toria11
Guru
Is it appropriate to bill for an attempted urethral dilation? The provider attempted to dilate with several different sizes before moving on to replace the SP Tube. Thanks!
POSTOPERATIVE DIAGNOSES: 1. Severe urethral stricture. 2. Urinary retention.
PROCEDURES PERFORMED: 1. Attempted cystoscopy with urethral dilation.
2. Upsizing a suprapubic catheter.
ANESTHESIA: General.
DRAINS: 18 French suprapubic catheter.
FINDINGS: Severely stenotic urethral stricture just inside the urethral meatus, unable to pass guidewire,
cystoscopy or dilate.
DISPOSITION: Stable to Recovery.
INDICATIONS FOR PROCEDURE: The patient is a 75-year-old male with a longstanding history of
urethral stricture who had a recent stroke. He went into urinary retention. He returned with a possibility of Foley catheter, but he had severe urethral stricture just inside his
urethral meatus. Therefore, he had a suprapubic catheter placed by interventional radiology. He had
previous dilation of his urethral stricture approximately 10 years ago. The patient presents today for
potential cystoscopy using dilation and SP tube removal. After risks, benefits, and alternatives were
explained to the patient, the patient elected to proceed, and informed consent was obtained.
DETAILS OF PROCEDURE: The patient was properly identified and brought back to the operating
room where he was laid supine on the operating room table. A proper time-out was performed. Under
the direction of Anesthesiology, the patient was intubated and induced under general anesthetic. Cipro 400
mg IV was given within one hour of the start of the procedure. A suprapubic catheter was then clamped
off. He was prepped and draped in a normal sterile surgical fashion and placed in the dorsal lithotomy
position. I attempted to dilate him with a 12-French Goodwin dilator, but had significant resistance right
inside his urethral meatus. I then downsized to a 10-French and it gave him that significant resistance. At
this time, I attempted to insert a rigid cystoscope with 17-French, but was not able to get inside his urethral
meatus as there appeared to be strictured down with slight phimosis of his penis. Therefore, I attempted
to pass a guidewire bluntly down his urethra to see, if I could find his true lumen and again this was
unsuccessful as kept some buckle. Therefore, I decided to abort this portion of the procedure and my
opinion was best just to leave him with suprapubic catheter now and we decided to go ahead upsize it.
Therefore, I instilled 100 cc of sterile water into his bladder. The balloon was deflated and I removed the
16 French SP tube and placed it with an 18 French SP tube. A 10 cc of sterile water was placed in the
balloon. The balloon was secured. The catheter was drained and irrigated properly. This concluded the
procedure. The patient was extubated and sent to the recovery room in stable condition. He will be
discharged home per PACU protocol with SP tube in place. I recommended that he continues with SP
tube going forward with upsizing it every month all the way up to at least a 22 French and I think it is the
best option moving forward to leave with the suprapubic catheter due to severe urethral stricture.
However, we discussed the treatment as postoperative appointment about his other options.
POSTOPERATIVE DIAGNOSES: 1. Severe urethral stricture. 2. Urinary retention.
PROCEDURES PERFORMED: 1. Attempted cystoscopy with urethral dilation.
2. Upsizing a suprapubic catheter.
ANESTHESIA: General.
DRAINS: 18 French suprapubic catheter.
FINDINGS: Severely stenotic urethral stricture just inside the urethral meatus, unable to pass guidewire,
cystoscopy or dilate.
DISPOSITION: Stable to Recovery.
INDICATIONS FOR PROCEDURE: The patient is a 75-year-old male with a longstanding history of
urethral stricture who had a recent stroke. He went into urinary retention. He returned with a possibility of Foley catheter, but he had severe urethral stricture just inside his
urethral meatus. Therefore, he had a suprapubic catheter placed by interventional radiology. He had
previous dilation of his urethral stricture approximately 10 years ago. The patient presents today for
potential cystoscopy using dilation and SP tube removal. After risks, benefits, and alternatives were
explained to the patient, the patient elected to proceed, and informed consent was obtained.
DETAILS OF PROCEDURE: The patient was properly identified and brought back to the operating
room where he was laid supine on the operating room table. A proper time-out was performed. Under
the direction of Anesthesiology, the patient was intubated and induced under general anesthetic. Cipro 400
mg IV was given within one hour of the start of the procedure. A suprapubic catheter was then clamped
off. He was prepped and draped in a normal sterile surgical fashion and placed in the dorsal lithotomy
position. I attempted to dilate him with a 12-French Goodwin dilator, but had significant resistance right
inside his urethral meatus. I then downsized to a 10-French and it gave him that significant resistance. At
this time, I attempted to insert a rigid cystoscope with 17-French, but was not able to get inside his urethral
meatus as there appeared to be strictured down with slight phimosis of his penis. Therefore, I attempted
to pass a guidewire bluntly down his urethra to see, if I could find his true lumen and again this was
unsuccessful as kept some buckle. Therefore, I decided to abort this portion of the procedure and my
opinion was best just to leave him with suprapubic catheter now and we decided to go ahead upsize it.
Therefore, I instilled 100 cc of sterile water into his bladder. The balloon was deflated and I removed the
16 French SP tube and placed it with an 18 French SP tube. A 10 cc of sterile water was placed in the
balloon. The balloon was secured. The catheter was drained and irrigated properly. This concluded the
procedure. The patient was extubated and sent to the recovery room in stable condition. He will be
discharged home per PACU protocol with SP tube in place. I recommended that he continues with SP
tube going forward with upsizing it every month all the way up to at least a 22 French and I think it is the
best option moving forward to leave with the suprapubic catheter due to severe urethral stricture.
However, we discussed the treatment as postoperative appointment about his other options.