CPT® Code 51565

Official Description

Cystectomy, partial, with reimplantation of ureter(s) into bladder (ureteroneocystostomy)

Common Language Description

Partial cystectomy is a surgical procedure that involves the removal of a portion of the bladder, typically performed to address localized malignant neoplasms within the bladder. This procedure is essential for patients diagnosed with bladder cancer, where the goal is to excise the tumor while preserving as much of the bladder as possible. The surgery is initiated by exposing the bladder through a low midline or transverse suprapubic incision, allowing the surgeon access to the bladder. Depending on the location of the tumor, the approach may vary; lesions located in the posterior bladder are generally accessed intraperitoneally, while those situated in the dome or anterior bladder are approached extraperitoneally. In cases where pelvic lymph node dissection is deemed necessary, this can be performed separately and is reported as a distinct procedure. Once the bladder is mobilized, stay sutures are placed at a distance from the lesion to facilitate a clear view of the area being treated. The bladder is then incised between these stay sutures, and the incision is enlarged to enhance visualization of the lesion. The excision involves removing the affected portion of the bladder along with surrounding perivesical fat and peritoneum, ensuring that a margin of healthy tissue is included to minimize the risk of cancer recurrence. After the lesion is excised, the bladder wall is reconstructed by closing the submucosa and muscle in layers. In addition to the partial cystectomy, CPT® Code 51565 includes ureteral re-implantation, which is necessary when the ureteral orifice must be sacrificed to achieve complete tumor removal. This involves selecting a site for re-implantation, creating a submucosal tunnel from the incision site to the new exit site for the ureter, and securing the ureter in place with sutures. This comprehensive approach ensures that the procedure not only addresses the malignancy but also maintains the functional integrity of the urinary system.

1. Indications

The partial cystectomy with ureteral re-implantation is indicated for specific conditions related to bladder malignancies. The following are the primary indications for this procedure:

Localized Malignant Neoplasm of the Bladder - This procedure is primarily performed for patients diagnosed with localized bladder cancer, where the tumor is confined to a specific area of the bladder.
Involvement of Ureteral Orifice - Ureteral re-implantation is indicated when the tumor's location necessitates the sacrifice of the ureteral orifice to ensure complete excision of the malignant lesion.

2. Procedure

The procedure for partial cystectomy with ureteral re-implantation involves several critical steps, each designed to ensure the effective removal of the tumor while preserving bladder function. The following outlines the procedural steps:

Step 1: Incision and Exposure - The surgery begins with the creation of a low midline or transverse suprapubic incision to expose the bladder. This access point is crucial for the subsequent steps of the procedure.
Step 2: Approach to the Lesion - Depending on the tumor's location, the surgeon will approach the lesion either intraperitoneally for posterior bladder lesions or extraperitoneally for those located in the dome or anterior bladder.
Step 3: Pelvic Lymph Node Dissection - If indicated, a separate pelvic lymph node dissection may be performed to assess the spread of cancer, which is reported as a distinct procedure.
Step 4: Mobilization of the Bladder - The bladder is carefully mobilized to provide adequate access to the lesion. Stay sutures are placed at a distance from the tumor to facilitate a clear surgical field.
Step 5: Incision and Excision - An incision is made between the stay sutures, and the bladder is enlarged to visualize the lesion effectively. The affected portion of the bladder, along with surrounding perivesical fat and peritoneum, is excised, ensuring that a margin of healthy tissue is included to reduce the risk of cancer recurrence.
Step 6: Closure of the Bladder - After the lesion is removed, the bladder wall is reconstructed by closing the submucosa and muscle in layers, ensuring proper healing and function.
Step 7: Ureteral Re-implantation - If the ureteral orifice was sacrificed, the surgeon selects a site for re-implantation. A submucosal tunnel is created from the incision site to the new exit site for the ureter, which is then passed through the tunnel and secured with sutures to maintain urinary function.

3. Post-Procedure

Post-procedure care following a partial cystectomy with ureteral re-implantation involves monitoring for complications and ensuring proper recovery. Patients may require a catheter for urinary drainage initially, and the healthcare team will monitor for signs of infection or complications related to the surgical site. Pain management is also an essential aspect of post-operative care. Patients are typically advised on activity restrictions and follow-up appointments to assess healing and function of the bladder and ureter. The expected recovery time may vary based on individual patient factors and the extent of the surgery performed.

Short Descr	REVISE BLADDER & URETER(S)
Medium Descr	CSTC PRTL W/RIMPLTJ URTR IN BLDR URTRONEOCSTOST
Long Descr	Cystectomy, partial, with reimplantation of ureter(s) into bladder (ureteroneocystostomy)
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)	0 - 150% payment adjustment for bilateral procedures does NOT apply.
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	112 - Other OR therapeutic procedures of urinary tract

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).
58	Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
78	Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
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)