# help please - need help with this



## elainehopf (Feb 7, 2014)

need help with this procedure code ... PLEASE




PREOPERATIVE DIAGNOSIS:  Urethral stricture.
POSTOPERATIVE DIAGNOSIS:  Urethral stricture.
PROCEDURES:
1.  Transecting anastomotic urethroplasty.
2.  Cystoscopy.
Dash 22 modifier for difficult exposure due to scar tissue and distorted
anatomy from his multiple prior perineal surgeries.
FINDINGS:
1.  Short mid bulbar urethral stricture, surrounded by dense scar tissue.
2.  Distorted perineal anatomy with no perceivable bulbospongiosus muscle
and dense scar around the site of prior sphincter placement.
DRAINS:  A 16-French urethral catheter.
COMPLICATIONS:  None.
INDICATIONS FOR PROCEDURE:  a 71-year-old man with a
history of urinary incontinence that was treated with an artificial urinary
sphincter.  This was done in 2013, and at that time, the patient was found
to have a cuff erosion and required removal about 5 months later in 2013. 
Since then, he has healed his urethra, but has developed recurrent bulbar
stricture disease.  His most recent exam in the operating room showed a
short bulbar stricture with dense white scar tissue endoscopically.  The
patient presents today for definitive urethroplasty with possible mucosal
graft harvest if required.  All risks and benefits of this procedure were
discussed in detail with the patient and all questions were answered to his
satisfaction.  Risks of surgery in general includes bleeding, infection,
cardiopulmonary event, stroke, DVT, positional injuries, even death.  Risk
of our surgery, in particular includes injury to the penis, urethra,
prostate, bladder; need for further procedures; need for prolonged
drainage; urinary extravasation; stricture recurrence as well as other
adverse events not otherwise anticipated.  The patient understands these
risks and strongly wishes to proceed.  He gave us his consent.
DETAILS OF PROCEDURE:   identified and consented
preoperatively.  He was then brought to the operating room where IV
antibiotics were administered and general anesthesia was induced.  SCDs
were placed and working prior to induction.  He was then placed in the
dorsal lithotomy position and prepped and draped in the usual fashion.  A
time-out was done to confirm the correct patient and procedure.
We then used a rigid ureteroscope and passed it through the urethra and
identified the bulbar urethral stricture.  We were barely able to negotiate
past it as it has recurred since his last procedure.  We then identified
moderately coapting lobes of the prostate with a very small median lobe. 
There were no bladder trabeculations, no bladder stones, no bladder
lesions.  We then left the wire in place and removed the ureteroscope.  We
then shot methylene blue down through the urethra.  Next, we used the
bougie to demarcate where the distal aspect of the stricture was.  We then
centered our midline perineal incision around this.  We used the old scar. 
We then carefully dissected through the perineum as the patient has had 2
prior perineal surgeries.  This took quite a while as there was no
discernable recognizable anatomy.  We carefully went through layer by
layer, so as not to injure the urethra.  Once we identified the corpus
spongiosum, with careful dissection, we noticed that at the site of the
prior sphincter placement, there was dense scar, causing a waist banding of
the bulbar urethra.  The proximal and distal aspects of the corpus
spongiosum were normal.  Once we cut through the dense scar, we
circumferentially dissected around the urethra.  We dissected all the way
up to the penoscrotal junction distally so that there would be enough
laxity to perform a transecting anastomotic urethroplasty.  We then also
dissected proximally.  Once this was done, we transected the urethra where
the scar tissue was and then excised the scar tissue.  We then spatulated
the proximal segment dorsally and the distal segment ventrally.  We then
placed seven 5-0 PDS holding sutures in an interrupted fashion.  We placed
it at 12 o'clock, 6 o'clock, 2 o'clock, 4 o'clock, 8 o'clock, 10 o'clock, 5
o'clock and 7 o'clock locations.  Once all our stitches were preplaced, we
put our 16-French urethral catheter into the bladder.  We then put 10 mL of
water into the balloon.  This drained clear urine.  We then tied down all
our sutures.  Once all our sutures were tied down, we used a 5-0 PDS in a
running fashion to close the tunica albuginea in a running fashion
circumferentially around the entire tunica albuginea of the corpus
spongiosum.  Once this was done, we irrigated the wound copiously with
saline.  We then closed the fibrotic layer consistent with bulbospongiosus
with 3-0 Vicryl in a running fashion.  We then closed the dartos and
Colles' fascia with 2-0 Vicryl in a running fashion.  We then closed the
skin with 2-0 chromic in a vertical interrupted mattress fashion.  There
was good hemostasis at the end of procedure.


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## trinalankford (Feb 13, 2014)

It would appear to me to be 53410, one-stage urethroplasty reconstruction of male anterior urethra, with the -22 difficulty modifier...and because CCI edits allow it, 52000 cystoscopy with modifier 51 for additional procedure.

I would be curious as to any other opinions, however, since my doc doesn't typically do urethroplasties.


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