Miko24
Guru
Initially, I passed a 22 French Storz cystoscope sheath into the urethra under direct vision. The anterior urethra appeared normal. In the bulbar urethra, he did have some evidence of chronic stricture, although I was able to pass the scope through it. Interestingly, right at the apex of the prostate lateral to the verumontanum, there were 2 wide open false passages which led into a very large cavity in the expected location of the prostate. This was easily large enough to drive the 22 French cystoscope into, and appeared to extend throughout the expected location of the prostate. It did appear to be epithelialized. I then retracted the scope and redirected it more anteriorly, and was able to advance the scope into the lumen of the bladder. The bladder was drained, and a large amount of dark/cloudy/purulent urine was drained. I then placed a 0.035 in flexible tip guidewire into the bladder in order to maintain access. The cystoscope was removed, and the 25 French Storz continuous-flow resectoscope sheath was passed into the bladder under direct vision using the visual obturator. I then basically unroofed the large infravesical cavity to allow it to freely communicate with the bladder and urethra. Tissue resected had the gross visual appearance of prostate. I did NOT resect the floor of the bladder, leaving it intact to level of the bladder neck. I was able to open these false passages and and drain out the fluid that was in them. There was no obvious pus. Please note that the original defect which allowed access into the cavity was very distal in the prostate, near the apex, lateral to the verumontanum as previously described. I did not do any formal resection distal to the verumontanum, but based on the location of the original lesions, I suspect that this patient may be at significantly increased risk for incontinence going forward. Once this had been accomplished, I elected to terminate the procedure. Specimen (prostate chips) were hand irrigated from the bladder and sent to pathology for routine analysis. I then placed a 24 French catheter into the bladder with 30 mL in the balloon. Catheter was hand irrigated to confirm placement. It was pulled down on traction and secured to the patient's leg. He was awakened brought to recovery in stable condition. He tolerated the procedure well. There were no immediate complications.
I am unsure if I should be coding the 52601 unless I possibly add the 52 modifier.
I am unsure if I should be coding the 52601 unless I possibly add the 52 modifier.