# nephroureterectomy



## daniel (Mar 5, 2014)

I'm looking at CPT 50234,38780..

Can I get some input on what you would select? thanks





OPERATION PERFORMED:  Laparoscopy, right nephroureterectomy (open single incision with bladder cuff) with retroperitoneal lymph node dissection.


FINDINGS:   
Intense induration in the area of the renal hilum and inferior to the hilum where the kidney and the proximal ureter were adjacent to the vena cava.
Laparoscopic nephrectomy converted to open due to this induration and tethering the vena cava to the kidney.   
Pericaval, perihilar, intra-aortic caval lymph nodes removed in lymph node dissection.  The lymph nodes were indurated and consistent with metastatic transitional cell carcinoma.
The kidney and ureter were removed en bloc with a cuff of bladder.  The bladder was closed in 2 layers.


DESCRIPTION OF OPERATIVE PROCEDURE:  The patient is a 67-year-old female who has a several month history of right flank pain and gross hematuria.  She was diagnosed with a poorly-functioning right kidney and a proximal ureteral mass.  Right nephroureterectomy was indicated.  We intended to do a laparoscopic technique if possible.  


The patient was sterilely prepped and draped and after appropriate time-out a midline incision was made around the umbilicus.  The gel port was placed.  The camera was inserted and abdomen inspected.  There were no significant abnormalities noted.  Next, a 10-12 port was placed in the midclavicular line above the gel port and a 5 mm port was placed in the midaxillary line, opposite the gel port and another 10-12 port was placed in approximately the midclavicular line inferior to the gel port.  The hand was inserted and advanced lapper scope was inserted.  An incision was made lateral to the colon at approximately the line of Toldt.  The right colon was reflected medially.  The vena cava was identified.  The duodenum was dissected off of the vena cava and retracted medially.  The kidney was found to be indurated and the area of the hilum and the kidney adjacent to identified the cava appeared to be indurated and mobile. An attempt at further dissection was undertaken by then mobilizing the vena cava off of the kidney and proximal ureter, it was clear that this intense induration and inflammatory reaction tethered the vena cava and it was deemed to not be the most prudent course to continue laparoscopically.  We then repositioned the patient and a midline incision was made from approximately the xiphoid down to the symphysis pubis.  The Bookwalter retractor was placed.  Using sharp and blunt dissection electrocautery the vena cava was dissected off of this inflammatory tissue.  It had the appearance of metastatic transitional cell carcinoma and was very indurated.  The right renal artery was identified.  It was double tied with 0 silk and transected.  The renal vein was identified and using the Endo-GIA stapler it was stapled.  The kidney was then mobilized and left attached to the ureter.  The kidney was mobilized down past the iliac vessels.  The retroperitoneal lymph node dissection was then undertaken and the indurated lymphatic tissue to the right side of the vena cava under the vena cava and in the interaortocaval region was removed.  The lymphatic pedicles were clipped with Hem-o-Lok clips, were tied with 0 Vicryl.  The tissue was sent as specimen.  There was no residual indurated tissue.  The right adrenal gland was spared.  Attention was then turned to the completion of the ureterectomy portion and removal of the cuff of bladder.  Using the LigaSure device the ureter was dissected distally to the level of the bladder.  Several ureteric branches from the internal iliac artery going medial to the ureter were controlled with 3-0 silk.  The ureter was dissected down to the level of the bladder and the intramural ureter was dissected.  The bladder cuff was removed and the 2 ends of bladder were identified.  Using a 2-0 Monocryl suture the distal end was identified and the Monocryl suture was used to run the mucosa superiorly.  Another 2-0 Monocryl suture used was used to reinforce bladder muscle over the closure.  The patient had a 22-French catheter in that was irrigated, there was no wound leak of the bladder.  The pelvis was irrigated.  Hemostasis was achieved and the pelvis reperitonealized.  Both ovaries and the uterus were viable and they had been retracted medially and they were repositioned.  A 10-French JP was placed.  The renal hilum and vena cava and renal fossa were then inspected and re-irrigated.  There was good hemostasis.  The right colon was placed in its normal position and the small bowel positioned.  The trocar sites were closed with #1 Vicryl Carter-Thomason.  The midline incision was closed with #1 double looped PDS and the subcutaneous tissue was closed with 0 Vicryl and the subcutaneous tissue was irrigated.  Hemostasis was achieved and the skin closed with staples.


RAPID FROZEN SECTION DIAGNOSIS:  None.

SPECIMENS REMOVED:  Right kidney, right ureter bladder cuff, para venocaval, perihilar and intra-aortic caval lymph nodes.


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## IndepCoder (Mar 5, 2014)

What do you think about 50236, the removed specimens was thru a second incision made midline from aprox xipoid down to the symphysis pubis able to remove (to the level of the bladder)? OP NOTE

In 50234 access is kidney and upper ureter (incision flank area).


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## IndepCoder (Mar 5, 2014)

As for the nodes I don't have access to CPT Assistant for help. Looking at report and the desk ref states use 38564 if retroperitoneal Lymphadenectomy. Falls under Limited 

Falls under Radical
38780 nodes are removed by groups.  

The removal was carried our as an integral compoent of service. Both are SP Codes see guidelines in CPT book.


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## daniel (Mar 6, 2014)

Thanks for the reply. I'll look into the code you recommended.


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## IndepCoder (Mar 7, 2014)

Welcome!


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