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An open nephrectomy with total ureterectomy and bladder cuff excision is a surgical procedure that involves the removal of a kidney along with its associated ureter and a portion of the bladder. This procedure is typically indicated in cases where there is a need to address significant renal pathology, such as tumors or severe infections. The surgery is performed through a wide flank incision, which is strategically placed below the lower border of the ribs or near the 11th or 12th rib, allowing for optimal access to the kidney and ureter. In some cases, an anterior subcostal approach may be utilized as an alternative access point. During the procedure, a Foley catheter is inserted to facilitate bladder drainage. The surgical team carefully isolates the renal artery and vein, ligating and dividing them to free the kidney from its vascular connections. The kidney is then meticulously dissected from the surrounding tissues and removed. Following the nephrectomy, the entire ureter is excised along with a section of the bladder at the ureterovesical junction (UVJ). This involves dissecting the ureter free from surrounding structures, incising the bladder just below the UVJ, and removing the bladder cuff. The bladder incision is subsequently closed, and measures are taken to control any bleeding, with drains placed as necessary before closing the incisions. It is important to note that if the procedure is performed through a single incision, a different CPT® code (50234) is reported, whereas CPT® code 50236 is specifically used when the nephrectomy is conducted through a flank or subcostal incision with a separate incision for the ureter and bladder cuff removal.
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Renal Pathology The procedure is indicated for patients with significant renal conditions, such as tumors, severe infections, or other pathologies that necessitate the removal of the kidney.
Ureteral Disease Conditions affecting the ureter, including obstruction or malignancy, may also warrant a total ureterectomy as part of the surgical intervention.
Bladder Pathology The excision of the bladder cuff is indicated in cases where there is a need to remove diseased tissue at the ureterovesical junction (UVJ) to ensure complete removal of the affected area.
Step 1: Anesthesia and Preparation The patient is placed under general anesthesia, and appropriate sterile techniques are employed to prepare the surgical site. A Foley catheter is inserted to facilitate bladder drainage during the procedure.
Step 2: Incision A wide flank incision is made immediately below the lower border of the ribs or near the 11th or 12th rib. Alternatively, an anterior subcostal approach may be utilized, depending on the surgeon's preference and the patient's anatomy.
Step 3: Exposure of the Kidney and Ureter The kidney and ureter are carefully exposed through the incision. This involves retracting surrounding tissues to provide a clear view of the renal structures.
Step 4: Isolation of Renal Vessels The renal artery and vein are isolated, which involves identifying and carefully dissecting these vessels from surrounding tissues. Once isolated, they are ligated and divided to sever the blood supply to the kidney.
Step 5: Nephrectomy The kidney is then dissected free from the surrounding tissue, ensuring that all attachments are carefully severed. Once fully mobilized, the kidney is removed from the body.
Step 6: Ureterectomy The entire ureter is excised by first dissecting it free from surrounding tissues. This step is crucial to ensure complete removal of the ureter along with any diseased segments.
Step 7: Bladder Cuff Excision The bladder is incised just below the ureterovesical junction (UVJ), and the bladder cuff is removed. This step is essential to ensure that any potentially affected tissue at the junction is excised.
Step 8: Closure After the bladder cuff is removed, the bladder incision is closed. The surgical team ensures that any bleeding is controlled, drains are placed as needed, and the incisions are closed in layers to promote proper healing.
Post-procedure care includes monitoring the patient for any signs of complications, such as bleeding or infection. The Foley catheter remains in place for a period to allow for proper bladder drainage and healing. Patients are typically advised on pain management and may require follow-up imaging to assess the surgical site. Recovery time may vary based on the individual patient's health and the extent of the surgery performed.
| Short Descr | REMOVAL OF KIDNEY & URETER | Medium Descr | NEPHRECTOMY TOT URETEREC&BLDR CUFF SEPAR INCISN | Long Descr | Nephrectomy with total ureterectomy and bladder cuff; through separate incision | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 104 - Nephrectomy, partial or complete |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| Pre-1990 | Added | Code added. |
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