Nephrouterostomy catheter anastomosis pass-through and curling around ileal conduit

rgeib

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PREOPERATIVE DIAGNOSIS: Stricture at the right ureteroileal
conduit anastomosis with right hydroureteronephrosis.

POSTOPERATIVE DIAGNOSIS: Stricture at the right ureteroileal
conduit anastomosis with right hydroureteronephrosis.

OPERATION: Cystoscopy through ileal conduit with attempted
ureteroscopy and stricture of Ureteroileal conduit anastomosis
attempted dilation,
; right percutaneous tract dilation
over existing tract, right percutaneous nephroureteroscopy with
attempted dilation of ureteroileal stricture placement of a right
nephrostoureterostomy catheter.

INDICATIONS FOR SURGERY:
The patient has history of bladder
cancer, for which he underwent a cystectomy with placement of an
ileal conduit. The patient developed a stricture in the right
ureteroileal conduit anastomosis with resulting hydronephrosis. He
had a nephrostomy too earlier in the day from
Interventional Radiology placed a nephroureteral catheter with 2
wires going through it into his conduit through the stricture. He
comes in for stricture dilation or incision.

DESCRIPTION OF OPERATION:
The patient was identified in waiting area, and brought into the
room. Preoperative antibiotics were provided. The patient received
Ancef and Levaquin prior to his nephrostomy tube manipulation. I
gave him another dose of gentamicin. After general anesthesia was
administered, the patient was placed in the supine position. His
ileal conduit bag was removed. The patient was prepped around his
conduit and around the right flank exposing the nephroureteral
catheter with 2 wires in it. After the whole area was prepped and
draped in a standard sterile fashion, time-out was performed.
Consent and laterality were verified. First, I put a flexible
cystoscope through the patient's ileal conduit, where I saw the 2
wires in view of the flexible grasper to pull them out of his ileal
conduit and secured them to the drape. One was a Super Stiff
Amplatz. The other one was a softer centralized wire. Next, I
passed the cystoscope back into the conduit, which formed an acute
angle. I was not able to manipulate the cystoscope to the level of
the ureteral anastomosis. I then passed a flexible ureteroscope
over one of the wires to the level of the ureteroileal anastomosis.
The proximal ureter was opacified by injecting contrast to the
patient's nephroureteral stent where the stricture was noted to be
approximately 1.5 cm in length. I repeatedly attempted to pass the
ureteroscope, but could not traverse the strictured area. I then
removed it and tried to pass a 4 cm x 5 mm balloon dilator over the
wire in order to dilate the stricture, but again I was not
successful in passing the balloon dilator sheath through the
stricture.

I then attempted the procedure percutaneously. The
patient had a 9-French nephroureteral catheter. I removed it before
which I opacified the collecting system. The renal pelvis was
clearly seen without any extravasation. Next, I passed a 10/12
ureteral access sheath over the Stiff Wire under fluoroscopic
guidance down the ureter which also dilated the tract.
I was able to pass the ureteral access
sheath into the distal ureter. The inner guide was then removed,
and first I passed a ureteroscope over the wire, but due to the
floppy nature of the ureter, the mobility with the scope was very
limited. I therefore decided to remove the wire, which I did,
gaining a little bit more mobility with ureteroscope, but still the
ureteroscope could not traverse the area of the stricture. I then
removed it. I tried to pass another wire through the stricture, but
was not successful and removed bluntly. I therefore removed the
ureteral access sheath. At this time, I attempted to pass the 4 cm
balloon dilator subcutaneously over my remaining wire. Again, I
could not traverse the stricture due to the tight nature. At this
point, I obtained an 8.5 nephroureterostomy stent. I passed it over
my remaining safety wire, and I was at this time able to pass it
through the stricture and actually out through the conduit stoma. I
positioned the proximal opening of the nephroureterostomy at the
level of the renal pelvis. The distal curl was then coiled outside
of the ostomy and inner guiding wire was removed. A nephrostogram
was performed, confirming good position of the coil and the openings
at the level of the renal pelvis and distally I then secured the
percutaneous portion to the skin with a clip, the end was capped.
At the distal end, I tied a 0 silk stitch to the coil. Dressing was
applied over the patient's flank and a new ostomy bag was secured
with the coil and string protruding into it. The patient tolerated
the procedure well and was sent to the recovery room in stable
condition. I will allow the nephroureteral stent to dilate the
stricture passively at this point.

So far, the best I have been able to come up with is 50693, but it's been suggested that an additional code (perhaps 52000) is warranted. Any help would be appreciated. Thanks in advance.
 
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