pattilebeau
Contributor
op note reads as follows: Dr. submitted (or wants to) 52332, 50548,50650) with 22 modifier. I am new to urology and it's been difficult for me so any help with this coding would be greatly appreciated. He also wants to list a "bedside assistant" as a co-surgeon to get her paid the same as him, quote unquote. HELP!!! TIA
Procedure in Detail:
After informed consent was confirmed, the patient was placed in the lithotomy position under general anesthesia with careful padding of the extremities. A pause for safety was carried out confirming administration of suitable prophylactic antibiotics timed according to protocol.
The 22-French cystoscope was introduced and a survey performed identifying modestly cloudy urine, a widely patent right upper pole neo-orifice, and slightly superolateral position of the lower pole ureter.
Efforts to flush the nephrostomy were not productive.
A guidewire was passed in the lower pole ureter under fluoroscopic guidance through an open ended catheter. A retrograde pyelogram was performed using Omnipaque diluted 1:1 with the findings demonstrated above, withdrawing the catheter during injection to demonstrate the distal ureter.
The guidewire was then advanced to the level of the renal pelvis under fluoroscopic guidance. The ureter was measured at 24 cm using the open ended catheter. An 8-French by 24-cm double-J ureteral stent was then passed over the guidewire. After removal of the guidewire, a full coil could be seen within the renal pelvis fluoroscopically, and a full coil was seen within the bladder under direct vision.
A similar technique was used in the upper pole ureter. The open ended catheter was exchanged for a dual lumen catheter. A retrograde was performed and the ureter irrigated to free any debris.
The catheter were removed, the bladder was drained through the cystoscope and the instrumentation removed. An 18 French catheter was placed and the string secured t the catheter.
The patient was repositioned supine, reprepped and draped and another pause performed. The bed was later inverted in Trendelenberg position and tilted to elevate the right kidney.
A Veress technique was used to obtain pneumoperitoneum from a point in the left lower quadrant, using the usual confirmatory techniques. I was not satisfied with the insufflation pressures. I tried a higher port site. And remained unsatisfied. I performed an open technique, noting a thicker muscular abdominal wall than anticipated. The peritoneum was accessed and the trocar introduced under direct vision with stay sutures.
A 12 mm Airseal port was inserted and te abdomen inspected to exclude injury.
Four additional 8 mm robotic ports were placed in a line in an oblique line directed to the right flank and pelvis.
The colon was reflected medially to avoid injury, lysing numerous adhesion. I encountered indurated and iinflamed retroperitoneal structures, and spent some time distinguishing the gonadal vessels from the upper and lower pole ureters, noting a clip high on the ureter. These tissues were vascular and indistinct, taking additional care to identify, verify the correct ureter using the stent as a guide, and mobilize without injuring the lower pole ureter.
Ultimately I identified the upper pole ureter, and when encountering the nephrostomy drain, opened it for verification, while removiing the nephrostomy.
The ureter was mobilized inferiorly to the iliac vessels. In this region it was difficult to identify the lower pole ureter. For this reason I resected the free portion and left the widely spatulated posterior portion intact to avoid injuring the lower pole ureter.
It was thereafter followed to the bladder, elevating the gonadal vessels, and transecting the round ligament, but preserving the uterine vessels, ovary and fallopian tubes.
During this dissection the bladder was mobilized lateral to the medial umbilical ligament to the level of the endopelvic fascia. The detrusor was incised to mobilize the ureter along Waldeyer's sheath.
Ultimately I was able to identify the stent within the bladder lumen.
A 2-0 Vicryl stay suture was placed, and the ureteral transection completed. The cystotomy was then closed with a pair of 3-0 V-lock,sutuires in 2 layers, after which it was filled with over 200 ccs, to demonstrated a water tight closure.
The pelvis and retroperitoneum were reinspected and irrigated to ensure hemostasis. The ureter was submitted in several sections for pathologic analysis.
.
A 15 French Blake drain was placed in the pelvis near the cystotomy. The ports were removed under direct vision.
The 12 mm Airseal incision was closed using #0 Vicryl. Subcuticular skin closure and/or surgical glue were used for skin closure. Each of the port sites were closed with a similar technique.
The entire procedure was tolerated well. Estimated blood loss was under 100 ml. Sponge, needle and instrument counts were confirmed prior to completion of the procedure. The patient was transferred to the recovery room in stable condition.
The procedure was prolonged, requiring significant additional time than would be expected for a simple ureterectomy due to the prior pelvic abscess, adhesions, and congential abnormality with the need to identify, separate and preserve the adjacent lower pole ureter. In this regard the extent and technique was essntially similar to a radical nephroureterectomy.
Procedure in Detail:
After informed consent was confirmed, the patient was placed in the lithotomy position under general anesthesia with careful padding of the extremities. A pause for safety was carried out confirming administration of suitable prophylactic antibiotics timed according to protocol.
The 22-French cystoscope was introduced and a survey performed identifying modestly cloudy urine, a widely patent right upper pole neo-orifice, and slightly superolateral position of the lower pole ureter.
Efforts to flush the nephrostomy were not productive.
A guidewire was passed in the lower pole ureter under fluoroscopic guidance through an open ended catheter. A retrograde pyelogram was performed using Omnipaque diluted 1:1 with the findings demonstrated above, withdrawing the catheter during injection to demonstrate the distal ureter.
The guidewire was then advanced to the level of the renal pelvis under fluoroscopic guidance. The ureter was measured at 24 cm using the open ended catheter. An 8-French by 24-cm double-J ureteral stent was then passed over the guidewire. After removal of the guidewire, a full coil could be seen within the renal pelvis fluoroscopically, and a full coil was seen within the bladder under direct vision.
A similar technique was used in the upper pole ureter. The open ended catheter was exchanged for a dual lumen catheter. A retrograde was performed and the ureter irrigated to free any debris.
The catheter were removed, the bladder was drained through the cystoscope and the instrumentation removed. An 18 French catheter was placed and the string secured t the catheter.
The patient was repositioned supine, reprepped and draped and another pause performed. The bed was later inverted in Trendelenberg position and tilted to elevate the right kidney.
A Veress technique was used to obtain pneumoperitoneum from a point in the left lower quadrant, using the usual confirmatory techniques. I was not satisfied with the insufflation pressures. I tried a higher port site. And remained unsatisfied. I performed an open technique, noting a thicker muscular abdominal wall than anticipated. The peritoneum was accessed and the trocar introduced under direct vision with stay sutures.
A 12 mm Airseal port was inserted and te abdomen inspected to exclude injury.
Four additional 8 mm robotic ports were placed in a line in an oblique line directed to the right flank and pelvis.
The colon was reflected medially to avoid injury, lysing numerous adhesion. I encountered indurated and iinflamed retroperitoneal structures, and spent some time distinguishing the gonadal vessels from the upper and lower pole ureters, noting a clip high on the ureter. These tissues were vascular and indistinct, taking additional care to identify, verify the correct ureter using the stent as a guide, and mobilize without injuring the lower pole ureter.
Ultimately I identified the upper pole ureter, and when encountering the nephrostomy drain, opened it for verification, while removiing the nephrostomy.
The ureter was mobilized inferiorly to the iliac vessels. In this region it was difficult to identify the lower pole ureter. For this reason I resected the free portion and left the widely spatulated posterior portion intact to avoid injuring the lower pole ureter.
It was thereafter followed to the bladder, elevating the gonadal vessels, and transecting the round ligament, but preserving the uterine vessels, ovary and fallopian tubes.
During this dissection the bladder was mobilized lateral to the medial umbilical ligament to the level of the endopelvic fascia. The detrusor was incised to mobilize the ureter along Waldeyer's sheath.
Ultimately I was able to identify the stent within the bladder lumen.
A 2-0 Vicryl stay suture was placed, and the ureteral transection completed. The cystotomy was then closed with a pair of 3-0 V-lock,sutuires in 2 layers, after which it was filled with over 200 ccs, to demonstrated a water tight closure.
The pelvis and retroperitoneum were reinspected and irrigated to ensure hemostasis. The ureter was submitted in several sections for pathologic analysis.
.
A 15 French Blake drain was placed in the pelvis near the cystotomy. The ports were removed under direct vision.
The 12 mm Airseal incision was closed using #0 Vicryl. Subcuticular skin closure and/or surgical glue were used for skin closure. Each of the port sites were closed with a similar technique.
The entire procedure was tolerated well. Estimated blood loss was under 100 ml. Sponge, needle and instrument counts were confirmed prior to completion of the procedure. The patient was transferred to the recovery room in stable condition.
The procedure was prolonged, requiring significant additional time than would be expected for a simple ureterectomy due to the prior pelvic abscess, adhesions, and congential abnormality with the need to identify, separate and preserve the adjacent lower pole ureter. In this regard the extent and technique was essntially similar to a radical nephroureterectomy.