Hi, how would you code the following? I was thinking 50650 but I'm not sure the bladder cuff was dissected here or how to code for the reimplant since it was performed open and not laparoscopically? Thanks for your help!
PROCEDURE PERFORMED:
1. Left distal ureterectomy.
2. Ureteroscopy with fulguration of proximal bladder tumor.
3. Ureteral reimplant into dome with psoas stitch.
The patient brought to the operating room, placed in supine position. After smooth induction of general anesthesia, a Foley catheter was placed and she was positioned with the kidney rest up and flexed to the table with an airplane of the table to the left in order to expose the left lower quadrant. She was then prepped and draped in a standard sterile fashion. A hockey-stick incision was made 2 fingerbreadths above the left iliac crest and carried down to the subcutaneous tissues. The external oblique fibers were opened in the direction of their fibers with cautery and then the muscle-splitting was performed in the direction of the internal oblique fibers to enter the retroperitoneal space. The space was developed and a Bookwalter was placed to gain adequate exposure. Ureter was readily identified, tortuous, and dilated. It was easily dissected free from the surrounding tissues. I then carefully dissected it down into the bladder beyond the beginning of the tumor and split the bladder muscle on the way down to gain the entire ureteral length. A right angle clip was then placed down on the portion of the most distal mucosa and the ureter divided. I then removed about a 2.5 inch segment that felt to be filled with tumor and sent to pathology. Pathology reviewed and stated the margins looked clear. We just safely performed ureteroscopy with a disposable flexible scope and identified a small papillary tumor a few centimeters above the area of transection. We then spatulated the ureter with Potts scissors, identified the small lesion, and removed it with forceps and cauterized the base. It only covered a couple of millimeters. We then investigated the rest of the ureter and there were no other tumors or suspicious lesions noted. The bladder was then freed up circumferentially and I used the Foley balloon to bring up the bladder up to the ureter where I could easily make a tension-free anastomosis. Two Allises were placed on either side of the dome on the left side and a small incision was made full thickness through into the mucosa. A ureteral anastomosis was then made with a running 4-0 Vicryl stitch over a 6 x 24 double-J stent. After this was secured, the bladder was pulled towards the psoas and a very superficial stitch was placed through the psoas muscle, being careful not to injure the genitofemoral nerve. The psoas stitch was then performed to tack the bladder to the side to take further tension off the anastomosis, it was water tight. Prior to the anastomosis, the mucosa of the bladder where the distal ureter had been removed was cauterized and a figure-of-eight stitch placed below the clamp to tie it down. The bladder wall was then closed in 2 layers of 3-0 Vicryl sutures to repair the defect where the intramural ureter had run. Now careful inspection was made and everything was hemostatic. A JP drain was stabbed through the muscle wall and brought down through to the bottom of the incision. The muscle layers were then closed with a running 0 looped PDS sutures. The skin edges were then anesthetized with Marcaine and the skin edges were then approximated with staples. The drain stitch was placed to tie the JP in place. Dry dressings were then applied. The patient was then awakened from anesthesia, extubated, brought to recovery room in stable condition. MC 20220803
PROCEDURE PERFORMED:
1. Left distal ureterectomy.
2. Ureteroscopy with fulguration of proximal bladder tumor.
3. Ureteral reimplant into dome with psoas stitch.
The patient brought to the operating room, placed in supine position. After smooth induction of general anesthesia, a Foley catheter was placed and she was positioned with the kidney rest up and flexed to the table with an airplane of the table to the left in order to expose the left lower quadrant. She was then prepped and draped in a standard sterile fashion. A hockey-stick incision was made 2 fingerbreadths above the left iliac crest and carried down to the subcutaneous tissues. The external oblique fibers were opened in the direction of their fibers with cautery and then the muscle-splitting was performed in the direction of the internal oblique fibers to enter the retroperitoneal space. The space was developed and a Bookwalter was placed to gain adequate exposure. Ureter was readily identified, tortuous, and dilated. It was easily dissected free from the surrounding tissues. I then carefully dissected it down into the bladder beyond the beginning of the tumor and split the bladder muscle on the way down to gain the entire ureteral length. A right angle clip was then placed down on the portion of the most distal mucosa and the ureter divided. I then removed about a 2.5 inch segment that felt to be filled with tumor and sent to pathology. Pathology reviewed and stated the margins looked clear. We just safely performed ureteroscopy with a disposable flexible scope and identified a small papillary tumor a few centimeters above the area of transection. We then spatulated the ureter with Potts scissors, identified the small lesion, and removed it with forceps and cauterized the base. It only covered a couple of millimeters. We then investigated the rest of the ureter and there were no other tumors or suspicious lesions noted. The bladder was then freed up circumferentially and I used the Foley balloon to bring up the bladder up to the ureter where I could easily make a tension-free anastomosis. Two Allises were placed on either side of the dome on the left side and a small incision was made full thickness through into the mucosa. A ureteral anastomosis was then made with a running 4-0 Vicryl stitch over a 6 x 24 double-J stent. After this was secured, the bladder was pulled towards the psoas and a very superficial stitch was placed through the psoas muscle, being careful not to injure the genitofemoral nerve. The psoas stitch was then performed to tack the bladder to the side to take further tension off the anastomosis, it was water tight. Prior to the anastomosis, the mucosa of the bladder where the distal ureter had been removed was cauterized and a figure-of-eight stitch placed below the clamp to tie it down. The bladder wall was then closed in 2 layers of 3-0 Vicryl sutures to repair the defect where the intramural ureter had run. Now careful inspection was made and everything was hemostatic. A JP drain was stabbed through the muscle wall and brought down through to the bottom of the incision. The muscle layers were then closed with a running 0 looped PDS sutures. The skin edges were then anesthetized with Marcaine and the skin edges were then approximated with staples. The drain stitch was placed to tie the JP in place. Dry dressings were then applied. The patient was then awakened from anesthesia, extubated, brought to recovery room in stable condition. MC 20220803