l1ttle_0ne
Guru
This one is really confusing me! Can anyone give me their opinion on what this would be coded as?? The doctor put 51555 partial cystectomy?? I'm not really sure if this would be right?? From what I can see it mostly talks about debriding the bladder. Would a unlisted code be more appropriate?? Also what about the bilateral ligation of the ureters?? I've never had to code a surgery quite like this, and want to make sure I'm not missing anything!! If someone could please give me their opinion I would appreciate it!! Also the doctor put that he wants to charge for the JP drain placement, this is bundled in correct??
Date of Surgery:
Pre-op Diagnosis: bladder disruption, sepsis, UTI
Post-op Diagnosis:necrotizing cystitis and necrotizing soft tissue of the pelvic preperitoneal space
Procedure: Exploratory laparotomy, adhesiolysis, debridement of necrotizing bladder and preperitoneal pelvic tissue, bilateral ureteral catheterization with retrograde pyelogram, ligation of bilateral ureters
Indication
xx year old with 3 week history of dysuria and cloudy urine. He was admitted with hypotension and difficulty voiding along with rising creatinine. He had CT KUB for renal failure that showed possible disruption of bladder. Follow up CT cystogram showed extravasation of contrast intraperitoneal, but very small. We discussed conservative measured with decompression of bladder with foley to see if UTI will resolve and bladder will heal and he was agreeable, however given the rising WBC, tachycardia, worsening renal failure and continued need for pressor support, we discussed exploration with cystoscopy and clot evacuation along with repair of bladder injury. He was agreeable and proceed with this.
Findings
Significant necrosis of bladder and bladder wall in the anterior/dome and posterior bladder along the wall. Although the majority of the bladder was intact, the tissue itself was necrotic and was removed. There was no tissue that was able to be approximated. Dirty dish water fluid with foul smelling purulent fluid in the intraperitoneal and extraperitoneal space drained. Necrotic tissue sent for pathology.
Procedure:
The patient was taken into the operating room after which general endotracheal tube anesthesia was administered. He had been on intravenous antibiotics, nevertheless cefazolin was given as the patient was prepped and draped. He then had central line placed by Dr xx. The patient was shaved and then prepped using Betadine solution to the genitalia and chloroprep to the abdomen. A sterile 18-French Foley catheter with a 30 cc balloon was inserted into the bladder without significant drainage, and what drainage there was significantly purulent. A lower midline incision was performed. The rectus fascia was opened sharply and the intraperitoneal space was entered. Exploration of the pelvic/lower peritoneal space showed significant purulent fluid that was suctioned. There was significant adhesions, and a 3 cm area of small bowel significantly adherent to the dome of the bladder. What appeared to the the bladder appeared to be grey and necrotic, without vascularization. The perivesical space and the retropubic space were developed bluntly, which revealed more necrotic tissue and purulent fluid. The necrotic tissue was debrided, after taking down adhesion between the bladder and small bowel as well as between bowel. Bookwalter retractor was then placed. Upon debridement, it was soon very evident that the necrotic tissue was actually bladder tissue and the foley balloon was seen. The dome, anterior, and posterior bladder was necrotic and required debridement, but the bladder neck and trigone appeared to be healthy and intact. Both ureteral orifice was identified, but not effluxing urine. Using a glidewire, the ureters were catheterized, and retrograde pyelogram were performed. An attempt at reapproximating the bladder edges was made, but it became apparent, however, that approximation of the viable edges of the bladder was insufficient, and a second opinion was asked by the on call urologist. Dr x was kind enough to assess the situation. Given the inability to achieve an adequate anastomosis, options were for diversion, ligation of ureters with nephrostomy tubes, cutaneous ureterostomy. Given the degree of infection, low nutrition status, renal failure, and pressor use, there was worry that any anastomosis would be at high risk for failure and worsening of sepsis from anastomotic leak. Furthermore, there was also concern that a cutaneous ureterostomy could potential foreshorten the ureters, making future diversion difficult. I opted to proceed with distal ureteral ligation to maintain as much length as possible and plan for nephrostomy tube postoperatively. The distal ends of the ureters were dissected, ensured to be the ureter as evidenced by the catheter used for retrograde pyelogram. The ureters were clipped with metal clips x 2 after removal of the ureteral catheters on each side. The abdomen was copiously irrigated with sterile saline, and Blake drains were placed into the pelvis along the paracolic gutters. The foley was used as a pelvic drain in the preperitoneal space. The fascia was then closed with #1 PDS, the skin was loosely reapproximated with staples, and a negative pressure wound dressing was placed over the skin. The peritoneal drains were placed to bulb suction, while the penile/pelvic drain was placed to gravity drain. He was then taken back to the ICU intubated in guarded condition.
Date of Surgery:
Pre-op Diagnosis: bladder disruption, sepsis, UTI
Post-op Diagnosis:necrotizing cystitis and necrotizing soft tissue of the pelvic preperitoneal space
Procedure: Exploratory laparotomy, adhesiolysis, debridement of necrotizing bladder and preperitoneal pelvic tissue, bilateral ureteral catheterization with retrograde pyelogram, ligation of bilateral ureters
Indication
xx year old with 3 week history of dysuria and cloudy urine. He was admitted with hypotension and difficulty voiding along with rising creatinine. He had CT KUB for renal failure that showed possible disruption of bladder. Follow up CT cystogram showed extravasation of contrast intraperitoneal, but very small. We discussed conservative measured with decompression of bladder with foley to see if UTI will resolve and bladder will heal and he was agreeable, however given the rising WBC, tachycardia, worsening renal failure and continued need for pressor support, we discussed exploration with cystoscopy and clot evacuation along with repair of bladder injury. He was agreeable and proceed with this.
Findings
Significant necrosis of bladder and bladder wall in the anterior/dome and posterior bladder along the wall. Although the majority of the bladder was intact, the tissue itself was necrotic and was removed. There was no tissue that was able to be approximated. Dirty dish water fluid with foul smelling purulent fluid in the intraperitoneal and extraperitoneal space drained. Necrotic tissue sent for pathology.
Procedure:
The patient was taken into the operating room after which general endotracheal tube anesthesia was administered. He had been on intravenous antibiotics, nevertheless cefazolin was given as the patient was prepped and draped. He then had central line placed by Dr xx. The patient was shaved and then prepped using Betadine solution to the genitalia and chloroprep to the abdomen. A sterile 18-French Foley catheter with a 30 cc balloon was inserted into the bladder without significant drainage, and what drainage there was significantly purulent. A lower midline incision was performed. The rectus fascia was opened sharply and the intraperitoneal space was entered. Exploration of the pelvic/lower peritoneal space showed significant purulent fluid that was suctioned. There was significant adhesions, and a 3 cm area of small bowel significantly adherent to the dome of the bladder. What appeared to the the bladder appeared to be grey and necrotic, without vascularization. The perivesical space and the retropubic space were developed bluntly, which revealed more necrotic tissue and purulent fluid. The necrotic tissue was debrided, after taking down adhesion between the bladder and small bowel as well as between bowel. Bookwalter retractor was then placed. Upon debridement, it was soon very evident that the necrotic tissue was actually bladder tissue and the foley balloon was seen. The dome, anterior, and posterior bladder was necrotic and required debridement, but the bladder neck and trigone appeared to be healthy and intact. Both ureteral orifice was identified, but not effluxing urine. Using a glidewire, the ureters were catheterized, and retrograde pyelogram were performed. An attempt at reapproximating the bladder edges was made, but it became apparent, however, that approximation of the viable edges of the bladder was insufficient, and a second opinion was asked by the on call urologist. Dr x was kind enough to assess the situation. Given the inability to achieve an adequate anastomosis, options were for diversion, ligation of ureters with nephrostomy tubes, cutaneous ureterostomy. Given the degree of infection, low nutrition status, renal failure, and pressor use, there was worry that any anastomosis would be at high risk for failure and worsening of sepsis from anastomotic leak. Furthermore, there was also concern that a cutaneous ureterostomy could potential foreshorten the ureters, making future diversion difficult. I opted to proceed with distal ureteral ligation to maintain as much length as possible and plan for nephrostomy tube postoperatively. The distal ends of the ureters were dissected, ensured to be the ureter as evidenced by the catheter used for retrograde pyelogram. The ureters were clipped with metal clips x 2 after removal of the ureteral catheters on each side. The abdomen was copiously irrigated with sterile saline, and Blake drains were placed into the pelvis along the paracolic gutters. The foley was used as a pelvic drain in the preperitoneal space. The fascia was then closed with #1 PDS, the skin was loosely reapproximated with staples, and a negative pressure wound dressing was placed over the skin. The peritoneal drains were placed to bulb suction, while the penile/pelvic drain was placed to gravity drain. He was then taken back to the ICU intubated in guarded condition.
Last edited: