Can we code the following procedure with
Left Percutaneous Nephrostomy Tube Internalization:
Patient admitted for left sided hydronephrosis with an
antegrade nephrostogram demonstrating a distal left ureteral
stenosis now status post left-sided percutaneous nephrostomy tube
placement. Patient referred for left sided percutaneous
nephrostomy tube internalization.
Initial scout images demonstrates a left flank pigtail catheter in
the expected location of the left renal pelvis.
The left flank, including the indwelling nephrostomy tube, was
prepped and draped in the usual sterile fashion. The nephrostomy
tube was then aspirated until clear. A gentle injection of
contrast through the nephrostomy tube was then performed to obtain
an antegrade nephrostogram. Multiple spot images were obtained.
This demonstrated good positioning of the nephrostomy tube with
its distal pigtail coiled within the left renal pelvis. No
hydroureteronephrosis is identified. There is complete occlusion
of the distal left ureter at the level of the ureteroenteric
After the administration of local anesthesia, the catheter was
then cut and removed over an Amplatz wire. A 4-French glide
Berenstein catheter was then advanced over the wire and positioned
within the renal pelvis. The Amplatz wire was then exchanged for
a Glidewire and the catheter and Glidewire were used to select the
left ureter. The catheter was advanced over the Glidewire and
positioned within the distal left ureter at the level of the
The Glidewire was exchanged for an Amplatz wire. The catheter was
then exchanged for a 7-French long sheath. The 4-French glide
Berenstein catheter was then readvanced over the wire and the
catheter and Glidewire were used to attempt to cross the occluded
distal left ureter. The Glidewire was then advanced beyond the
obstruction and the catheter was advanced over the wire. A gentle
injection of contrast was then performed which demonstrated a
false passage with contrast flowing into the peritoneum
surrounding loops of bowel.
The catheter was then pulled back into the distal left ureter
central to the occlusion. An 018 gold tip Glidewire was then
coaxially loaded through a 3-French catheter. The catheter and
Glidewire were then coaxially loaded through the glide Berenstein
catheter. The 018 gold tip Glidewire was then used to cross the
occluded distal left ureter over which the 3-French microcatheter
was advanced. The 018 glide wire was then removed.
A gentle injection of contrast was then performed through the
microcatheter which demonstrated ileal folds confirming good
positioning of the microcatheter within the ileal conduit.
A V18 wire was then advanced through the microcatheter and into
the ileal conduit. The 4-French glide Berenstein catheter was
then advanced over the wire and microcatheter and into the ileal
conduit. The V18 wire and microcatheter were removed. A gentle
injection of contrast confirmed good positioning of the catheter
within the ileal conduit.
The wire was then readvanced through the 4-French glide Berenstein
catheter. The catheter and Glidewire were then advanced through
the ileal conduit and used to cannulate the ileal conduit stoma.
The Glidewire was removed a gentle injection of contrast was
performed. This demonstrated free flow of contrast into the ileal
conduit bag confirming good positioning of the glide Berenstein
catheter outside the ileal conduit.
An Amplatz wire was then advanced through the catheter and out the
ileal conduit stoma to obtain through and through access.
The catheter and sheath were then removed and the distal tip of
the Amplatz wire were secured to the patient. The patient was
then repositioned into the supine position on the fluoroscopic
The right lower quadrant, including the indwelling ileal conduit
stoma and through and through Amplatz wire, was then prepped and
draped in the usual sterile fashion.
A 10-French by 45-cm multi-sidehole pigtail drainage catheter was
then advanced over the wire and positioned with its distal pigtail
coiled within the left renal pelvis. The Amplatz wire was then
removed and a gentle injection of contrast confirmed good
positioning the retrograde nephroureteral stent with its distal
pigtail coiled within the left renal pelvis.
The catheter was then aspirated until clear and flushed with 10 cc
The ileal conduit ostomy bag was then repositioned over the stoma
with the distal tip of the retrograde nephroureteral stent within
the ostomy bag.
Left-sided antegrade nephrostogram demonstrating occlusion of the
distal left ureter at the level of the ureteroenteric anastomosis.
Successful cannulation of the occluded left-sided ureteroenteric
anastomosis and internalization with a 10 French x 45 cm
multi-sidehole pigtail catheter retrograde nephroureteral stent as
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