toria11
Guru
Hello! How would you recommend I code this? 52000 alone? Thanks!
POSTOPERATIVE DIAGNOSIS:
1. Urinary retention.
2. Urethral stricture with a history of prostate cancer.
PROCEDURE PERFORMED:
1. 12-French punch suprapubic tube placement.
2. Cystoscopy, dilation of urethral stricture and placement of difficult Foley over a
wire 18-French.
ANESTHESIA:
General.
INDICATIONS:
The patient is a 65-year-old gentleman with a history of prostate cancer, status post
radiation who was having increasing difficulty urinating and went into retention with
bladder scan showing 800 mL in the bladder. Nurses were unable to pass the catheter in
the ER and Urology was consulted. I tried to pass a catheter with a wire guide
unsuccessfully and I could not get Van Buren to convincingly find the urethra. After a
couple of a delicate attempts, I decided that it would be best to bring him to the
operating room and we had more control and could get a catheter under direct vision. The
risks, benefits, alternatives reviewed. He agreed to proceed.
DESCRIPTION OF PROCEDURE:
The patient brought to the operating room, placed on the table in supine position. After
smooth induction of general anesthesia, he was placed in dorsal lithotomy. His perineum
was prepped and draped in sterile fashion. A 21-French cystoscope obturator sheath passed
per urethra and the anterior urethra was normal, but when I got down to the bulbous
urethra, there was both an anterior and a posterior false passage. I could not find the
urethral opening into the prostatic urethra nor could I get a wire to pass. I therefore
used a spinal needle down into the suprapubic area to locate the bladder and then placed a
12-French punch suprapubic catheter into the bladder with 10 mL in the balloon. I then
drained the bladder of some old brownish colored urine and once the bladder was completely
drained, I looked back in through the urethra and was able to now press downward with the
emptied bladder and did go up over the high bladder neck and into the bladder. Within the
bladder, there were no tumors, stones, foreign bodies appreciated other than the balloon
over the suprapubic tubes in the anterior wall. Ureteral orifices were slit-like
configuration in the usual orientation on the trigone. The prostatic urethra was normal.
All the false passages were done in the bulb. I placed a wire into the bladder under
direct vision and then passed an 18-French Council tipped easily into the bladder and
inflated the balloon with 10 mL and irrigated well. Rectal exam was performed and the
rectum was flat, firm, consistent with post radiated state. There were no injuries to the
rectal wall. The stitch was placed to hold the suprapubic tube in place and it was capped
off and the Foley was placed to drainage. We will remove the suprapubic tube once the
suprapubic tract has a chance to mature. The patient was then awakened from anesthesia,
extubated, brought to recovery room in stable condition. He tolerated the procedure well. AH 20211104
POSTOPERATIVE DIAGNOSIS:
1. Urinary retention.
2. Urethral stricture with a history of prostate cancer.
PROCEDURE PERFORMED:
1. 12-French punch suprapubic tube placement.
2. Cystoscopy, dilation of urethral stricture and placement of difficult Foley over a
wire 18-French.
ANESTHESIA:
General.
INDICATIONS:
The patient is a 65-year-old gentleman with a history of prostate cancer, status post
radiation who was having increasing difficulty urinating and went into retention with
bladder scan showing 800 mL in the bladder. Nurses were unable to pass the catheter in
the ER and Urology was consulted. I tried to pass a catheter with a wire guide
unsuccessfully and I could not get Van Buren to convincingly find the urethra. After a
couple of a delicate attempts, I decided that it would be best to bring him to the
operating room and we had more control and could get a catheter under direct vision. The
risks, benefits, alternatives reviewed. He agreed to proceed.
DESCRIPTION OF PROCEDURE:
The patient brought to the operating room, placed on the table in supine position. After
smooth induction of general anesthesia, he was placed in dorsal lithotomy. His perineum
was prepped and draped in sterile fashion. A 21-French cystoscope obturator sheath passed
per urethra and the anterior urethra was normal, but when I got down to the bulbous
urethra, there was both an anterior and a posterior false passage. I could not find the
urethral opening into the prostatic urethra nor could I get a wire to pass. I therefore
used a spinal needle down into the suprapubic area to locate the bladder and then placed a
12-French punch suprapubic catheter into the bladder with 10 mL in the balloon. I then
drained the bladder of some old brownish colored urine and once the bladder was completely
drained, I looked back in through the urethra and was able to now press downward with the
emptied bladder and did go up over the high bladder neck and into the bladder. Within the
bladder, there were no tumors, stones, foreign bodies appreciated other than the balloon
over the suprapubic tubes in the anterior wall. Ureteral orifices were slit-like
configuration in the usual orientation on the trigone. The prostatic urethra was normal.
All the false passages were done in the bulb. I placed a wire into the bladder under
direct vision and then passed an 18-French Council tipped easily into the bladder and
inflated the balloon with 10 mL and irrigated well. Rectal exam was performed and the
rectum was flat, firm, consistent with post radiated state. There were no injuries to the
rectal wall. The stitch was placed to hold the suprapubic tube in place and it was capped
off and the Foley was placed to drainage. We will remove the suprapubic tube once the
suprapubic tract has a chance to mature. The patient was then awakened from anesthesia,
extubated, brought to recovery room in stable condition. He tolerated the procedure well. AH 20211104