l1ttle_0ne
Guru
Can someone help me find a CPT code for this?? I'm having trouble...
PREOPERATIVE DIAGNOSIS: Penile fracture.
POSTOPERATIVE DIAGNOSIS: Penile fracture.
PROCEDURE: Cystoscopy, penile exploration.
FINDINGS: No bladder tumor or stone. No evidence of urethral injury on cystoscopy. The phallus was degloved. No defect in the corpora identified. Area consistent with hematoma near the dorsal vein without obvious defect of the dorsal vein.
INDICATIONS FOR PROCEDURE: This is a male who suffered injury to the phallus during intercourse consistent with penile fracture. Surgical exploration was recommended. The risks and benefits were explained and informed consent was obtained.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to the operating room. He was placed supine on the table. He underwent general anesthesia with LMA. Timeout was held. Preoperative IV antibiotics were confirmed. The patient was prepped and draped in a sterile fashion. The Olympus flexible cystoscope was carefully passed per urethra to the level of bladder. Cystoscopy was performed. No evidence of bladder tumor, no bladder stone, no erythematous lesions. Bilateral ureteral orifices were in their correct anatomical location with clear efflux of urine. The scope was retroflexed. No abnormalities noted at the bladder neck. The scope was brought back to the prostatic urethra and slowly withdrawn. There is no evidence of urethral injury or urethral stricture disease. A 16 French Silastic catheter was then passed per urethra into the bladder with clear urine back. Balloon was inflated with 10 mL of sterile water. This was placed to a drainage bag. Circumferential penile block was performed using plain 0.5% bupivacaine. Circumferential incision was then performed with a #15 blade scalpel at the patient's prior circumcision scar. The phallus was then degloved. The area of ecchymosis was on the left aspect. This area was explored thoroughly. There was no defect to the corpora cavernosa identified. There was increased area of bleeding around the dorsal vein proximally near the base of the phallus without obvious defect at the dorsal vein. This area was cauterized for hemostasis. The wound was then irrigated, the skin was reapproximated in 4 quadrants with 3-0 Vicryl interrupted sutures. The remainder skin was closed using 4-0 chromic interrupted sutures until hemostasis was assured, and the skin was reapproximated. Antibiotic ointment was placed at the incision site. A one-inch cling dressing was applied. The catheter was removed. The patient was awakened, transferred to postanesthesia care unit in stable condition. He will return to clinic in 2 weeks for followup evaluation. He was recommended to have no sexual intercourse for 4 weeks
PREOPERATIVE DIAGNOSIS: Penile fracture.
POSTOPERATIVE DIAGNOSIS: Penile fracture.
PROCEDURE: Cystoscopy, penile exploration.
FINDINGS: No bladder tumor or stone. No evidence of urethral injury on cystoscopy. The phallus was degloved. No defect in the corpora identified. Area consistent with hematoma near the dorsal vein without obvious defect of the dorsal vein.
INDICATIONS FOR PROCEDURE: This is a male who suffered injury to the phallus during intercourse consistent with penile fracture. Surgical exploration was recommended. The risks and benefits were explained and informed consent was obtained.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to the operating room. He was placed supine on the table. He underwent general anesthesia with LMA. Timeout was held. Preoperative IV antibiotics were confirmed. The patient was prepped and draped in a sterile fashion. The Olympus flexible cystoscope was carefully passed per urethra to the level of bladder. Cystoscopy was performed. No evidence of bladder tumor, no bladder stone, no erythematous lesions. Bilateral ureteral orifices were in their correct anatomical location with clear efflux of urine. The scope was retroflexed. No abnormalities noted at the bladder neck. The scope was brought back to the prostatic urethra and slowly withdrawn. There is no evidence of urethral injury or urethral stricture disease. A 16 French Silastic catheter was then passed per urethra into the bladder with clear urine back. Balloon was inflated with 10 mL of sterile water. This was placed to a drainage bag. Circumferential penile block was performed using plain 0.5% bupivacaine. Circumferential incision was then performed with a #15 blade scalpel at the patient's prior circumcision scar. The phallus was then degloved. The area of ecchymosis was on the left aspect. This area was explored thoroughly. There was no defect to the corpora cavernosa identified. There was increased area of bleeding around the dorsal vein proximally near the base of the phallus without obvious defect at the dorsal vein. This area was cauterized for hemostasis. The wound was then irrigated, the skin was reapproximated in 4 quadrants with 3-0 Vicryl interrupted sutures. The remainder skin was closed using 4-0 chromic interrupted sutures until hemostasis was assured, and the skin was reapproximated. Antibiotic ointment was placed at the incision site. A one-inch cling dressing was applied. The catheter was removed. The patient was awakened, transferred to postanesthesia care unit in stable condition. He will return to clinic in 2 weeks for followup evaluation. He was recommended to have no sexual intercourse for 4 weeks