Cystoscopy/urethral dilation/transurethral resection multiple bladder/prostatic lesio

Pam Brooks

True Blue
Local Chapter Officer
NAB Member
Messages
2,113
Location
South Berwick, ME
Best answers
0
Can anyone offerer suggestions or shed light on what would be the appropriate code/codes to use? Thanks, Pam

PREOPERATIVE DIAGNOSIS
Probable bladder tumor, history of benign prostatic hypertrophy and bladder neck contracture.

POSTOPERATIVE DIAGNOSIS
Probable bladder tumor, history of benign prostatic hypertrophy and bladder neck contracture, pending pathology.

PROCEDURE
Cystoscopy, urethral dilatation, transurethral resection multiple bladder and prostatic urethral lesions medium in toto.

ANESTHESIA
General.

SURGEON
Roger Evans, MD

INDICATIONS
This gentleman had been previously cystoscoped and found to have lesions. This was after some bleeding. He has had previous prostate surgery done quite some time ago.

DESCRIPTION OF THE PROCEDURE
He was given prophylactic Levaquin based on previous urine culture. The patient had a moderate sedation anesthetic and topical Xylocaine was placed to the urethra and a #21-panendoscope was introduced and there was a urethral stricture just distal to the verumontanum. I was able to dilate this with the #21 scope. There was irregularity consistent with his previous surgery in the prostatic fossa on the right wall of the prostatic fossa was about a 1-cm area of yellow, almost necrotic appearing area. The bladder neck was somewhat opened. There was frondular tissue suspicious of tumor on the left aspect of the bladder neck. On the left trigone, surrounding the area of the left ureter was frondular area, and there was a third area inside the bladder behind the trigone on the left side.

I took a couple of cold punch biopsies of these areas on the posterior wall and on the area near the ureter and then used a #24 continuous low resectoscope that I was able to dilate up and get in and fulgurated these. I did a transurethral resection in the trigone of a separate area that was inflamed medial to the ureter on the left side as well as at the left side of the bladder neck. I also resected the lesion that was yellowish on the right side of the prostate.

I then left in a #24 Foley catheter. Bleeding was fairly minimal and seemed to be well-controlled at the conclusion.[/COLOR]
 
Top