new coder needs help - operation: cystoscopy


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operation: cystoscopy, TUR, medium-sized bladder region over the left ureteral orifice.

note: the physician did not remove any tumor.

op note reads: cystoscopy revealed a normal bladder mucosa without evidence of recurrent tumor. The right ureteral orifice was along the right side of the interureteric ridge. On the left side of the interureteric ridge there was obvious scarring and crystallization over the left ureteral orifice with tight obstruction. Attempts at passing a guidewire or a ureteral access catheter of this obstructed ureteral orifice was impossible. Using the 26-French resectoscope the left ureteral tunnel was resected in hopes of exposing an opening of the left ureteral tunnel. After taking at least four specimens of tissue along the left ureteral tunnel no obvious ureteral orifice could be identified. At one point the ureteral access catheter went up what appeared to be a tunnel and a retrograde pyelogram was performed but this showed no evidence of the ureter so this was in a false passage. Further attempts were abandoned. The bladder was drained and the patient was sent to recovery room in excellent condition.