toria11
Guru
Hi! How would you code this balloon dilation of the prostatic urethra for BPH? Thank you!
POSTOPERATIVE DIAGNOSIS: BPH refractory to medical therapy.
PROCEDURES PERFORMED: Cystoscopy with balloon dilation of prostatic
urethra with Optilume DCB balloon procedure.
The patient was taken to the operating room and positively identified as
well as the side of surgery during a time-out. After adequate general anesthesia, he was transferred into
the modified dorsal lithotomy position and prepped and draped in the usual sterile fashion for cystoscopy.
A 22-French cystoscope sheath was passed with the obturator place. The Foroblique lens was then
inserted and careful panendoscopy was performed. Bladder had mild trabeculation, but otherwise was
unremarkable. He had bilobar BPH with the slightly eccentric right lateral lobe. Verumontanum was
unremarkable. He had no anterior urethral strictures. Cystoscope sheath was then positioned in the
bladder. The commissurotomy balloon dilator was passed through the cystoscope sheath. The sheath was
then removed. The cystoscope sheath and Foroblique lens were then passed adjacent to the balloon
dilator. The balloon dilator was then positioned with the opaque maker at the level of the external
sphincter. The balloon dilator was inflated and a commissurotomy was created. The balloon was left
inflated for total of a minute. The scope and balloon were then removed. The cystoscope was then
passed under direct vision. An anterior commissurotomy was identified. The scope was then repositioned
in the bladder and the Optilume CBD balloon dilator was passed through the sheath. The sheath was then
removed leaving the catheter in position. The cystoscope sheath was then passed again under direct
vision adjacent to the catheter. The white radiopaque maker was then positioned at the external sphincter
and balloon inflated to 3 atmospheres and left inflated for a total of 10 minutes. Cystoscope sheath was
then removed leaving the balloon catheter in position. After 10 minutes the balloon was deflated and
catheter was removed. A 20-French 30 cc Foley catheter was then passed with mild resistance. The
balloon was inflated to 30 cc and placed on gauze traction. The catheter was irrigated freely, and the
effluent came back pink tinged. He tolerated the procedure well without complications. WM 20220428
POSTOPERATIVE DIAGNOSIS: BPH refractory to medical therapy.
PROCEDURES PERFORMED: Cystoscopy with balloon dilation of prostatic
urethra with Optilume DCB balloon procedure.
The patient was taken to the operating room and positively identified as
well as the side of surgery during a time-out. After adequate general anesthesia, he was transferred into
the modified dorsal lithotomy position and prepped and draped in the usual sterile fashion for cystoscopy.
A 22-French cystoscope sheath was passed with the obturator place. The Foroblique lens was then
inserted and careful panendoscopy was performed. Bladder had mild trabeculation, but otherwise was
unremarkable. He had bilobar BPH with the slightly eccentric right lateral lobe. Verumontanum was
unremarkable. He had no anterior urethral strictures. Cystoscope sheath was then positioned in the
bladder. The commissurotomy balloon dilator was passed through the cystoscope sheath. The sheath was
then removed. The cystoscope sheath and Foroblique lens were then passed adjacent to the balloon
dilator. The balloon dilator was then positioned with the opaque maker at the level of the external
sphincter. The balloon dilator was inflated and a commissurotomy was created. The balloon was left
inflated for total of a minute. The scope and balloon were then removed. The cystoscope was then
passed under direct vision. An anterior commissurotomy was identified. The scope was then repositioned
in the bladder and the Optilume CBD balloon dilator was passed through the sheath. The sheath was then
removed leaving the catheter in position. The cystoscope sheath was then passed again under direct
vision adjacent to the catheter. The white radiopaque maker was then positioned at the external sphincter
and balloon inflated to 3 atmospheres and left inflated for a total of 10 minutes. Cystoscope sheath was
then removed leaving the balloon catheter in position. After 10 minutes the balloon was deflated and
catheter was removed. A 20-French 30 cc Foley catheter was then passed with mild resistance. The
balloon was inflated to 30 cc and placed on gauze traction. The catheter was irrigated freely, and the
effluent came back pink tinged. He tolerated the procedure well without complications. WM 20220428