# Robotic Cystectomy



## emilyadams1993@yahoo.com (Apr 16, 2015)

Procedure Performed:
Robotic radical cystectomy
Robotic radical prostatectomy
Robotic bilateral pelvic lymph node dissection.
Ileal conduit urinary diversion
Ureteral stents placement
Left radical nephroureterectomy
Robotic extensive lysis of adhesions more than 1.5 hours


Indications:
64 y.o. male with history of gross hematuria, severe LUTS. Found to have at least high volume HG T1 UC of the bladder covering the majority of his bladder with cancer in diverticula. In addition he was found to have left renal mass with atrophic kidney and right lower pole renal stones. The patient had foley catheter for weeks and had multiple UTI's these were never cleared due to his high volume cancer. I explained to the patient that a cystectomy is a major operation to remove the bladder. In men, the bladder, prostate, seminal vesicles and lymph nodes are removed. In women, the bladder, urethra, part of the vagina and lymph nodes are removed. In addition, the uterus, fallopian tubes and ovaries may be removed. I explained that possible post operative complications. Overall 65% of patient will have a complication such as but not only, infection, bleeding, bowel obstruction, bowel leakage, erectile dysfunction in males, cardiovascular, pulmonary and clotting complications. Most of these complications are low grade complications and about 13% having high grade complications. And the risk of death is around 3% within the first 3 months after surgery.


I explained to the patient that when the urinary bladder is removed another method must be devised for urine to exit the body. Urinary reconstruction and diversion is a surgical method to achieve this goal. 


The patient was informed that he may have more complications due to his history of multiple abdominal surgeries. The fact that he had SBO and bowel resection and the fact that he will need nephroureterectomy  


Findings:
This was an extremely complex surgery. The patient had extensive adhesions that were taken down laparoscopically, then robotically and after extraction more was done to free the loops of bowel. We did the nephroureterectomy first followed by the rest of the procedure. There was extensive inflammatory reaction around the bladder and we had difficulty dissecting the rectum off the prostate. No bowel injury was noticed. 



Procedure:    
After informed consent was obtained, the patient was brought to the operative table and placed in supine position. Intravenous antibiotics were administered. After successful induction of general anesthesia with endo tracheal intubation without difficulty, sequential compression device were placed on lower extremities. The patient was repositioned into a modified dorsal lithotomy position with spreader bars. All pressure points were padded adequately. Bimanual examination revealed a mobile bladder with no direct invasion to the pelvic side wall.  

The patient was prepped and draped in standard sterile fashion. 22 French urinary catheter was placed in sterile condition, the ballon was inflated with 30cc sterile water. and placed to gravity drainage. The table was tilted to the right side at 45 degrees for the nephrectomy part. 

 A scalpel was used to make an incision of 12 mm in length in the midline above the umbilicus, through which the Veress needle was placed. Using a 10 cc syringe with normal saline the position was confirmed. The abdomen was insufflated and a 12-mm port was placed.  The scope was used to guide placement of the remaining ports including three 8-mm ports for the robotic instruments and a single 12-mm port for the assistant. One extra port was placed in the LUQ for the nephrectomy part.  The robot was then docked and the remainder of the radical cystoprostatectomy and pelvic lymph node dissection was done robotically.     


Nephrectomy:


The robot was then docked on the left side of the patient. The remainder of the procedure was done robotically. The colon was reflected away from the underlying retroperitoneum and gerota's fascia. The spleen was reflected as much as possible to open this space, eventually allowing identification of gonadal veins and the ureter. These were dissected to the renal vein. The aorta was eventually identified to aid in the location of the renal artery. Upon controlling the artery and vein. The renal artery was triple clipped with Hem-o-loc clips proximally and one distally, the renal vein was stapled with EndoGIA with vascular staple. The gonadal vein was spared. The perinephric fat was dissected off the spleen and pancrease. A plane was developed between the upper pole and adrenal gland and the adrenal was spared.  The kidney was completely freed, the ureter was clipped. Hemostasis was confirmed and Nu-knit was placed. The specimen was placed in a endobag.   


The camera port was extended in the peri umbilical area. The specimen was extracted. A gel port was placed for the rest of the procedure, the camera post was placed through the gel port.          

The ascending colon was mobilized by incising along the white line of Toldt laterally. This was swept around the base of the cecum, up to the root of the small bowel to the crossing of the duodenum. The right ureter was identified as it coursed deeply into the pelvis. Vesseloop was used to isolate the ureter and help dissecting it. The dissection was carried all the way to the bladder wall and superiorly above the pelvic rim. All vessels were cauterized or clipped. The ureter was then clipped with a large Hem-o-loc clip proximally and divided with scissors. The sigmoid colon was similarly mobilized by incising along the white line of Toldt laterally. The left ureter was identified dissected and clipped and divided in similar fashion. 


Bilateral pelvic lymph node dissection was stared at the bifurcation of the aorta and vena cava just below the IMA. Common iliac nodes were swept distally down to the level of the bifurcation of the common iliac vessels and extended distally to the lymph node of Cloquet. All identified lymphatics were clipped or ligated. The external iliac artery and vein were stripped of their lymphatic tissues and swept into the obturator fossa. The obturator nerve and vessels were identified and preserved through out there course. The lymph node dissection included the external iliac, obturator, the hypogasteric and the presacral lymph nodes. These were sent as separated specimen and.




The posterior plane was then dissected widely including the seminal vesicles and the plane between the rectum and prostate.  At this point, the lateral dissection was performed, leaving the urachus intact to maintain anterior retraction of the bladder.  The cul-de-sac was then opened and a plane was created between the rectum and the bladder exposing the posterior pedicles. The lateral vascular pedicles were identified and taken down to the level of the pelvic floor with Endo-GIA stapling device with vascular clips. Identical dissection was done on the contralateral side. The posterior pedicles were then isolated, clamped and ligated with Endo-GIA stapler and later oversewn with 2-0 Vicryl sutures after removing the bladder. To the level of the seminal vesicles and the prostate. The endopelvic fascia was open bilaterally. The levators were brushed laterally. The periprostatic nerves were identified and dissected off the prostatic capsule. 


The urachus was then divided and the bladder was dropped.  The dorsal vein complex was controlled with a Vicryl suture and divided.  The specimen was then placed in an EndoCatch bag.  The pelvis was then irrigated and inspected for hemostasis, which was confirmed.  The left ureter  was tunneled under the sigmoid mesentery.  The extraction       incision was then made around umbilicus of 2 inches in length. The specimen was then extracted and the ureters brought up through this incision including the segment of ileum.  


Attention was then turned to the formation of the ileal conduit. Approximately 12-15 cm of ileum was isolated about 15 cm from the ileocecal valve. Mesenteric windows were made in the usual fashion using Ligasure, then the bowel was divided with an Endo-GIA stapler. The small bowel continuity was restored in a side to side fashion using the end GIA and the TA 55 staplers. The anastomosis was widely patent and there was no evidence of ischemia or leakage. The ends of the staple line were covered with mesenteric fat using 3-0 silk sutures. The crotch of the anastomosis was secured and the mesenteric trap was closed with interrupted 3-0 silk sutures. 


Both ureters were implanted into the proximal end of the ileal conduit over 8 French feeding tubes in a Bricker type fashion using interrupted 4-0 Vicryl sutures. Both ureters were tacked to the conduit with 5-0 silk sutures. The conduit was then filled with a sterile saline solution both ureters freely refluxed and there was no evidence of leakage from the anastomoses. 


Attention was then turned to formation of the stoma. A previously selected site in the right lower quadrant was utilized. A circle of skin was removed using the skin knife and then the subcutaneous fat was spread down to the fascia which was opened in a cruciate fashion. The rectus muscle was spread using Kelly clamps and then the conduit was brought through the abdominal wall taking care not to torque the mesentery. The stoma was matured in a rose bud type fashion after tacking the stoma to the fascia with four interrupted Vicryl sutures to prevent peristoma hernia. The stents were secured in place with drain sutures. The abdomen was reinspected for hemostasis, the bowel was run from the small bowl anastomosis to the ligament of Trietz and replaced in its normal position the bowel was covered with omentum. 


 The midline extraction incision was then closed using interrupted figure-of-eight Tycron sutures.  The port sites were then closed with Biosyn and Dermabond, using Vicryl to reapproximate the fascia at the 12-mm port sites.  The On-Q pain pump system was used for additional postoperative analgesia with placement of two catheters tunneled subcutaneously to the extraction site incision continuous infusion of Marcaine.  The patient was then taken to the recovery room after reversal of anesthesia.  He will be admitted for standard postoperative 


How Would I code this? 
There is no code for laparoscopic cystectomy


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## emcee101 (Apr 20, 2015)

You are definitely correct about the lack of a code for a laproscopic cystectomy. I'd love to know a reason why CPT has failed to add this when so many are performed. I would code this as follows: 

*50546-LT *- nephrectomy, including partial ureterectomy. (this is not a radical nephrectomy since the doctor states in the op note that the adrenal was spared)


*51999 *- Unlisted laproscopic procedure, bladder - since this is an unlisted code, you      should send an op note with the paper claim after the first claim gets denies. I        would asso send a letter of explanation signed by the doctor, showing the  similarity of the work he performed to the code for the correct open procedure (51595 - this code includes the prostatectomy, urinary diversion and the bilateral pelvic lymphadenectomy)
With this information you should be paid accordingly, based off of RVU values to the open procedure. 

Although he mentions them briefly and notes that they were secured, there is not documentation of stents placement and how it was done so I did not code for this. 

Also, the lysis of adhesions, which was done out of necessity to perform the intended procedure, would not be billed separately since it is bundled into the nephrectomy. If there was better documentation of the extensive amount of time taken at multiple points during the procedure then you should also make note of this in the letter of explanation that you should send with the op note and paper claim. This may help to increase your reimbursement but there is no guarantee.


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