Penile Implant Reservoir Infection Case

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Hello All,

Does any have any experience code a Penile Implant Reservoir Infection? I am needing some coding guidance. :)

DATE OF PROCEDURE:
August 16, 2016

SURGEON:
AUK, MD

PREOPERATIVE DIAGNOSIS:
Chronic infection of penile implant reservoir with retroperitoneal fistula and abscess formation left retroinguinal area.

POSTOPERATIVE DIAGNOSIS:
1. Chronic infection of penile implant reservoir with retroperitoneal fistula and abscess formation left retroinguinal area.
2. Complex abscess formation with fistulous tract extending to obturator canal.

PROCEDURE PERFORMED:
1. Retroperitoneal vascular control of iliac vessels through a flank approach on the left.
2. Incision and drainage of complex left retroperitoneal abscess formation extending to the obturator canal.
3. Removal of foreign body with placement of VAC device.

ASSISTANT:
JC, MD

ANESTHESIA:
General.

FINDINGS AND PROCEDURE:
With the patient under satisfactory endotracheal general anesthesia, the anterior abdomen, left flank, and inguinal area draped and prepped in the usual fashion on the left side. Patient identification and proposed procedure confirmed by the operative team. The patient received the usual prophylactic antibiotic and anticoagulation regimens. A flank incision performed on the left using a semi longitudinal incision above the inguinal ligament to expose the external and internal obliques. Muscle-splitting approach to the internal oblique, which was then transected transversely to enter the preperitoneal space on the left, through which, using a long curved retractor, we exposed the iliac artery and vein and encircled the vessels with umbilical tapes. There was significant inflammation in the area of the space of Retzius and that reflected a chronic infection that has being going on for a few months. This patient had 3 or 4 local explorations with persistent drainage of a left-sided penile reservoir, associated with a silicon device. Once control of the vessels throughout retroperitoneal flank approach had been obtained, longitudinal incision was made following the previous open chronic wound, and severe inflammatory process was identified. Methylene blue was placed to identify the tract. We were able to extend this incision superiorly and inferiorly enough to place a self-retaining retractor which allowed then exposure of the sinus tract that extended down to the posterior inguinal ligament into the obturator space. A large amount of purulent material was removed eventually using a long instrument. We were able to identify the foreign body which was easily extracted, located posterior to the arterial and venous structures along the inguinal ligament posteriorly. Irrigation of this area allowed placement of a 15 drain that was placed the previous space and exteriorized medially through the open wound. The lateral flank incision was closed with running sutures of #0 Vicryl and the skin with staples. The medial incision, which was grossly contaminated, was left open and a VAC device was placed in position for control. Dressings were applied. The patient was awakened and transferred to recovery room in stable condition.

ESTIMATED BLOOD LOSS:
Less than 150 cc.

COMPLICATIONS:
There were no significant intraoperative complications.
 
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