KaylaRieken
True Blue
Can I get help coding this operative report? Patient had a cystectomy with ileal conduit formation 10 years ago. Now has a ureteral ileal anastomotic stricutre.
He was then flipped prone onto the operating room table. His prior nephrostomy and antegrade stent tubing were prepped into the field and he was draped in the usual sterile fashion. We begain by placing a wire down the nephrostomy tube and assuring access. I then removed the nephrostomy and place the dual-lumen access catheter over the wire and placed a second wire down the ureter. I then remove the access catheter and advanced a NephroMax balloon dilator. I use this to dialte and create a nephrostomy tract into the renal pelvis. I had performed an antegrade nephrostogram to verify where we were prior to this. Once this was in place I advanced the nephrostomy sheath over the NephroMax balloon and removed the balloon. All this was under fluroscopic guidance. I then advanced the flexible cystoscopy nephroscope under camera guidance into the renal pelvis. I evaluated the renal pelvis on are to biopsy which I did so and then fulgurated and then 1 in the proximal ureter as well. None of this looked terribly papillary but there was some abnormal tissue. I then advanced the cystoscopy nephroscopy down to the anastomosis on narrowing but the ureteral stent was through the area and was reasonably open. I did biopsy the anastomosis and I did not cauterize this. I then removed the scope and put a 16 French council tip silicone catheter over the wire into the renal pelvisput 2 to 3 cc of contrast in the balloon to verify its location and then remove the sheath and sewed gthe nephrostomy tube in place. We performed an antegrade nephrostogram to prove where we were.
Would this be 50555? 50557?
He was then flipped prone onto the operating room table. His prior nephrostomy and antegrade stent tubing were prepped into the field and he was draped in the usual sterile fashion. We begain by placing a wire down the nephrostomy tube and assuring access. I then removed the nephrostomy and place the dual-lumen access catheter over the wire and placed a second wire down the ureter. I then remove the access catheter and advanced a NephroMax balloon dilator. I use this to dialte and create a nephrostomy tract into the renal pelvis. I had performed an antegrade nephrostogram to verify where we were prior to this. Once this was in place I advanced the nephrostomy sheath over the NephroMax balloon and removed the balloon. All this was under fluroscopic guidance. I then advanced the flexible cystoscopy nephroscope under camera guidance into the renal pelvis. I evaluated the renal pelvis on are to biopsy which I did so and then fulgurated and then 1 in the proximal ureter as well. None of this looked terribly papillary but there was some abnormal tissue. I then advanced the cystoscopy nephroscopy down to the anastomosis on narrowing but the ureteral stent was through the area and was reasonably open. I did biopsy the anastomosis and I did not cauterize this. I then removed the scope and put a 16 French council tip silicone catheter over the wire into the renal pelvisput 2 to 3 cc of contrast in the balloon to verify its location and then remove the sheath and sewed gthe nephrostomy tube in place. We performed an antegrade nephrostogram to prove where we were.
Would this be 50555? 50557?