Miko24
Guest
I am not sure on the codes for the following antegrade procedure. My thoughts are 50955 and 52332 or 52354 and 52332
After obtaining informed consent answer all questions the patient was transported to the operating room. General anesthesia was induced. After adequate anesthesia the patient was positioned in the right lateral position on the table. All pressure points were padded. The left flank and capped nephrostomy tube were prepped and draped in the usual sterile fashion. A timeout procedure was performed.
A 0.035 guidewire was inserted through the nephrostomy tube and curled in the renal pelvis under fluoroscopic guidance. The nephrostomy tube was offloaded from the guidewire. A Lieberman catheter was advanced over the guidewire and into the renal pelvis. The guidewire was removed. Contrast was injected. The guidewire was advanced through the catheter and I was able to advance this down the ureter and into the bladder where a curl was noted fluoroscopically. A second guidewire, Amplatz Super Stiff, was inserted through the Lieberman catheter and into the bladder under fluoroscopic guidance. The Lieberman catheter was offloaded from the guidewires.
The safety wire was coiled and clamped to the drape. A 28 cm ureteral access sheath was advanced over the working wire and into the renal pelvis under fluoroscopic guidance. The working wire was removed. A flexible ureteroscope was advanced through the access sheath and into the renal pelvis. The ureteroscope was advanced through the UPJ, proximal ureter, mid ureter, and into the distal ureter. The mucosa of the distal ureter appears abnormal. It is somewhat hemorrhagic in appearance. There is no obvious papillary tumor identified. I am able to advance the scope through the distal ureter and into the neobladder. However, the distal ureter is narrowed. At this point, it is my impression that the patient likely has a stricture of the distal ureter but I cannot rule out a malignant stricture. Therefore I decided to obtain biopsy samples. A cold cup biopsy device is inserted through the ureteroscope and used to obtain 4 small samples of the mucosa in this area. The samples are obtained and labeled accordingly for pathology.
The ureteroscope was slowly removed through the ureter and once again I do not see any obvious papillary appearing tumors. The scope was replaced into the renal pelvis. The access sheath is pulled back to the level of the entry point into the kidney. I systematically surveyed the kidney and did not find any obvious papillary tumors. No obvious mucosal irregularities are noted. No stones are identified. The scope along with the access sheath are removed at this point.
A 6 French single-J stent is then advanced over the safety wire and into the bladder under fluoroscopic guidance. The guidewire was pulled back and a good curl was noted within the bladder. The guidewire was removed. The stent exits the skin for approximately 5 to 6 cm. A Luer-Lok cap is placed on the stent. A 3-0 nylon suture is used to secure the stent to the skin. This is the end of the procedure.
The patient is awakened and extubated in the operating room. He is transported to the postanesthesia care unit in satisfactory condition. The plan will be to await pathology findings. If cancer is present then patient will require a nephro ureterectomy. Otherwise, we could attempt balloon dilation of a stricture. We may also want to consider a nuclear medicine renal scan to ensure that the kidney has adequate function.
Thank you for your time.
After obtaining informed consent answer all questions the patient was transported to the operating room. General anesthesia was induced. After adequate anesthesia the patient was positioned in the right lateral position on the table. All pressure points were padded. The left flank and capped nephrostomy tube were prepped and draped in the usual sterile fashion. A timeout procedure was performed.
A 0.035 guidewire was inserted through the nephrostomy tube and curled in the renal pelvis under fluoroscopic guidance. The nephrostomy tube was offloaded from the guidewire. A Lieberman catheter was advanced over the guidewire and into the renal pelvis. The guidewire was removed. Contrast was injected. The guidewire was advanced through the catheter and I was able to advance this down the ureter and into the bladder where a curl was noted fluoroscopically. A second guidewire, Amplatz Super Stiff, was inserted through the Lieberman catheter and into the bladder under fluoroscopic guidance. The Lieberman catheter was offloaded from the guidewires.
The safety wire was coiled and clamped to the drape. A 28 cm ureteral access sheath was advanced over the working wire and into the renal pelvis under fluoroscopic guidance. The working wire was removed. A flexible ureteroscope was advanced through the access sheath and into the renal pelvis. The ureteroscope was advanced through the UPJ, proximal ureter, mid ureter, and into the distal ureter. The mucosa of the distal ureter appears abnormal. It is somewhat hemorrhagic in appearance. There is no obvious papillary tumor identified. I am able to advance the scope through the distal ureter and into the neobladder. However, the distal ureter is narrowed. At this point, it is my impression that the patient likely has a stricture of the distal ureter but I cannot rule out a malignant stricture. Therefore I decided to obtain biopsy samples. A cold cup biopsy device is inserted through the ureteroscope and used to obtain 4 small samples of the mucosa in this area. The samples are obtained and labeled accordingly for pathology.
The ureteroscope was slowly removed through the ureter and once again I do not see any obvious papillary appearing tumors. The scope was replaced into the renal pelvis. The access sheath is pulled back to the level of the entry point into the kidney. I systematically surveyed the kidney and did not find any obvious papillary tumors. No obvious mucosal irregularities are noted. No stones are identified. The scope along with the access sheath are removed at this point.
A 6 French single-J stent is then advanced over the safety wire and into the bladder under fluoroscopic guidance. The guidewire was pulled back and a good curl was noted within the bladder. The guidewire was removed. The stent exits the skin for approximately 5 to 6 cm. A Luer-Lok cap is placed on the stent. A 3-0 nylon suture is used to secure the stent to the skin. This is the end of the procedure.
The patient is awakened and extubated in the operating room. He is transported to the postanesthesia care unit in satisfactory condition. The plan will be to await pathology findings. If cancer is present then patient will require a nephro ureterectomy. Otherwise, we could attempt balloon dilation of a stricture. We may also want to consider a nuclear medicine renal scan to ensure that the kidney has adequate function.
Thank you for your time.