excision of urachus
2. Open excision or destruction of other lesion or tissue of

bladder
Partial cystectomy
1. Excision of :
Bladder dome

Trigonectomy
Wedge resection of bladder
Total cystectomy
1. Radical cystectomy
Pelvic exteration in male
Removal of bladder, prostate, seminal vesicles and fat
Removal of bladder, urethra and fat in a female
2. Other total cystectomy
Other repair of urinary bladder
1. Suture of laceration of bladder
2. Closure of cystostomy
3. Repair of fistula involving of bladder
4. Cystourethroplasty and plastic repair of bladder neck
5. Repair of bladder extrophy
6. Reconstruction of urinary bladder
7. Other anastomosis of bladder
8. Other repair of bladder
Other operation on bladder
1. Sphincterotomy of bladder
2. Dilatation of bladder neck
3. Control of (post operative) hemorrhage of bladder
4. Insersion of indwelling urinary catheter
5. Replacement of indwelling urinary catheter
6. Implantation of electronic bladder stimulator
7. Replacement of electronic bladder stimulator
8. Removal of electronic bladder stimulator
9. Other operation on bladder, not otherwise specified
10. Laparoscopic radical cystectomy
11. Laparoscopic bladder diverticulectomy
12. Laparoscopic repair of fistula involving bladder
Operation on urethra
Urethrotomy
1. Excision of urethral septum
Formation of urethrovaginal fistula

Perineal urethrostomy
Removal of calculus from urethra by incision
Urethral meatotomy
1. Incision of urethral meatus
Diagnostic procedures on urethra
2. Perineal urethroscopy
3. Other urethroscopy
4. Biopsy of urethra
5. Biopsy of periurethral tissue
6. Other diagnostic procedures on urethra and periurethral

tissue
Excision/ destruction of lesion or tissue of urethra
1. Endoscopic excision/destruction of lesion or tissue of
urethra
2. Other local excision/destruction of lesion or tissue of
urethra
Repair of urethra
1. Suture of laceration of urethra
 2. Closure of urethrostomy
3. Closure of other fistula of urethra
4. Reanastomosis of urethra
5. Repair of hipospadias/epipadias
6. Other reconstruction of urethra
7. Urethral meatoplasty
8. Other repair of urethra
Release of urethral stricture
1. Cutting of urethral sphincter
Internal urethral meatotomy
urethrolysis
Dilatation of urethra
1. Dilation of urethrovesical junction
Passage of sounds through urethra
Removal of calculus from urethra without incision
Other operations on urethra and periurethral tissue
9. Incision of periurethral tissue
10. Excision periurethral tissue
11. Implantation of artificial urinary sphincter
12. Other operations on urethra and periurethral tissue, not

otherwise specified
13. Incision, excision and division of pelvic bones
14. Other operations on oral cavity (buccal graft harvesting)
Operations on prostate and seminal vesicles
Incision of prostate
1. Drainage of prostatic abscess

Prostatolithotomy
Diagnostic procedures on prostate and seminal vesicles
1. Closed (percutaneous) (needle) biopsy of prostate
Transrectal

Transurethral
Punch biopsy
2. Open biopsy of prostate
3. Closed (percutaneous) biopsy of seminal vesicles
4. Open biopsy of seminal vesicles
5. Biopsy of periprostatic tissue
Lampiran prosedur Tindakan Kardiologi
1. EKG, Treadmill, Holter
2. Echocardiography transthorakal dan transesofageal
3. USG Doppler Vaskuler
4. Kardioversi dan DC Shock
5. Kateterisasi jantung dan angiografi koronaria
6. Pacu jantung sementara
7. Perikardiosentesis
8. Pemasangan kanul vena sentral
9. Manajemen perioperative pada operasi non kardiak
10. PTCA
Lampiran Pulmonologi
1. Pungsi cairan pleura
2. Pleurodesis
Lampiran Reumatologi
1. Penyuntikan intra artikuler
2. Aspirasi cairan sendi (artrosentesis)
Lampiran Ginjal hipertensi
1. Peritoneal dialisis akut
Lampiran Gastroenterohepatologi
1. Parasentesis abdomen
2. Pemasangan selang nasogastrik
Lampiran Hematomegali Onkologi Medik
1. Tranfusi darah
2. Pemasangan darah
3. Pemasangan nutricath
4. Flebotomi
Rekomendasi DISETUJUI DISETUJUI DENGAN TIDAK DISETUJUI
CATATAN
Tanggal :
Catatan :

Ketua Komite Medik, Ketua Sub Komite Kredensial,