Bernadette10
Guru
Would this be 52281-52 or 52281 alone? There's no documentation that the cystoscope went into the bladder, only the urethra. It wouldn't be 53600, would it? And I don't think there's enough for 51610.
Postop diagnosis:
Recurrent UTI
Urethral stricture
Procedure(s):
CYSTOSCOPY, RETROGRADE URETHROGRAM /C DILATION urethral stricture, Foley insertion
Anesthesia: general
Indications: Recurrent UTI, urethral stricture.
Description of Procedure:
The patient was placed on the OR table in the lithotomy position. He was sterilely prepped and draped in usual manner. The 22 French cystoscope was introduced. No meatal strictures were noted. Cystoscopically the urethra did narrow in the pendulous urethra. Photographic documentation was performed. The scope was removed and using a 50 cc syringe a urethrogram was obtained. This showed some narrowing in the pendulous to bulbous urethra. A sensor wire was placed cystoscopically and monitored on the fluoroscope. It coiled within the bladder. Amplatz dilators were used. The 8 French 84 cm follower was placed over the wire and left in place. It was passed down to the level of approximately the prostatic urethra. Dilatation was carried out with a 12 French dilator. At this point anesthesia let me know the patient was becoming hypotensive and asked if we could abbreviate the procedure. The 14 French dilator was placed also to the level of the prostatic urethra. The 8 French catheter was removed over the wire. The wire was then used to place a council catheter. Clear urine was obtained. Culture was sent. The catheter was placed to gravity drainage. The patient was taken out of lithotomy. The patient continued to deteriorate as per anesthesia. I introduced about 120 cc of dye into the bladder and no extravasation was noted. Patient continued to deteriorate and any further study with a cystogram was cut short as we needed to remove the fluoroscope to make way for other equipment.
Operative Findings: Urethral stricture
Postop diagnosis:
Recurrent UTI
Urethral stricture
Procedure(s):
CYSTOSCOPY, RETROGRADE URETHROGRAM /C DILATION urethral stricture, Foley insertion
Anesthesia: general
Indications: Recurrent UTI, urethral stricture.
Description of Procedure:
The patient was placed on the OR table in the lithotomy position. He was sterilely prepped and draped in usual manner. The 22 French cystoscope was introduced. No meatal strictures were noted. Cystoscopically the urethra did narrow in the pendulous urethra. Photographic documentation was performed. The scope was removed and using a 50 cc syringe a urethrogram was obtained. This showed some narrowing in the pendulous to bulbous urethra. A sensor wire was placed cystoscopically and monitored on the fluoroscope. It coiled within the bladder. Amplatz dilators were used. The 8 French 84 cm follower was placed over the wire and left in place. It was passed down to the level of approximately the prostatic urethra. Dilatation was carried out with a 12 French dilator. At this point anesthesia let me know the patient was becoming hypotensive and asked if we could abbreviate the procedure. The 14 French dilator was placed also to the level of the prostatic urethra. The 8 French catheter was removed over the wire. The wire was then used to place a council catheter. Clear urine was obtained. Culture was sent. The catheter was placed to gravity drainage. The patient was taken out of lithotomy. The patient continued to deteriorate as per anesthesia. I introduced about 120 cc of dye into the bladder and no extravasation was noted. Patient continued to deteriorate and any further study with a cystogram was cut short as we needed to remove the fluoroscope to make way for other equipment.
Operative Findings: Urethral stricture