Liz2013
Contributor
I’m having trouble coding the following case:
POSTOPERATIVE DIAGNOSES: Bladder cancer.
PROCEDURE PERFORMED:
1. Robotic partial cystectomy.
2. Robotic left distal ureterectomy.
3. Left stent change.
4. Robotic left pelvic lymph node dissection and use of tissue barrier.
5. Psoas hitch.
ANESTHESIA: General endotracheal anesthesia.
INDICATIONS: This is a 74-year-old female diagnosed with an invasive bladder cancer, refused to undergo radical cystectomy, underwent neoadjuvant chemotherapy and opted for a focal excision understanding the high risk of recurrence.
DESCRIPTION OF PROCEDURE: The patient was brought to the Operating Room and was placed under general endotracheal anesthesia and was prepped and draped in standard sterile fashion. Preoperative antibiotics were given. She had multiple previous abdominal scars. We gained access to the abdomen through a midclavicular line port site.
We cut down doing a Hasson technique and gained access to the peritoneum. Hasson port was placed and peritoneum was created. The camera was inserted and no injury was identified. All other ports were placed under direct vision.
The patient was placed in steep Trendelenburg and the robot was docked to the ports. After an extensive adhesion takedown, we identified left ureter, which was hydronephrotic due to tumor over the iliac vessels. This we were able to skeletonize down to the level of the bladder. We made a cystotomy, identified and cored out the left trigone and left wall. There was no obvious tumor.
The right ureteral orifice was identified through the cystotomy and was protected. Frozen sections at the bladder cuff were sent off and were negative. We then transected the ureter and distal ureter specimens proximal to the area of interest were sent off and were negative for tumor on frozen section. There was a previous stent which was extracted. Specimen was placed within a bag.
At this time, we closed our cystotomy with a V-Loc suture and was tested by irrigating the bladder, which seemed to be watertight. It should be noted that due to adhesions we got into the vagina, this was carefully separated off of the bladder and was closed separately. The fat and peritoneum were harvested locally and were used to separate the bladder and the repaired vagina.
We then approached the lymph node dissection and the external and internal iliac lymph nodes were dissected free as well as the obturator nodes. These were all sent off as specimen. We then mobilized the bladder taking down the anterior attachments and entering the space of Retzius. Using a V-Loc suture we performed a psoas hitch in order to take the tension off the ureteral anastomosis.
At this time we made a cystotomy for the ureteral anastomosis. The ureter was spatulated. Using Monocryl suture anastomosis was performed. Prior to closure of the anastomosis a 6-French 24 cm double-J stent was placed within the bladder.
Once the anastomosis was complete, using the Amniox tissue graft as a tissue barrier we wrapped and tacked this down to our anastomosis site to protect it from adhesions.
A Jackson-Pratt drain was placed. Hemostasis was excellent. The robot was undocked. We took the specimen out through our initial Hasson port. This was then closed at the fascia. All other ports were closed at the skin with staples and the patient was awakened and brought to the Recovery Room in stable fashion
I’m thinking to code it as followed:
- 50948
- 51550
- 50949 (Benchmark to 50650)
- 38571-52
- 17999
if someone has some input, can you please advise? I will appreciate your help
POSTOPERATIVE DIAGNOSES: Bladder cancer.
PROCEDURE PERFORMED:
1. Robotic partial cystectomy.
2. Robotic left distal ureterectomy.
3. Left stent change.
4. Robotic left pelvic lymph node dissection and use of tissue barrier.
5. Psoas hitch.
ANESTHESIA: General endotracheal anesthesia.
INDICATIONS: This is a 74-year-old female diagnosed with an invasive bladder cancer, refused to undergo radical cystectomy, underwent neoadjuvant chemotherapy and opted for a focal excision understanding the high risk of recurrence.
DESCRIPTION OF PROCEDURE: The patient was brought to the Operating Room and was placed under general endotracheal anesthesia and was prepped and draped in standard sterile fashion. Preoperative antibiotics were given. She had multiple previous abdominal scars. We gained access to the abdomen through a midclavicular line port site.
We cut down doing a Hasson technique and gained access to the peritoneum. Hasson port was placed and peritoneum was created. The camera was inserted and no injury was identified. All other ports were placed under direct vision.
The patient was placed in steep Trendelenburg and the robot was docked to the ports. After an extensive adhesion takedown, we identified left ureter, which was hydronephrotic due to tumor over the iliac vessels. This we were able to skeletonize down to the level of the bladder. We made a cystotomy, identified and cored out the left trigone and left wall. There was no obvious tumor.
The right ureteral orifice was identified through the cystotomy and was protected. Frozen sections at the bladder cuff were sent off and were negative. We then transected the ureter and distal ureter specimens proximal to the area of interest were sent off and were negative for tumor on frozen section. There was a previous stent which was extracted. Specimen was placed within a bag.
At this time, we closed our cystotomy with a V-Loc suture and was tested by irrigating the bladder, which seemed to be watertight. It should be noted that due to adhesions we got into the vagina, this was carefully separated off of the bladder and was closed separately. The fat and peritoneum were harvested locally and were used to separate the bladder and the repaired vagina.
We then approached the lymph node dissection and the external and internal iliac lymph nodes were dissected free as well as the obturator nodes. These were all sent off as specimen. We then mobilized the bladder taking down the anterior attachments and entering the space of Retzius. Using a V-Loc suture we performed a psoas hitch in order to take the tension off the ureteral anastomosis.
At this time we made a cystotomy for the ureteral anastomosis. The ureter was spatulated. Using Monocryl suture anastomosis was performed. Prior to closure of the anastomosis a 6-French 24 cm double-J stent was placed within the bladder.
Once the anastomosis was complete, using the Amniox tissue graft as a tissue barrier we wrapped and tacked this down to our anastomosis site to protect it from adhesions.
A Jackson-Pratt drain was placed. Hemostasis was excellent. The robot was undocked. We took the specimen out through our initial Hasson port. This was then closed at the fascia. All other ports were closed at the skin with staples and the patient was awakened and brought to the Recovery Room in stable fashion
I’m thinking to code it as followed:
- 50948
- 51550
- 50949 (Benchmark to 50650)
- 38571-52
- 17999
if someone has some input, can you please advise? I will appreciate your help