# Need HELP! Cystoscopy with transurethral incision of the prostate.



## jwschroeterjr@gmail.com (Feb 22, 2011)

How would you code this procedure?
PREOPERATIVE DIAGNOSIS:
Bladder outlet obstruction.

POSTOPERATIVE DIAGNOSIS:
Bladder outlet obstruction.

OPERATION:
Cystoscopy with transurethral incision of the prostate.

ANESTHESIA:
General by LMA.

ESTIMATED BLOOD LOSS:
5 to 10 mL.

SPECIMENS:
None.

DRAINS:
22-French Foley catheter.

COMPLICATIONS:
None.

FINDINGS:
Elevated bladder neck. Moderate bladder trabeculation. Mild lateral lobe enlargement of the prostate.

INDICATIONS;
This is a gentleman with significant outlet obstruction, documented urodynamically with elevated voiding pressures and poor flow rate. He has a constellation of symptoms, including frequent urination, nocturia, urgency and diminished urinary stream. He presents now for the above procedure after thorough discussion about the risks and benefits. He has a history of elevated PSA, Previous prostate ultrasound done in May revealed a 40-gram prostate. His biopsies were all negative. He understands the risks' of infection, bleeding, postoperative incontinence. He also understands that he will have retrograde ejaculation following this procedure as a natural result of the procedure.

TECHNIQUE:
The patient was given prophylactic antibiotics. He was administered general anesthesia by LMA. He was then prepped and draped in lithotomy position, The 24-French resectoscope sheath was introduced with the Timberlake obturator. Using a 12-degree lens and a Collins knife, the incision was made at the 6 o'clock position after identifying the orifices and carefully avoiding them throughout the procedure. The incision was made from just inside the bladder neck and carried all the way to the verumontanum. This was a full-thickness incision through all muscle layers, which resulted in a wide-open outlet. Spot cautery was then used for any hemostasis. No significant bleeding was noted. A 22-French Foley catheter was introduced with a catheter guide. A leg bag was applied.

The patient was taken back to the recovery room in stable condition. I will see him back tomorrow for catheter removal in the office.
Undo


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## Kelly_Mayumi (Feb 26, 2011)

A TUIP is 52450.  The AUA recommends for an incision of a bladder neck contracture with a knife to use 52276.


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## NaliniAAPC (Feb 26, 2011)

Hi,
Cystoscopy with transurethral incision of the prostate-52450.

Regards,
Nalini CPC


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