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Question Which is the Unlisted?

maryir

Networker
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Hello,

I am clearly out of my realm of expertise. Please assist with the unlisted and the CPT's for the note below - The Dr used CPT 52287, 51960, 50845, 53899 w/mod 22.

From how I'm reading it, I'm thinking the 53899 is for the extensive "dissection" done (3rd paragraph), or is it for the bladder neck closure, or both - and I'm thinking either would be included in the 51960/50845.

Am I on the right track? And, of course, are the other CPT's accurate as well?

ANY help would be much appreciated.

As a result of his spinal cord injury, he suffered from stress incontinence and the inability to empty his bladder. He has undergone 3 prior sling procedures to try to alleviate his stress incontinence and these have failed to alleviate his stress incontinence. He is also now unable to catheterize per urethra after his latest stress urinary incontinence procedure. Given that he is still leaking and cannot cath per urethra, he had been temporized with a suprapubic tube. He desired catheterizable stoma and bladder neck closure.

The patient was brought to the OR. After induction of general anesthesia, he was placed in the supine position, prepped and draped in the normal sterile fashion. We began by attempting bedside flexible cystoscopy. Just at the distal end of the prostate, there was a tight area where his last bladder neck sling had been performed. We were unable to traverse this was a 16-French scope. We were unable to place a catheter from below. A Bentson wire was placed through the area and he was dilated with Heyman dilators from 12-French up to 18-French. We were then able to place a 14-French silicone catheter fashioned as a Councill tip catheter through this.

This being done, we then made an incision from just below the umbilicus to the pubic symphysis. The SP tract was followed down to the bladder. We dissected through the subcutaneous tissue through the fascia and entered the extraperitoneal space. The space of Retzius was developed. This was difficult as the patient had dense scarring from his last bladder neck sling procedure. The bladder was opened at the SP site (which was removed) and a Bookwalter retractor set up. With a good deal of dissection, we were able to dissect out of the patient's bladder neck where it met the prostate. With a great deal of effort we were able to dissect around the urethra and bladder neck as it entered into the prostate. An umbilical tape was passed with a right angle passer and the urethra exiting the bladder was sharply incised. We then dissected a bit posteriorly behind the bladder to have some mobilization. The bladder neck/urethra was then closed with 2-0 PDS suture in a running fashion. It was watertight at this time. We then lemberted this closed for a 2nd layer of closure.

We then turned our attention to the bladder augmentation and catheterizable stoma portion of the procedure. We entered the peritoneal space and extended our incision to just below the xiphoid. The cecum was identified. The right ascending colon was identified and we proceeded to dissect the white line of Toldt away. This mobilized the ascending colon and cecum. An appendectomy was performed. Approximately 15 cm of ascending colon and cecum were then identified and a GI stapler was fired across this. We then took 12 cm of distal ileum and stapled across this as well. Our cecum, ascending colon and ileum were then kept away while we reanastomosed ileum to ascending colon. The staple lines were cut. A 100 GIA stapler was then fired. There was no bleeding within the anastomosis and a TA stapler was fired across this to bring them back into continuity. There was no large mesenteric trap to close at this point. The TA staple line was lemberted closed with silk sutures.

We then turned our attention to the ascending colon and cecum and ileum to be used in our augment/catheterizable stoma. The staple line across the ileum was removed and that across the ascending colon was removed as well. The bowel was washed out copiously. We then went along the side of the taenia anteriorly and opened the ascending colon down to the cecum. The ileocecal valve was identified. The ileum itself was then tapered with a GIA stapler around a 14-French red Rob-Nel catheter to make a cath stoma. We then closed the appendix site in the cecum. We buttressed the ileocecal valve where the tapering had begun to taper off, as we did not want to injure the ileocecal valve. We took several more Ethibond sutures and tapered the ileal channel as it entered the cecum.

We then went down to the bladder. The bladder was clam shelled anterior to posterior. This was done in a wide fashion. The cecum and ascending colon was then anastomosed to the bladder with running 2-0 Vicryl stitches in a running fashion. This created a very nice augment; and following this. Just prior to closure, 300 units of Botox were injected into the bladder for paralysis in order to protect our bladder neck closure and our augment anastomosis. A 24-French SP tube was placed in the patient's left lower bladder and sutured into place. Then, 10 mL of sterile saline was put into the balloon. We finished off our augment bladder anastomosis. This was tested and there was no leak. There was also no leak from either the bladder neck closure or through the ileal channel itself. The ileal channel was then brought up towards the umbilicus. Prior to this, the omentum had been incised to gain a bit more length and this was placed in between the bladder neck closure and the prostatic urethra, which had also been closed with several 2-0 Vicryl interrupted stitches. With the omentum put into place to interpose between the 2 tissues, we set about maturing our catheterizable stoma.
 
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