Hi All, Im looking for a bit of advice on this procedure. Any assistance is appreciated.
Im looking at 51040 cystotomy with drainage, and the 52332 stent. Any other suggestions out there?
TIA
Post-op Diagnosis
* Persistent gross hematuria [R31.0]
* Bladder rupture [N32.89]
PROCEDURES:
Procedures:
* BLADDER REPAIR
* CYSTOSCOPY STENT PLACEMENT
DRAINS:
Closed/Suction Drain 1 Left Abdomen Bulb 19 Fr. (Active)
Closed/Suction Drain 2 Right Abdomen Bulb 19 Fr. (Active)
Urethral Catheter Double-lumen 22 Fr. (Active)
Suprapubic Catheter Non-latex 24 Fr. (Active)
[REMOVED] Urethral Catheter Latex 24 Fr. (Removed)
FINDINGS:
1. Over 1 L of material dense clot in the bladder.
2. Pathologically thickened bladder wall, no more than 2 to 3 mm. Large patulous bladder.
3. Grossly denuded right posterior bladder dome, without any normal-appearing mucosa. Point of perforation could not be identified, therefore unable to close any definitive leak.
4. Clear fluid in the peritoneum, without gross blood.
5. Good placement of bilateral single-J 7 French ureteral catheters on fluoroscopy IntraOp.
DESCRIPTION OF PROCEDURE: The patient was identified and taken to the operative suite was placed in the low lithotomy position. He was prepped and draped in a sterile manner. Timeout was performed. At this point I performed a hypogastric midline incision from just below the umbilicus (patient has a small umbilical hernia) to the symphysis pubis. This was carried through the fascia using electrocautery, and the midline between the rectus muscles entered. With dissection over the symphysis pubis I entered the retroperitoneum. I bluntly dissected the peritoneum from the bladder anteriorly. The bladder was noted to be grossly distended. The peritoneum was adherent to the dome of the bladder, and I did not therefore further dissected.
I longitudinally opened the bladder. Per above, bladder wall thickness was no more than 2 mm a large amount of clot was manually removed from the bladder. The entire bladder wall was grossly erythematous. Inspection of the right dome revealed a large area that was completely denuded without any normal overlying mucosa. I probed in the area, but was not able to find a clear-cut area of perforation. Dr. Vasquez from general surgery at this point joined me and assisted through the remainder of the procedure. We explored the bladder, and identified no active bleeding source.
At this point I was able to identify the ureteral orifice ease, and cannulated each side with a 0.035 sensor wire. I passed the wires, sequentially, until I met resistance. I initially did the right side. I then passed a 7 French single-J cystectomy catheter up the right ureter until I met resistance. I removed the wire. We were careful not to further manipulate that side. I then similarly passed another catheter up the left ureter.
At this point I cut off the tip of the 24 French three-way Foley catheter, and was able to pass one of the single-J stents through the Foley catheter to the outside of the meatus. The catheter was not large enough for the second catheter to be passed through it, and therefore I cannulated the Foley with the 0.035 sensor wire and passed into the bladder. I removed the Foley catheter over the 1 single-J catheter that been passed through it, and at this point passed the second straight end of the single-J catheter through the urethra to the meatus. Good placement of the catheters was grossly noted visually. I then inserted a 22 French Silastic/silicone soft Foley catheter alongside the 2 single-J catheters. Fluoroscopy was brought in, and the stents appeared to be well into the upper ureter bilateral. On the right side the stent was clearly coiled in the apparent collecting system, but I could not clearly identify the proximal tip of the left catheter. I then made a small stab wound and passed the open-ended catheters into the Foley catheter, and then approximated the 2 stents to the Foley catheter multiple locations from the meatus to the hub of the catheter using 0 silk ties. A bedside bag was then attached, internalizing the single-J stents. There was urine E flux noted from both stents.
We again directed our attention to finding the area of perforation, but were not able to do so from inside the bladder. We then opened the peritoneum, and patient was noted to have some adhesions between peritoneal contents and the bladder dome. Some were taken down, but this became progressively difficult and I felt it would be dangerous to try to free up the entire bladder dome. Moreover, as mentioned above, the bladder wall thickness was significantly abnormal and I was concerned that I was going to disrupt the already denuded posterior bladder dome. At this point, we elected not to further explore or try to find the area of perforation. This was apparently fairly small given the fact there was no blood in the peritoneum but extremities significant amount of clot within the bladder. Moreover, I had hopefully bypassed the bladder by placing the 2 ureteral catheters.
At this point I placed a 19 Blake suction drain through the left lower quadrant stab wound into the peritoneum. This was anchored with a 0 silk suture.
I then aggressively irrigated the peritoneum with several liters of sterile water. I then closed the peritoneum using a running 2-0 Vicryl suture. I then closed the bladder in 2 layers with a running 3-0 Vicryl mucosal suture and a running 2-0 Vicryl imbricating muscularis suture. Per the above, bladder wall was so thin that it was impossible to clearly close the muscularis as 1 layer and therefore I simply imbricated the mucosal line under the 2-0 Vicryl closure line. Prior to doing this, I passed a 24 French soft silicone Foley catheter through a left stab wound going through the rectus muscle and into the left side of the bladder. I placed a 2-0 Vicryl pursestring suture around the cystostomy. This was anchored to the skin with a 0 silk suture.
I then passed a second 19 Blake suction drain through right lower quadrant stab wound and placed it across the retroperitoneum. This was also anchored using a 0 silk suture. I irrigated the retroperitoneum.
I then closed the rectus fascia using a running #1 PDS looped suture. I irrigated the subcutaneous layer, and then the skin was closed using skin clips.
I then placed several additional 0 silk ligatures around the urethral catheter and the 2 ureteral catheters to try to protect them from inadvertent removal.
The patient was extubated, and taken to the intensive care unit in serious condition.
There were no complications, and no break in sterile technique
Im looking at 51040 cystotomy with drainage, and the 52332 stent. Any other suggestions out there?
TIA
Post-op Diagnosis
* Persistent gross hematuria [R31.0]
* Bladder rupture [N32.89]
PROCEDURES:
Procedures:
* BLADDER REPAIR
* CYSTOSCOPY STENT PLACEMENT
DRAINS:
Closed/Suction Drain 1 Left Abdomen Bulb 19 Fr. (Active)
Closed/Suction Drain 2 Right Abdomen Bulb 19 Fr. (Active)
Urethral Catheter Double-lumen 22 Fr. (Active)
Suprapubic Catheter Non-latex 24 Fr. (Active)
[REMOVED] Urethral Catheter Latex 24 Fr. (Removed)
FINDINGS:
1. Over 1 L of material dense clot in the bladder.
2. Pathologically thickened bladder wall, no more than 2 to 3 mm. Large patulous bladder.
3. Grossly denuded right posterior bladder dome, without any normal-appearing mucosa. Point of perforation could not be identified, therefore unable to close any definitive leak.
4. Clear fluid in the peritoneum, without gross blood.
5. Good placement of bilateral single-J 7 French ureteral catheters on fluoroscopy IntraOp.
DESCRIPTION OF PROCEDURE: The patient was identified and taken to the operative suite was placed in the low lithotomy position. He was prepped and draped in a sterile manner. Timeout was performed. At this point I performed a hypogastric midline incision from just below the umbilicus (patient has a small umbilical hernia) to the symphysis pubis. This was carried through the fascia using electrocautery, and the midline between the rectus muscles entered. With dissection over the symphysis pubis I entered the retroperitoneum. I bluntly dissected the peritoneum from the bladder anteriorly. The bladder was noted to be grossly distended. The peritoneum was adherent to the dome of the bladder, and I did not therefore further dissected.
I longitudinally opened the bladder. Per above, bladder wall thickness was no more than 2 mm a large amount of clot was manually removed from the bladder. The entire bladder wall was grossly erythematous. Inspection of the right dome revealed a large area that was completely denuded without any normal overlying mucosa. I probed in the area, but was not able to find a clear-cut area of perforation. Dr. Vasquez from general surgery at this point joined me and assisted through the remainder of the procedure. We explored the bladder, and identified no active bleeding source.
At this point I was able to identify the ureteral orifice ease, and cannulated each side with a 0.035 sensor wire. I passed the wires, sequentially, until I met resistance. I initially did the right side. I then passed a 7 French single-J cystectomy catheter up the right ureter until I met resistance. I removed the wire. We were careful not to further manipulate that side. I then similarly passed another catheter up the left ureter.
At this point I cut off the tip of the 24 French three-way Foley catheter, and was able to pass one of the single-J stents through the Foley catheter to the outside of the meatus. The catheter was not large enough for the second catheter to be passed through it, and therefore I cannulated the Foley with the 0.035 sensor wire and passed into the bladder. I removed the Foley catheter over the 1 single-J catheter that been passed through it, and at this point passed the second straight end of the single-J catheter through the urethra to the meatus. Good placement of the catheters was grossly noted visually. I then inserted a 22 French Silastic/silicone soft Foley catheter alongside the 2 single-J catheters. Fluoroscopy was brought in, and the stents appeared to be well into the upper ureter bilateral. On the right side the stent was clearly coiled in the apparent collecting system, but I could not clearly identify the proximal tip of the left catheter. I then made a small stab wound and passed the open-ended catheters into the Foley catheter, and then approximated the 2 stents to the Foley catheter multiple locations from the meatus to the hub of the catheter using 0 silk ties. A bedside bag was then attached, internalizing the single-J stents. There was urine E flux noted from both stents.
We again directed our attention to finding the area of perforation, but were not able to do so from inside the bladder. We then opened the peritoneum, and patient was noted to have some adhesions between peritoneal contents and the bladder dome. Some were taken down, but this became progressively difficult and I felt it would be dangerous to try to free up the entire bladder dome. Moreover, as mentioned above, the bladder wall thickness was significantly abnormal and I was concerned that I was going to disrupt the already denuded posterior bladder dome. At this point, we elected not to further explore or try to find the area of perforation. This was apparently fairly small given the fact there was no blood in the peritoneum but extremities significant amount of clot within the bladder. Moreover, I had hopefully bypassed the bladder by placing the 2 ureteral catheters.
At this point I placed a 19 Blake suction drain through the left lower quadrant stab wound into the peritoneum. This was anchored with a 0 silk suture.
I then aggressively irrigated the peritoneum with several liters of sterile water. I then closed the peritoneum using a running 2-0 Vicryl suture. I then closed the bladder in 2 layers with a running 3-0 Vicryl mucosal suture and a running 2-0 Vicryl imbricating muscularis suture. Per the above, bladder wall was so thin that it was impossible to clearly close the muscularis as 1 layer and therefore I simply imbricated the mucosal line under the 2-0 Vicryl closure line. Prior to doing this, I passed a 24 French soft silicone Foley catheter through a left stab wound going through the rectus muscle and into the left side of the bladder. I placed a 2-0 Vicryl pursestring suture around the cystostomy. This was anchored to the skin with a 0 silk suture.
I then passed a second 19 Blake suction drain through right lower quadrant stab wound and placed it across the retroperitoneum. This was also anchored using a 0 silk suture. I irrigated the retroperitoneum.
I then closed the rectus fascia using a running #1 PDS looped suture. I irrigated the subcutaneous layer, and then the skin was closed using skin clips.
I then placed several additional 0 silk ligatures around the urethral catheter and the 2 ureteral catheters to try to protect them from inadvertent removal.
The patient was extubated, and taken to the intensive care unit in serious condition.
There were no complications, and no break in sterile technique