Hello, looking for coding direction for the following surgery:
Self-inflicted and retained penile/urethral foreign object
Urethral trauma
Penile pain
I performed cystoscopy with a flexible cystoscope and a flexible ureteroscope until I identified the location of the foreign object, with external palpation and with the use of an ultrasound, I was able to identify the general vicinity of the foreign object embedded within the penile tissue/urethra. I created a vertical midline incision at the penoscrotal junction as the object is in the area of the distal bulbar urethra. Skin was incised with a #15 blade then subcutaneous tissues were dissected with use of Bovie, scissors, and blunt dissection where appropriate I was on top of the urethra. The tissue planes were not cleared due to the inflammatory changes and induration of the tissue surrounding the urethra and the distal bulbar region. I placed a Foley catheter with the aid of a cystoscope and with palpation I identified the midline of the area where the object was expected. I eventually cut over the object and made an opening about 3 cm into that open space. I was able to extract the object and 1 piece and it was sent to pathology for identification. Some fluid was irrigated over the object and sent for wound culture. Urine culture was also sent at the beginning of the procedure. Understanding that the urethra is severely traumatized throughout the bulbar region, my goal was to close the opening we created into the space for the foreign object was. After removal of the object the area was irrigated with Aricept thoroughly and I repeated that throughout all the steps of the closure. I used 5-0 PDS and closed the space with a foreign object was. I then reinforced that with another 5-0 PDS in a watertight fashion. I believe that its space within the spongiosum of the bulbar urethra most likely. Good hemostasis was noted. I then closed the surgical field in multiple layers first I used 2 layers with 4-0 PDS then I closed 2 layers with 3-0 Monocryl. I used Irrisept irrigation throughout each layer multiple times. I did not feel that it was appropriate to keep the wound open as majority of the tissues looked healthy other than where the object was dislodged and the immediate surrounding tissue. That being said patient is at risk of infection and we will keep him on broad-spectrum antibiotics. Local was injected and 4-0 Monocryl was used to close the wound in subcuticular fashion. I then reinforced the closure with 2-0 chromic in a running fashion. No concern for injuries to surrounding or penile structures. Good hemostasis
Self-inflicted and retained penile/urethral foreign object
Urethral trauma
Penile pain
I performed cystoscopy with a flexible cystoscope and a flexible ureteroscope until I identified the location of the foreign object, with external palpation and with the use of an ultrasound, I was able to identify the general vicinity of the foreign object embedded within the penile tissue/urethra. I created a vertical midline incision at the penoscrotal junction as the object is in the area of the distal bulbar urethra. Skin was incised with a #15 blade then subcutaneous tissues were dissected with use of Bovie, scissors, and blunt dissection where appropriate I was on top of the urethra. The tissue planes were not cleared due to the inflammatory changes and induration of the tissue surrounding the urethra and the distal bulbar region. I placed a Foley catheter with the aid of a cystoscope and with palpation I identified the midline of the area where the object was expected. I eventually cut over the object and made an opening about 3 cm into that open space. I was able to extract the object and 1 piece and it was sent to pathology for identification. Some fluid was irrigated over the object and sent for wound culture. Urine culture was also sent at the beginning of the procedure. Understanding that the urethra is severely traumatized throughout the bulbar region, my goal was to close the opening we created into the space for the foreign object was. After removal of the object the area was irrigated with Aricept thoroughly and I repeated that throughout all the steps of the closure. I used 5-0 PDS and closed the space with a foreign object was. I then reinforced that with another 5-0 PDS in a watertight fashion. I believe that its space within the spongiosum of the bulbar urethra most likely. Good hemostasis was noted. I then closed the surgical field in multiple layers first I used 2 layers with 4-0 PDS then I closed 2 layers with 3-0 Monocryl. I used Irrisept irrigation throughout each layer multiple times. I did not feel that it was appropriate to keep the wound open as majority of the tissues looked healthy other than where the object was dislodged and the immediate surrounding tissue. That being said patient is at risk of infection and we will keep him on broad-spectrum antibiotics. Local was injected and 4-0 Monocryl was used to close the wound in subcuticular fashion. I then reinforced the closure with 2-0 chromic in a running fashion. No concern for injuries to surrounding or penile structures. Good hemostasis