# Cystourethroscopy help needed please



## Kisha (Aug 3, 2012)

*Operative Procedure*:  
1. Cystourethroscopy with ureteral stent removal
2. Left ureteroscopy/pyeloscopy with laser lithotripsy
3. Left ureteral stent placement
4. Attempted basket extraction of left renal stone
5. Fluoroscopy with interpretation

The patient was taken to the operating suite.  After general anesthesia the patient was placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion. All pressure points were appropriately padded.  A time out was performed including confirmation that the patient had received appropriate preoperative antibiotics.  A pelvic exam was performed demonstrating anodular 25 gm prostate.  Cystourethroscopy was performed with a 22 french rigid cystoscope and the urethra, bladder neck, and bladder mucosa were surveyed and noted to be nromal.  The ureteral orifices were identified and noted to be in orthotopic position.  A scout KUB was performed with fluoroscopy with the above findings.  The left ureter was identified with a left ureteral stent in place. The distal end of the stent was grasped and brought to the urethral meatus.  An attempt was made to pass a sensor wire under fluoroscopic guidance via the ureteral stent, however, the stent had become dislodged. Rigid cystoscopy was performed and the left ureteral orifice was identified and intubated with a sensor wire, which was guided to the level of the renal pelvis under fluoroscopic guidance.  Over the wire a 5 french open-ended cathter was placed under fluoroscopic guidance into the distal ureter.  The wire was removed and a retrograde pyelogram was performed and interpreted with no hydronephrosis or abnormal filling defects except the left lower pole stone previously mentioned.   The sensor wire was replaced to the level of the renal pelvis under fluoroscopic guidance and the 5 french catheter was removed.  The bladder was emptied and the cystoscope was removed leaving the wire in place.  Over the wire and under fluoroscopic guidance 8 and 10 french coaxial dilators were placed into the ureter to just proximal to the level of the sacroiliac joint. The 8 french was removed.  A benson wire was placed via the 10 french catheter to the level of the renal pelvis under fluoroscopic guidance and the 10 french was removed.  The benson wire was secured as a safety wire and the sensor was used as a working wire.  The flexible ureteroscope was passed over wire under fluoroscopic guidance to the level of renal pelvis.  The working wire was removed.  There were small 1-2mm fragments of stone in the mid pole system and the larger ~1cm stone in the lower pole. It was difficulty to navigate into the lower pole system and an attempt to lithotripsy the stone with a 600 um fiber was not successful. Three different baskets/endoscopic graspers were attempted to manipulate the stone out of the lower pole to an easier location for lithotripsy without success.  An attempt was made to perform lithotripsy with a 270 um fiber with the holmium laser. This was unsuccessful. A smaller 2mm stone fragment was treated with the laser and fragmented into dust.  Pyeloscopy and ureteroscopy was performed confirming no additional stone burden other than that mentioened.  The ureteroscope was removed completely and atraumatically.  It was decided that the best avenue for treatment of this lower pole stone would be a percutaneous nephrostolitomy.  A 6F x 24cm JJ ureteral stent was placed over the safety wire in the usual fashion under fluoroscopic guidance.  The proximal curl was confirmed in the renal pelvis under fluoroscopy and the distal curl  In the bladder under directed visualization. The bladder was emptied and all instruments were removed completely and atraumatically.

I come up with 52353, 52332, 50392-53, 50390. My supvr wants me to delete the last 2cpt's and add 50081. I don't agree with that.


----------



## cwharvey (Aug 3, 2012)

I agree that you cannot report  the 50081, there was no nephrolithotomy performed.  I only see 52353-LT and 52332-LT.


----------

