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Complicated Ureteral-Ileal Anastomosis With Existing Loop

Published on Sun May 13, 2012

How would you report this procedure?Test your operative report interpretation skills with this case study from a Urology Coding Alert subscriber in Illinois.Preoperative diagnosis: Bilateral ureteral traumaPostoperative diagnosis: Bilateral ureteral traumaProcedure: Bilateral ureterolysis and bilateral ureteral-ileal anastomosisDrains: Bilateral single J ureteral stents and 10-mm Jackson-Pratt drainHistory: Patient is a 63-year-old man undergoing colorectal surgery. There was extensive scarring and during the course of the colorectal surgery, it was discovered that both ureters had been transected from the patient's existing ileal loop which had been placed in December 2011 following radical cystectomy for bladder cancer. Operative Procedure: With the patient asleep and with the abdomen open from the colorectal surgeon, I was able to scrub and enter the operative field. The ileal loop was identified including a small stump of the right transected ureter noted and the left ureter appeared to have been transected at the level of the [...]
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