CPT® Code 51535

A cystotomy for excision, incision, or repair of a ureterocele is a surgical procedure aimed at addressing a ureterocele, which is a congenital condition characterized by the cystic dilation of the submucosa of the ureter. This dilation typically occurs at the distal end of the ureter, near the junction where the ureter meets the bladder, known as the ureterovesical junction. During the procedure, a midline extraperitoneal abdominal approach is employed to gain access to the bladder. The surgical team carefully divides the rectus and transversalis fascia, creating an incision that extends through the space of Retzius, allowing for the identification of the anterior bladder wall and the vesical neck. Once the bladder dome is incised, the surgeon inspects the bladder wall, including critical areas such as the trigone, ureteral orifices, and bladder neck, to locate the ureterocele. Treatment options for the ureterocele include excision, incision, or repair. Excision involves making a circumferential incision around the ureterocele with electrocautery to remove the dilated submucosal tissue. Incision entails deflating the ureterocele by making a full-thickness incision that starts at the roof and extends to the base of the defect. Repair consists of excising the ureterocele and subsequently repairing any associated defects in the ureteral or bladder wall. This procedure is essential for alleviating symptoms and preventing complications associated with ureteroceles.