I would code this as 54326 rather than 53520, but I'm wondering your thoughts since the diagnosis is a fistula due to a piercing rather than hypospadias. I still feel the 54326 most accurately represents what was done. Thanks!
Indication: history of distal urethral cutaneous fistula secondary to a previous piercing. He initial fistula closure earlier this year but has a recurrence.
Preoperative diagnosis: Urethrocutaneous fistula
Postop diagnosis: Same
Findings: Fossa navicularis urethrocutaneous fistula. Penile skin flap used for the urethroplasty
Operation performed: Urethroplasty using penile skin flap
Description of operation:
The patient's meatus was calibrated to 30 French using sounds. A circumcision incision was then
made and incision was extended in the midline ventrally towards the fistula site. The fistula
opening was exposed. The fistula was at the fossa navicularis site. The fistula was then entirely
opened from the fossa navicularis to the urethral meatus. An approximately 1 x 1 centimeter
penile skin flap was then taken from the distal aspect of the penis on the left side and brought to
the fossa navicularis. The penile skin flap was then sutured in place to the urethral mucosa using
4-0 Vicryl in interrupted and running fashion. Glans flaps were also performed. Subcutaneous
tissue was then taken from the right side of the penile skin and placed over the repair site. The
glans was then sutured in place using 2-0 Vicryl in a interrupted fashion. The skin was
reapproximated using 3-0 chromic in a interrupted and running fashion. Sterile dressing was then
applied. The LMA was then removed. And patient was taken to recovery room stable condition.
Indication: history of distal urethral cutaneous fistula secondary to a previous piercing. He initial fistula closure earlier this year but has a recurrence.
Preoperative diagnosis: Urethrocutaneous fistula
Postop diagnosis: Same
Findings: Fossa navicularis urethrocutaneous fistula. Penile skin flap used for the urethroplasty
Operation performed: Urethroplasty using penile skin flap
Description of operation:
The patient's meatus was calibrated to 30 French using sounds. A circumcision incision was then
made and incision was extended in the midline ventrally towards the fistula site. The fistula
opening was exposed. The fistula was at the fossa navicularis site. The fistula was then entirely
opened from the fossa navicularis to the urethral meatus. An approximately 1 x 1 centimeter
penile skin flap was then taken from the distal aspect of the penis on the left side and brought to
the fossa navicularis. The penile skin flap was then sutured in place to the urethral mucosa using
4-0 Vicryl in interrupted and running fashion. Glans flaps were also performed. Subcutaneous
tissue was then taken from the right side of the penile skin and placed over the repair site. The
glans was then sutured in place using 2-0 Vicryl in a interrupted fashion. The skin was
reapproximated using 3-0 chromic in a interrupted and running fashion. Sterile dressing was then
applied. The LMA was then removed. And patient was taken to recovery room stable condition.