# Second opinion needed



## akj (Nov 14, 2014)

Please see OP note below.  For anesthesia service provided for procedure referenced below, I am coming up with 00864--Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; total cystectomy.  Can anyone confirm this, or suggest another code?  Thanks! 

OPERATION PERFORMED:
1.  Radical cystoprostatectomy with ileal loop urinary diversion.
2.  Extended bilateral pelvic lymph node dissection.
3.  Appendectomy.

POSTOPERATIVE DIAGNOSIS:
Muscle-invasive bladder cancer.

DESCRIPTION OF PROCEDURE:

The patient was taken back to the operating room in good and stable condition and underwent general endotracheal anesthetic without difficulty.  The patient was in the supine position on the operating table.  The region of the perineum and abdomen were sterilely prepped and draped in the usual fashion.  A midline incision was then performed from the pubis up to the left of the umbilicus and approximately 2 cm above the umbilicus.  This was dissected down to the anterior rectus sheath which was then opened in the midline.  The peritoneum was entered.  Using dissection, the urachus was taken down to the dome of the bladder.  The space of Retzius was opened up.  Primary extensive lymph node dissection was then performed in routine fashion over the right and left.  The dissection went from the common iliac down to the takeoff of the circumflex and the external iliac vein and down to the region of the obturator.  All the lymph nodes were sent to pathology, both on the right and left.  Of note, the hypogastric distal to the posterior rectal branch was ligated.  The obliterans umbilicus was taken down on the right and left which allowed good exposure of the ureters.  The ureters were taken down near the region of the intramural ureter where they were clamped and ligated.  The distal ureters were sent to pathology; frozen sections were negative. 

Our attention was then turned to the cystoprostatectomy.  The peritoneal 
reflection was taken down between the bladder as well as the rectal space.  This space was opened up using blunt and sharp dissection.  Having completed the above, the endopelvic fascia was opened primarily.  The dorsal venous complex was ligated with a #1 Vicryl tie.  The dorsal venous complex was taken down. The urethra was cut at the apex of the prostate.  The posterior pedicles of the prostate were taken down using a right angle and 0 silk ties.  Having completed the above, the only part of the dissection that was left was the posterior pedicle of the bladder.  This was taken down using Pean clamps with #1 Vicryl suture ligatures.  A specimen was then removed.  Hemostasis was meticulously achieved.  

Our attention was then turned to developing the ileal neobladder.  This was
performed in a classic fashion using approximately 65 cm of ileum, 15 cm from
the ileocecal junction.  This was taken down with its mesentery, taking great
care to preserve the mesentery.  The bowel anastomosis was then performed 
superior to the ileum that was going to be used for the neobladder and this was performed in a side-to-side fashion using a GIA 55 stapler, closing the end with a TA 60 stapler, and oversewing all suture lines with interrupted 3-0 silk sutures, resulting in inverting the staple line inward.  Mesenteric defect was also closed with a running 3-0 silk suture.  The bowel was then opened up in a classic fashion at its antimesenteric side.  The bowel was configured in a W fashion.  The posterior limbs of the W were then sutured together using a 2-0 Vicryl suture full-thickness single-layer through and through.  Subsequently the W was brought around and sutured with a 2-0 Vicryl as well, single-layer full-thickness.  The neobladder neck was developed at the very inferior aspect of the W.  The mucosa was everted outward and sutured in place with interrupted 2-0 chromic sutures.  Subsequently the urethra was sutured to the neobladder neck using the Greenwald sound and putting a 2-0 Monocryl suture at 2, 5, 6, 8, 10 and 12 o'clock respectively.  A 22-French catheter was then used to cross this anastomosis as a bridge and as the permanent Foley catheter.  Subsequently the ureters were sutured into the neobladder in an anti-refluxing fashion by making a small submucosal trough and then suturing it in a spatulated fashion in the posterior wall of the W.  The ureters were spatulated for approximately 2 cm.  The ureteral mucosa was sutured to the mucosa of the ileum with interrupted 4-0 Monocryl sutures.  The ureter was fastened to the neobladder with interrupted 3-0 Vicryl sutures, serosa-to-serosa, outside of the neobladder. The anastomoses were then stented with 8-French variable length stents which were indwelling.  The neobladder was then completely closed with full-thickness
2-0 Vicryl sutures. The neobladder was then filled with approximately 300 mL
and tested to be watertight.  The bladder was irrigated clear, no leakage was
identified.  A 10-French Jackson-Pratt drain was then placed in the pelvis and
exited through a separate stab incision over the left.  The abdominal incision
was closed with a running #1 PDS x2, after ensuring all instruments, lap,
sponge, and needle counts were correct.  The skin was reapproximated with
staples.  

Of note, the patient's appendix was identified coming off the cecum.  The
patient underwent an appendectomy in classic fashion to avoid the potential of having to return secondary to appendicitis down the road.  The appendix was ligated at the base of the cecum and was excised.  The ligated appendiceal stump of note had been tied with a 2-0 silk tie.  The appendiceal stump was then inverted into the cecum using a pursestring suture of 3-0 silk, having inverted this in completely.  The patient was noted to have good hemostasis to this area.  

The abdominal incision was closed with a running #1 PDS x2, after ensuring all instruments, lap, sponge, and needle counts were correct.  The skin was
reapproximated with staples.  

COMPLICATIONS: None.  

CONDITION: Stable.  

DRAINS: A 10-French JP drain and two 8-French urinary diversion stents.


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## Amy Pritchett (Nov 14, 2014)

Do you have an Anesthesia Cross-Coder? You can look up your CPT codes and then cross-reference to the anesthesia. This is a great tool to purchase if you do not have one


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## akj (Nov 17, 2014)

Hi Amy--I have access to two different cross walks.  Urology is not my favorite to code and I am just looking for validation....


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## Amy Pritchett (Nov 18, 2014)

I came out with CPT code 51575 and 44979. The anesthesia code would be 00864 according to the cross-coder. 

I hope this helps you!


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## akj (Nov 18, 2014)

Yes, thank you...the confirmation helps me.


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