LAMPIRAN Lampiran 1. Surat Ijin Penelitian 65
66
Lampiran 2. Surat Persetujuan Melakukan Penelitian 67
68
Lampiran 3. Data Sekunder Penelitian 69
No. Pekerjaan Alamat Umur Tanggal BPH Diagnosa Tanggal Hernia/Non- Skor Hernia IPSS 1 KKM K Surabaya 59 23 Jul 2012 (BPH + LUTS) - - Pandu II 2 - Surabaya 56 20 Sept 2011 BPH 22 Okt 2010-3 - Bangkalan 50 24 Jul 2013 BPH - - 4 - Sampit 46 4 Mar 2013 BPH 5 Mar 2013 - (Hemorrhoid Gr III) 5 - Bangkalan 52 11 Dec 2013 BPH - - 6 Supervisor Surabaya 58 7 Mar 2013 BPH 10 Jun 2013 (ISK) - 7 Manager Surabaya 57 2 Apr 2012 BPH - - 8 - Lombok 51 3 Okt 2013 BPH 9 Okt 2013 (Massa di - Buli-buli) 9 - Surabaya 54 4 Mar 2013 BPH - - 10 Senior Surabaya 55 9 Sept 2013 (BPH Gr. I + LUTS) 9 Sept 2013 (BBB) - Staff II 11 Renbangri Surabaya 51 18 Feb 2013 BPH 12 Mar 2014 (Sub- - Konj Bleed) 12 Admin Surabaya 55 4 Jul 2013 BPH 8 Jul 2013 (ISK) - 70
13 - Surabaya 56 30 Apr 2013 BPH - - 14 Kepala Surabaya 55 31 Okt 2011 BPH 24 Jul 2013 (LUTS) - Cabang 15 TPS Mojokerto 54 29 Okt 2009 (BPH Gr. II) 4 Des 2013 (BSK) - 16 - Bangkalan 76 27 Nov 2012 BPH - - 17 Kepanduan Sidoarjo 74 22 Apr 2013 (BPH + Retentio) 12 Mar 2012 - (Hemorrhoid) 18 Dokter Surabaya 69 15 Mei 2010 (BPH + LUTS) 31 Jul 2010 (H. - Nephro+Ureter (S)) 19 PNS Surabaya 61 19 Apr 2012 BPH - - 20 Pensiunan Surabaya 69 23 Sep 2013 BPH - - 21 Pensiunan Surabaya 74 6 Jun 2011 (BPH + Retentio) 3 Jun 2011/18 May - 2012 (HIM (D)) 22 - Surabaya 61 29 Jun 2009 (BPH + LUTS) 4 Feb 2014 (HIL (D)) - 23 PNS Surabaya 61 18 Mei 2013 (BPH + Retentio) - - 24 - Surabaya 68 21 Feb 2013 (BPH Gr. II + Retentio) - - 25 - Surabaya 61 4 Mei 2011 BPH - - 26 Direktur Surabaya 72 5 Mar 2008 (BPH Gr. I) - - 27 Pensiunan Surabaya 68 15 Sep 2010 (BPH Gr. II) - - 28 Pensiunan Surabaya 63 21 Sep 2012 (BPH Gr. II + Retentio) - - 29 Programm Surabaya 61 25 Feb 2013 (BPH Gr. II + LUTS) 24 Jun 2013 - er (Hemorrhoid Gr.III) 30 Supervisor Surabaya 59 5 Agu 2012 BPH 23 Nov 2012 ( Adeno - 71
Ca Prostate) 31 - Surabaya 70 11 Nov 2012 BPH - - 32 - Surabaya 61 19 Mei 2009 (BPH Gr. II) 2 Apr 2012 (CKD Gr. - II) 33 Pensiunan Surabaya 59 8 Feb 2009 (BPH Gr. I) - - 34 - Surabaya 65 6 Feb 2012 BPH - - 35 - Surabaya 67 25 Mei 2011 BPH - - 36 - Surabaya 64 6 Jan 2012 (BPH Gr. II + Retentio) - - 37 Pandu Surabaya 60 29 Nov 2011 BPH - - Madya I 38 - Surabaya 61 1 Mar 2013 (BPH Gr. III + BBB) - - 39 PNS Surabaya 62 14 Okt 2013 (BPH + LUTS) 12 Nov 2012 (Batu - Calix) 40 Gate Operation Staff Bangkalan 65 7 Okt 2013 (BPH + LUTS Berat) 7 Jul 2008 (ISK) - 41 PT. Pelni Surabaya 62 13 Mar 2013 (BPH + Retentio) 13 Mar 2013 - (H.Nephro (D)+Kista Ginjal (S)) 42 Pensiunan Surabaya 65 28 Agu 2013 BPH 28 Agu 2013 (Batu Ren (D)) - 43 - Surabaya 56 27 Feb 2012 BPH 25 Jan 2011 - (Hemorrhoid) 72
44 Juru Mudi Kapal Pandu Surabaya 59 20 Apr 2010 BPH 2 Sept 2013 (DKD Gr. II) 21 Okt 2013 (Orchitis)- 45 Direktur Surabaya 56 23 Nov 2010 BPH - 24 46 Dokter/PN Surabaya 72 21 Feb 2011 (BPH Gr. III + 11 Jul 2012 (Adeno Ca - S Retentio) Prostate) 47 PLN Surabaya 77 20 Nov 2013 BPH 14 Juli 2011 (HIL (D)) - 13 Juli 2011 (TB) 48 - Bangkalan 58 19 Jan 2009 BPH - - 49 Document Service Staff I Gresik 60 25 Jan 2013 BPH 25 Jan 2013 (CKD) - 50 Control Center Supp. Surabaya 62 2 Feb 2013 BPH - - 51 KKM Surabaya 56 5 Juni 2008 BPH 8 Mar 2013 (Post Op 17 Armata III HI Kambuh (2002)) 52 Direksi Surabaya 62 29 Mei 2013 BPH - - 53 - Pamekasan 54 18 Jul 2012 (BPH + LUTS) 28 Mar 2012 - (Hydrocele Testis (S)) 54 - Surabaya 64 28 Mar 2011 BPH - - 55 Pelaksana Pelayanan Surabaya 60 26 Des 2012 BPH 5 Des 2012 (CKD) - - 73
Gudang 56 - Bangkalan 67 21 Mei 2012 (BPH + LUTS) - - 57 PNS Surabaya 71 2 Apr 2012 (BPH Gr. III) - - 58 - Surabaya 71 1 Okt 2013 BPH - - 59 - Surabaya 63 30 Sep 2013 BPH 30 Sep 2013 (ISK + - Nephrolithiasis) 60 - Bangkalan 55 14 Feb 2013 (BPH Gr. II) 16 Feb 2013 (Batu Ginjal Bilateral) - 61 PNS Bangkalan 62 13 Mei 2013 (BPH Gr. II + 18 Sep 2013 (ISK) - Prostatitis Kronis) 62 Ass. Manager Sidoarjo 57 2 Feb 2012 (BPH + LUTS) - - 63 PNS Pamekasan 71 10 Jun 2013 (BPH Gr. II + 28 Agu 2013 (Colitis) - Hematuria) 64 - Bangkalan 67 4 Jul 2013 (BPH Gr. III-IV + Retentio) 10 Jul 2013 - (Hydronephrosis Ringan (D)) - - 65 PNS Bangkalan 71 27 Nov 2013 (BPH + ISK + Retentio) 66 - Bangkalan 76 16 Sep 2013 BPH 16 Sep 2013 (Susp. tumor Recti) 67 - Sampang 57 23 Okt 2013 BPH 23 Okt 2013 (Batu Ginjal (D) + Cystitis) - - 74
68 - Tulungagu 63 10 Mei 2013 (BPH Gr. II + LUTS) 19 Mei 2013 (HIL 7 ng Bilateral + HIM) 69 - Bangkalan 60 29 Jul 2013 (BPH + Retentio) 23 Jul 2013 (Kista - Ginjal (D)) 70 PNS Pamekasan 90 11 Nov 2013 (BPH + Retentio) 11 Nov 2013 (Kista - Ginjal (D)) 71 Gardening Surabaya 59 10 Jan 2011 BPH - - Supp. 72 Pensiunan Sidoarjo 59 17 Jan 2011 (BPH Gr. I + LUTS) 10 73 - Surabaya 71 29 Mar 2011 BPH - - 74 Pelaksana Surabaya 58 3 Des 2011 (BPH + Hematuria) - - Adm III 75 - Surabaya 63 26 Agu 2013 BPH 14 Des 2011 (Batu - Ureter (D) + Hydronephrosis Gr. I) 76 Cab. Dinas Jombang 59 13 Agu 2012 BPH - 4 Armada 77 Admin Surabaya 67 21 Mar 2013 BPH - - 78 - Surabaya 66 12 Mei 2008 BPH - IPSS Prom 79 PNS Surabaya 64 23 Nov 2009 (BPH + BBB) - - 80 - Surabaya 74 5 Jul 2013 BPH 22 Okt 2013 - (HT+CKD+Obstipasi) 75
81 PNS Surabaya 57 17 Feb 2011 (BPH Gr. II) - - 82 Direksi Surabaya 68 28 Okt 2013 BPH - - Pelabuhan / Pensiunan 83 Manager Pasuruan 59 6 Agu 2012 BPH - - 84 Pensiunan Surabaya 63 25 Nov 2009 BPH 9 Nov 2009 (Batu - Ginjal (D) + BBB) 85 - Surabaya 59 9 Okt 2012 BPH 17 Des 2013 (DKD Gr. - II) 86 Pensiunan Surabaya 60 9 Jun 2008 BPH 25 Mar 2009 (HIM - Imminens Bilateral) 87 PNS Bangkalan 68 3 Jun 2009 (BPH Gr. I + Retentio) 25 Jul 2012 (ISK) - 88 - Surabaya 61 4 Nov 2013 BPH 4 Nov 2013 (BSK) - 89 - Surabaya 52 10 Jun 2013 BPH - - 90 Pensiunan Surabaya 62 14 Okt 2009 BPH 14 Okt 2009 (Kista - Ginjal (S)) 91 - Sampang 52 6 Feb 2013 BPH - - 92 PNS Banjarmasi n 66 6 Mei 2013 (BPH + Retentio) - - 93 Pandu / Surabaya 63 10 Jul 2012 (BPH Gr. II-III) 29 Jun 2012 (HIL (D)) - Pensiunan 14 Jan 2013 (HIM (D)) 94 PNS Bangkalan 68 20 Mei 2013 BPH 4 Jun 2013 (HIL (D)) - 76
95 - Pamekasan 65 20 Des 2012 (BPH + Kista Ginjal - - (D)) 96 - Bangkalan 57 26 Agu 2013 (BPH + Retentio) - - 97 - Jakarta 59 23 Feb 2013 BPH - - 98 - Surabaya 74 6 Mei 2013 (BPH + Retentio) - - 99 PLN Surabaya 57 2 Okt 2013 BPH 23 Okt 2013 (CKD Gr. - V) 15 Nov 2013 (Batu Ginjal (D)) 100 - Surabaya 67 16 Jul 2013 BPH 19 Okt 2013 (BSK) - 101 - Bangkalan 63 16 Des 2013 (BPH + Retentio) - - 102 - Bangkalan 59 28 Okt 2013 BPH 28 Okt 2013 (Batu - Ginjal (D) + Hydronephrosis (D)) 103 - Surabaya 65 24 Feb 2013 (BPH + Retentio) - - 104 - Bangkalan 71 13 Agu 2013 BPH 13 Agu 2013 (BBB) - 105 - Surabaya 67 6 Jul 2013 (BPH + ISK + - - Retentio) 106 - Bangkalan 80 18 Jul 2013 (BPH + Retentio) 18 Jul 2013 (BBB) - 107 - Probolingg 70 7 Jul 2013 (BPH + Retentio) - - o 108 - Surabaya 71 13 Jun 2012 BPH - - 109 - Surabaya 68 30 Des 2013 BPH - - 77
110 - Surabaya 52 19 Jun 2013 BPH - - 111 - Sampang 61 29 Sep 2013 BPH - - 112 - Gresik 59 14 Okt 2013 BPH - - 113 - Bangkalan 70 26 Nov 2013 (BPH Gr. II) - - 114 - Sidoarjo 58 10 Des 2013 (Mild BPH) 10 Des 2013 (CKD Gr. - III+Batu Ginjal (S)) 115 - Surabaya 60 18 Nov 2013 BPH - - 116 Staff Muda Blitar 59 27 Agu 2010 BPH 28 Jan 2009-18 Des - 2013 (BSK) 117 - Surabaya 59 8 Jul 2011 (BPH XXL) - - 118 Operation Surabaya 61 21 Feb 2012 BPH 30 Jul 2013 (HIL (D)) - Senior Staff 119 Supervisor Surabaya 60 11 Jul 2011 BPH 13 Mei 2013 (LUTS) - 120 Supervisor Sidoarjo 57 5 Nov 2008 (BPH Gr. I + LUTS) - - 121 - Bangkalan 59 26 Jun 2013 BPH - - 122 Admin Surabaya 61 1 Feb 2010 (BPH Gr. I) - 15 123 Pandu Surabaya 63 26 Nov 2012 BPH 22 Apr 2013 (ISK) 11 Madya I 124 - Bangkalan 75 8 Apr 2013 (BPH Gr. II) - - 125 Pensiunan Surabaya 68 3 Des 2011 BPH 5 Des 2011 (Kista - Ginjal Bilateral + Divertikel Buli-Buli) 78
126 - Surabaya 75 14 Okt 2013 BPH 9 Nov 2012 (Massive - Urothelial Ca) 127 - Bangkalan 63 30 Okt 2013 (BPH Gr. II + LUTS) - - 128 - Surabaya 64 6 Agu 2013 (BPH + Retentio) - - 129 - Surabaya 87 12 Apr 2013 (BPH + Retentio) 5 Mei 2013 (ISK + - Obstipasi + Nefrolithiasis) 130 - Surabaya 47 17 Jun 2013 (BPH + LUTS) - - 79