toria11
Guru
Hi! How would you code this? The provider suggested 50548 and 51703, but I'm wondering if there's a way to bill for the laparoscopic removal of the bladder cuff and lymph nodes? Perhaps with the addition of 38571-52? Thanks for your help!
POSTOPERATIVE DIAGNOSIS:
1. Left renal pelvic mass suspicious for transitional cell carcinoma.
2. History of bladder cancer.
3. Gross hematuria.
4. Hypertension.
5. Benign prostatic hyperplasia.
PROCEDURE PERFORMED:
1. Robotic-assisted laparoscopic left nephroureterectomy with bladder cuff, regional lymphadenectomy.
2. Insertion of difficult Foley catheter.
ANESTHESIA:
General.
UNANTICIPATED EVENTS/COMPLICATIONS:
None.
PREOPERATIVE ANTIBIOTICS:
Ancef 2 g IV.
DRAINS:
1. A 20-French coude catheter to gravity drainage.
2. A 15-French JP drain to bulb suction.
SPECIMENS REMOVED:
1. Left kidney with entire ureter and bladder cuff.
2. Left perihilar lymph nodes.
INDICATIONS:
The patient is 80-year-old Caucasian male with a history of bladder cancer. He had recent onset of intermittent gross hematuria. He had a cystoscopy done which was negative for any recurrent bladder cancer. He underwent a CT urogram which showed a filling defect in his left renal pelvis extending to the left lower pole calyx concerning for transitional cell carcinoma, it was approximately 1.7 cm in size. After describing the findings to the patient, the patient did mention approximately 3 to 4 years ago, he had a ureteroscopy on that side and attempted biopsy of a mass in the lower kidney, but the biopsy was unsuccessful and the result was subsequently lost, but he was told that it was likely benign. However, due to his history of bladder cancer and his persistent hematuria, treatment options discussed including repeat diagnostic ureteroscopy with biopsy versus removal of his left kidney and ureter. After the risks, benefits, and alternatives of each were described, he elected to proceed with removal of his left kidney and ureter via robotic approach. Therefore, after risks, benefits, and alternatives were explained to the patient including risk of renal failure, positive margin, continued bladder surveillance, need for adjuvant therapy, and anesthetic risks, the patient elected to proceed and informed consent was obtained.
DESCRIPTION OF PROCEDURE:
The patient was properly identified, brought back to the operating room, laid supine on the operative table. A proper time-out was performed. Under the direction of Anesthesiology, the patient immediately was induced under general anesthetic. Ancef 2 g IV was given 1 hour at the start of procedure. The nursing staff attempted to place a 20-French three-way Foley catheter, but met significant resistance. Therefore, they asked for assistance. I initially attempted to pass the 20-French three-way Foley catheter, but again, was meeting resistance near the prostate. Therefore, I switched to a 20-French regular coude catheter and I was able to pass this into the patient's bladder with minimal difficulty. Dark yellow urine returned. The catheter was secured. At this point, the patient was then placed in right lateral decubitus position with left side up. The table was appropriately flexed. All pressure points were padded. He was then prepped and draped in normal sterile surgical fashion. A stab incision was made between his xiphoid process and his 11th rib just superior and lateral to his umbilicus. A Veress needle was then carefully passed into the abdominal cavity. I began insufflation. Once pneumoperitoneum was achieved, I then passed an 8 mm robotic trocar into the abdominal cavity under direct visualization. The abdominal cavity was carefully inspected. There was no evidence of any intraabdominal injury or bleeding. At this time, four other ports were placed including an 8 mm robotic port in the left upper quadrant just 2 fingerbreadths below the subcostal margin, a 12 mm AirSeal port in the midline superior to the umbilicus, a 12 mm robotic port with ACE sheath in the left lower quadrant and an 8 mm robotic port in the midline 2 fingerbreadths above the pubic symphysis. Again, all ports were placed under direct visualization. There is no evidence of intraabdominal injury or bleeding. At this time, the robot was then brought on the patient's left-hand side and docked appropriately. I began by reflecting the colon medially by taking down the white line of Toldt. I then developed a plane inferiorly where I found the ureter and the gonadal vein. A robotic Hem-o-lok applier was then applied and I placed Hem-o-lok across the mid ureter. I then followed the gonadal vein up to its insertion point of the renal vein. The gonadal vein was then divided with the SynchroSeal. At this point, the large renal vein and artery were then carefully dissected out circumferentially. Each one was taken separately with the robotic stapler using a vascular load. The staple lines appeared to be clean and intact and with no evidence of any bleeding. Excellent hemostasis was achieved at this point. At this time, I further mobilized the kidney superior and laterally. At this time, I then worked my way caudally to dissect the ureter all the way down to the bladder. Once I was able to dissect the ureter all the way down the bladder, I ligated the superior vesical artery and dissected out the intramural ureter. A Hem-o-lok was then applied at the very most distal ureter and bladder cuff. A portion of bladder was taken with the ureter. At this point, the kidney was then placed in the lower pelvis for later extraction. The pelvis was copiously irrigated. Hemostasis was excellent. The external iliac artery could be seen pulsating. At this time, I then went back up to the renal hilar area to inspect it. There appeared to be several large masses near the renal hilum which appeared to be solid for hard lymph nodes. One of the lymph nodes had a significant desmoplastic reaction around it and could not safely develop a plane around the lymph node to peel off the aorta. However, the more cephalad lymph node around the actual renal artery, I was able to dissect out in its entirety. This will be sent off as perihilar lymph node. At this time, hemostasis appeared to be excellent. Tisseel and Arista were then used in the renal fossa and hilum for additional hemostatic purposes. The abdominal pressure was brought down to 7 mmHg and there was no bleeding seen. At this point, both the lymph nodes and the kidney, ureter and bladder cuff were placed in separate EndoCatch bags and they were extracted through left lower quadrant incision. The left lower quadrant incision was then closed in two layers. I then reinsufflated the abdomen. A second look was performed. The renal fossa appeared to be dry. Hemostasis was excellent. I examined the pelvis, which I did not see any bleeding at this time as well. The extraction incision was visualized and was free of any bowel in the abdomen. At this point, remaining all the ports were then removed under direct visualization. A 15-French JP drain was then placed through the lower midline port and secured with 3-0 nylon. The remaining incisions were closed with Monocryl and reinforced with Dermabond. This concluded the procedure. Sponge, instrument, and needle counts were correct at the end of the case. Estimated blood loss 100 mL. The patient was extubated, sent to
recovery in stable condition without immediate complications. He will be transferred to the floor for routine postoperative care.
POSTOPERATIVE DIAGNOSIS:
1. Left renal pelvic mass suspicious for transitional cell carcinoma.
2. History of bladder cancer.
3. Gross hematuria.
4. Hypertension.
5. Benign prostatic hyperplasia.
PROCEDURE PERFORMED:
1. Robotic-assisted laparoscopic left nephroureterectomy with bladder cuff, regional lymphadenectomy.
2. Insertion of difficult Foley catheter.
ANESTHESIA:
General.
UNANTICIPATED EVENTS/COMPLICATIONS:
None.
PREOPERATIVE ANTIBIOTICS:
Ancef 2 g IV.
DRAINS:
1. A 20-French coude catheter to gravity drainage.
2. A 15-French JP drain to bulb suction.
SPECIMENS REMOVED:
1. Left kidney with entire ureter and bladder cuff.
2. Left perihilar lymph nodes.
INDICATIONS:
The patient is 80-year-old Caucasian male with a history of bladder cancer. He had recent onset of intermittent gross hematuria. He had a cystoscopy done which was negative for any recurrent bladder cancer. He underwent a CT urogram which showed a filling defect in his left renal pelvis extending to the left lower pole calyx concerning for transitional cell carcinoma, it was approximately 1.7 cm in size. After describing the findings to the patient, the patient did mention approximately 3 to 4 years ago, he had a ureteroscopy on that side and attempted biopsy of a mass in the lower kidney, but the biopsy was unsuccessful and the result was subsequently lost, but he was told that it was likely benign. However, due to his history of bladder cancer and his persistent hematuria, treatment options discussed including repeat diagnostic ureteroscopy with biopsy versus removal of his left kidney and ureter. After the risks, benefits, and alternatives of each were described, he elected to proceed with removal of his left kidney and ureter via robotic approach. Therefore, after risks, benefits, and alternatives were explained to the patient including risk of renal failure, positive margin, continued bladder surveillance, need for adjuvant therapy, and anesthetic risks, the patient elected to proceed and informed consent was obtained.
DESCRIPTION OF PROCEDURE:
The patient was properly identified, brought back to the operating room, laid supine on the operative table. A proper time-out was performed. Under the direction of Anesthesiology, the patient immediately was induced under general anesthetic. Ancef 2 g IV was given 1 hour at the start of procedure. The nursing staff attempted to place a 20-French three-way Foley catheter, but met significant resistance. Therefore, they asked for assistance. I initially attempted to pass the 20-French three-way Foley catheter, but again, was meeting resistance near the prostate. Therefore, I switched to a 20-French regular coude catheter and I was able to pass this into the patient's bladder with minimal difficulty. Dark yellow urine returned. The catheter was secured. At this point, the patient was then placed in right lateral decubitus position with left side up. The table was appropriately flexed. All pressure points were padded. He was then prepped and draped in normal sterile surgical fashion. A stab incision was made between his xiphoid process and his 11th rib just superior and lateral to his umbilicus. A Veress needle was then carefully passed into the abdominal cavity. I began insufflation. Once pneumoperitoneum was achieved, I then passed an 8 mm robotic trocar into the abdominal cavity under direct visualization. The abdominal cavity was carefully inspected. There was no evidence of any intraabdominal injury or bleeding. At this time, four other ports were placed including an 8 mm robotic port in the left upper quadrant just 2 fingerbreadths below the subcostal margin, a 12 mm AirSeal port in the midline superior to the umbilicus, a 12 mm robotic port with ACE sheath in the left lower quadrant and an 8 mm robotic port in the midline 2 fingerbreadths above the pubic symphysis. Again, all ports were placed under direct visualization. There is no evidence of intraabdominal injury or bleeding. At this time, the robot was then brought on the patient's left-hand side and docked appropriately. I began by reflecting the colon medially by taking down the white line of Toldt. I then developed a plane inferiorly where I found the ureter and the gonadal vein. A robotic Hem-o-lok applier was then applied and I placed Hem-o-lok across the mid ureter. I then followed the gonadal vein up to its insertion point of the renal vein. The gonadal vein was then divided with the SynchroSeal. At this point, the large renal vein and artery were then carefully dissected out circumferentially. Each one was taken separately with the robotic stapler using a vascular load. The staple lines appeared to be clean and intact and with no evidence of any bleeding. Excellent hemostasis was achieved at this point. At this time, I further mobilized the kidney superior and laterally. At this time, I then worked my way caudally to dissect the ureter all the way down to the bladder. Once I was able to dissect the ureter all the way down the bladder, I ligated the superior vesical artery and dissected out the intramural ureter. A Hem-o-lok was then applied at the very most distal ureter and bladder cuff. A portion of bladder was taken with the ureter. At this point, the kidney was then placed in the lower pelvis for later extraction. The pelvis was copiously irrigated. Hemostasis was excellent. The external iliac artery could be seen pulsating. At this time, I then went back up to the renal hilar area to inspect it. There appeared to be several large masses near the renal hilum which appeared to be solid for hard lymph nodes. One of the lymph nodes had a significant desmoplastic reaction around it and could not safely develop a plane around the lymph node to peel off the aorta. However, the more cephalad lymph node around the actual renal artery, I was able to dissect out in its entirety. This will be sent off as perihilar lymph node. At this time, hemostasis appeared to be excellent. Tisseel and Arista were then used in the renal fossa and hilum for additional hemostatic purposes. The abdominal pressure was brought down to 7 mmHg and there was no bleeding seen. At this point, both the lymph nodes and the kidney, ureter and bladder cuff were placed in separate EndoCatch bags and they were extracted through left lower quadrant incision. The left lower quadrant incision was then closed in two layers. I then reinsufflated the abdomen. A second look was performed. The renal fossa appeared to be dry. Hemostasis was excellent. I examined the pelvis, which I did not see any bleeding at this time as well. The extraction incision was visualized and was free of any bowel in the abdomen. At this point, remaining all the ports were then removed under direct visualization. A 15-French JP drain was then placed through the lower midline port and secured with 3-0 nylon. The remaining incisions were closed with Monocryl and reinforced with Dermabond. This concluded the procedure. Sponge, instrument, and needle counts were correct at the end of the case. Estimated blood loss 100 mL. The patient was extubated, sent to
recovery in stable condition without immediate complications. He will be transferred to the floor for routine postoperative care.
