toria11
Guru
How would you recommend coding this? I haven't come across a balloon dilation of the urethra before and I'm not sure if it's just included in the tumor resection. It seems I will need to query the provider on the size of the tumor.. Thanks!
Indication for operation: 78-year-old male with history of bladder cancer found to have sessile
bladder cancer recurrence at the posterior bladder and the left lateral wall
Preoperative diagnosis: Bladder cancer
Postoperative diagnosis: Same
Findings: Tight urethra at the penoscrotal junction requiring balloon dilation to 30 French to
accommodate the 26 French continuous flow resectoscope. Sessile lesions posterior bladder
and left lateral wall. Brisk obturator reflex causing small perforation at the left lateral wall.
Specimens: Bladder tumor
Operation performed:
1. Cystoscopy with balloon dilation of urethral
2. Transurethral resection bladder tumor
3. Instillation of gemcitabine into the bladder
Description of operation: After informed consent was obtained, the patient was brought back to
operating room and underwent general LMA anesthesia. He was placed in the low lithotomy
position. His genitalia was prepped and draped in a sterile surgical manner. Time-out was
performed.
A 26 French continuous flow resectoscope was inserted into the urethra advanced proximally
until it met resistance at the penoscrotal junction. It appeared that his urethra was narrowed at
the penoscrotal junction. The junction was dilated using male sounds, however, it still was not
enough to allow the resectoscope the past. Subsequently a 22 French rigid cystoscope was
inserted into the urethra advanced to the bladder. A guidewire was placed into the bladder under
direct visualization. The cystoscope was removed and a 30 French balloon catheter was placed
over the wire and the junction was dilated to 30 French. After dilatation the resectoscope could
be placed into the urethra advanced to the bladder. It was noted that the balloon the cause small
perforations of the penoscrotal junction. There was sessile bladder tumors at the posterior
bladder wall along with the left lateral wall. The posterior bladder wall tumor was resected using
a bipolar loop. During resection of the left lateral wall sessile tumor, he had brisk obturator reflex
that caused a small perforation in the bladder. The tumor was then removed with cold cup
bladder biopsy forceps. Hemostasis was obtained using the bipolar loop. The resectoscope was
removed and a 20 French Foley catheter was placed. 2 grams of gemcitabine in 100 milliliters of
normal saline was then instilled into the bladder. Will be left in place for 1 hour. Patient was
returned to the supine position, the LMA was removed, and he was taken to recovery room stable
condition. 20220113 WH
Indication for operation: 78-year-old male with history of bladder cancer found to have sessile
bladder cancer recurrence at the posterior bladder and the left lateral wall
Preoperative diagnosis: Bladder cancer
Postoperative diagnosis: Same
Findings: Tight urethra at the penoscrotal junction requiring balloon dilation to 30 French to
accommodate the 26 French continuous flow resectoscope. Sessile lesions posterior bladder
and left lateral wall. Brisk obturator reflex causing small perforation at the left lateral wall.
Specimens: Bladder tumor
Operation performed:
1. Cystoscopy with balloon dilation of urethral
2. Transurethral resection bladder tumor
3. Instillation of gemcitabine into the bladder
Description of operation: After informed consent was obtained, the patient was brought back to
operating room and underwent general LMA anesthesia. He was placed in the low lithotomy
position. His genitalia was prepped and draped in a sterile surgical manner. Time-out was
performed.
A 26 French continuous flow resectoscope was inserted into the urethra advanced proximally
until it met resistance at the penoscrotal junction. It appeared that his urethra was narrowed at
the penoscrotal junction. The junction was dilated using male sounds, however, it still was not
enough to allow the resectoscope the past. Subsequently a 22 French rigid cystoscope was
inserted into the urethra advanced to the bladder. A guidewire was placed into the bladder under
direct visualization. The cystoscope was removed and a 30 French balloon catheter was placed
over the wire and the junction was dilated to 30 French. After dilatation the resectoscope could
be placed into the urethra advanced to the bladder. It was noted that the balloon the cause small
perforations of the penoscrotal junction. There was sessile bladder tumors at the posterior
bladder wall along with the left lateral wall. The posterior bladder wall tumor was resected using
a bipolar loop. During resection of the left lateral wall sessile tumor, he had brisk obturator reflex
that caused a small perforation in the bladder. The tumor was then removed with cold cup
bladder biopsy forceps. Hemostasis was obtained using the bipolar loop. The resectoscope was
removed and a 20 French Foley catheter was placed. 2 grams of gemcitabine in 100 milliliters of
normal saline was then instilled into the bladder. Will be left in place for 1 hour. Patient was
returned to the supine position, the LMA was removed, and he was taken to recovery room stable
condition. 20220113 WH