toria11
Guru
How would you code the following? Thank you!
POSTOPERATIVE DIAGNOSIS:
Severe phimosis, rule out carcinoma.
PROCEDURE PERFORMED:
1. Removal of foreskin mass.
2. Lysis of severe foreskin to glans adhesions.
3. Phalloplasty with circumcision.
DESCRIPTION OF PROCEDURE:
After successful induction of anesthesia, the patient's penis was sterilely prepped and draped. One could palpate a 1 cm to 2 cm mass involving the tip of the foreskin with severe scarring to the underlying glans and meatus. Using careful dissection, the foreskin was split on the dorsal and ventral aspect down to what appeared to be the meatus. The foreskin was totally adhered to the glans at this point. Using combination of blunt and sharp dissection, the foreskin was carefully dissected away from the glans itself until normal tissue was reached. Next, the foreskin showed a hard nodular mass measuring approximately 1 cm to 2 cm involving the tip of the foreskin. This area of the foreskin was resected. Once that was accomplished, attention turned towards reconstructing the penis. The penile skin was trimmed eliminating redundant foreskin. Once that was accomplished, all bleeding points were fulgurated. Again, there was severe adherence of the undersurface of the foreskin to the glans. Next, the edges of the skin were reapproximated with interrupted 3-0 chromic catgut sutures. All bleeding points were then again fulgurated. The meatus was wide open and a catheter was placed. Bacitracin and Xeroform dressing was then used and the patient taken to the recovery room in good condition having tolerated the procedure well.
POSTOPERATIVE DIAGNOSIS:
Severe phimosis, rule out carcinoma.
PROCEDURE PERFORMED:
1. Removal of foreskin mass.
2. Lysis of severe foreskin to glans adhesions.
3. Phalloplasty with circumcision.
DESCRIPTION OF PROCEDURE:
After successful induction of anesthesia, the patient's penis was sterilely prepped and draped. One could palpate a 1 cm to 2 cm mass involving the tip of the foreskin with severe scarring to the underlying glans and meatus. Using careful dissection, the foreskin was split on the dorsal and ventral aspect down to what appeared to be the meatus. The foreskin was totally adhered to the glans at this point. Using combination of blunt and sharp dissection, the foreskin was carefully dissected away from the glans itself until normal tissue was reached. Next, the foreskin showed a hard nodular mass measuring approximately 1 cm to 2 cm involving the tip of the foreskin. This area of the foreskin was resected. Once that was accomplished, attention turned towards reconstructing the penis. The penile skin was trimmed eliminating redundant foreskin. Once that was accomplished, all bleeding points were fulgurated. Again, there was severe adherence of the undersurface of the foreskin to the glans. Next, the edges of the skin were reapproximated with interrupted 3-0 chromic catgut sutures. All bleeding points were then again fulgurated. The meatus was wide open and a catheter was placed. Bacitracin and Xeroform dressing was then used and the patient taken to the recovery room in good condition having tolerated the procedure well.