toria11
Guru
How would you code this? I'm thinking 52281-22? Thank you!
POSTOPERATIVE DIAGNOSIS:
1. Urethral disruption, status post traumatic Foley removal.
2. History of prostate cancer, status post robotic prostatectomy with bilateral pelvic lymph node dissection.
PROCEDURE PERFORMED:
Flexible cystourethroscopy with urethral dilation and difficult Foley catheter placement.
ANESTHESIA:
General.
DRAINS:
1. A 16-French Councill-tip Foley catheter capped.
2. A 14-French SP tube to gravity drainage.
ESTIMATED BLOOD LOSS:
Minimal.
FINDINGS:
1. Urethral disruption with significant urethral tissue occluding the lumen with anastomotic stitches visible.
2. Successful realignment of urethra with bladder over a 16-French Councill-tip catheter.
INDICATIONS:
The patient is with a history of Gleason 3+4=7 prostate cancer who underwent robotic prostatectomy, pelvic lymph node dissection, and subsequent SP tube placement on 12/02/2021 due to his intermediate risk prostate cancer. During his procedure, vesicourethral anastomosis was quite tenuous and difficult and therefore he had an SP tube placed as well. Late in the evening on postop day #1, he traumatically and accidentally removed his Foley catheter by pulling on it. However, his bladder remained protected with an SP tube that was draining without issues. He was then set up today for potential realignment of the vesicourethral anastomosis. After risks, benefits, and alternatives were explained to the patient, the patient agreed to proceed. An informed consent was obtained.
DESCRIPTION OF PROCEDURE:
The patient was properly identified, brought back to the cystoscopy suite, and laid supine on the cystoscopy table. Appropriate time-out was performed under direction of Anesthesiology. The patient was able to be induced under general anesthetic. Preoperative antibiotics in the form of Ancef 2 g IV were given within an hour of start of the procedure. The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile surgical fashion. The SP tube was then clamped off with a hemostat. At this time, I passed a flexible cystoscope down his urethra toward the bladder neck. Once I got toward the area of the anastomosis, I did see my green anastomotic stitches, but his lumen initially appeared to be blind ending. However, I knew from the previous anastomosis that anteriorly they came together, but posteriorly there was a large gap. Therefore, I maneuvered the flexible cystoscope anteriorly until I was able to find a small dark lumen in which I slowly advanced the scope at this point to the 1 o'clock position. It appeared to have this cystic dome-type structure and in the distance I could see the balloon of the SP tube. Therefore, I passed a hybrid wire through the flexible cystoscope and into the structure and I was able to advance the cystoscope into this area. I then carefully examined and it was truly the bladder that was occupying and I could see the SP tube. Therefore, at this point, I left the wire in place and removed the flexible cystoscope. I then used the Bard dilator set and dilated this area from a 12-French all the way up to an 18-French. I initially attempted to pass a 20-French Councill-tip over this wire, but __________ resistance of buckling and so I downsized all way to 16-French, which was included in the Bard catheter kit. The 16-French was able to easily pass over the wire into the bladder. The wire was removed and light pink urine returned. I then placed 20 mL in the balloon. I irrigated the catheter and successfully irrigated without any difficulty. At this point, I then capped off the Foley catheter and unclamped the SP tube to drainage. This concluded the procedure. Sponge, instrument, and needle counts were correct at the end of the case. Estimated blood loss was minimal. The patient was extubated and sent to Recovery in stable condition. He will be transferred to the floor for routine postop care. The plan will be to keep the urethral Foley catheter __________ to hopefully allow the vesicourethral anastomosis to heal over the catheter with time. RC 20211206
POSTOPERATIVE DIAGNOSIS:
1. Urethral disruption, status post traumatic Foley removal.
2. History of prostate cancer, status post robotic prostatectomy with bilateral pelvic lymph node dissection.
PROCEDURE PERFORMED:
Flexible cystourethroscopy with urethral dilation and difficult Foley catheter placement.
ANESTHESIA:
General.
DRAINS:
1. A 16-French Councill-tip Foley catheter capped.
2. A 14-French SP tube to gravity drainage.
ESTIMATED BLOOD LOSS:
Minimal.
FINDINGS:
1. Urethral disruption with significant urethral tissue occluding the lumen with anastomotic stitches visible.
2. Successful realignment of urethra with bladder over a 16-French Councill-tip catheter.
INDICATIONS:
The patient is with a history of Gleason 3+4=7 prostate cancer who underwent robotic prostatectomy, pelvic lymph node dissection, and subsequent SP tube placement on 12/02/2021 due to his intermediate risk prostate cancer. During his procedure, vesicourethral anastomosis was quite tenuous and difficult and therefore he had an SP tube placed as well. Late in the evening on postop day #1, he traumatically and accidentally removed his Foley catheter by pulling on it. However, his bladder remained protected with an SP tube that was draining without issues. He was then set up today for potential realignment of the vesicourethral anastomosis. After risks, benefits, and alternatives were explained to the patient, the patient agreed to proceed. An informed consent was obtained.
DESCRIPTION OF PROCEDURE:
The patient was properly identified, brought back to the cystoscopy suite, and laid supine on the cystoscopy table. Appropriate time-out was performed under direction of Anesthesiology. The patient was able to be induced under general anesthetic. Preoperative antibiotics in the form of Ancef 2 g IV were given within an hour of start of the procedure. The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile surgical fashion. The SP tube was then clamped off with a hemostat. At this time, I passed a flexible cystoscope down his urethra toward the bladder neck. Once I got toward the area of the anastomosis, I did see my green anastomotic stitches, but his lumen initially appeared to be blind ending. However, I knew from the previous anastomosis that anteriorly they came together, but posteriorly there was a large gap. Therefore, I maneuvered the flexible cystoscope anteriorly until I was able to find a small dark lumen in which I slowly advanced the scope at this point to the 1 o'clock position. It appeared to have this cystic dome-type structure and in the distance I could see the balloon of the SP tube. Therefore, I passed a hybrid wire through the flexible cystoscope and into the structure and I was able to advance the cystoscope into this area. I then carefully examined and it was truly the bladder that was occupying and I could see the SP tube. Therefore, at this point, I left the wire in place and removed the flexible cystoscope. I then used the Bard dilator set and dilated this area from a 12-French all the way up to an 18-French. I initially attempted to pass a 20-French Councill-tip over this wire, but __________ resistance of buckling and so I downsized all way to 16-French, which was included in the Bard catheter kit. The 16-French was able to easily pass over the wire into the bladder. The wire was removed and light pink urine returned. I then placed 20 mL in the balloon. I irrigated the catheter and successfully irrigated without any difficulty. At this point, I then capped off the Foley catheter and unclamped the SP tube to drainage. This concluded the procedure. Sponge, instrument, and needle counts were correct at the end of the case. Estimated blood loss was minimal. The patient was extubated and sent to Recovery in stable condition. He will be transferred to the floor for routine postop care. The plan will be to keep the urethral Foley catheter __________ to hopefully allow the vesicourethral anastomosis to heal over the catheter with time. RC 20211206