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The CPT® Code 51845 refers to an abdomino-vaginal vesical neck suspension procedure, which is a surgical intervention aimed at addressing anatomical incontinence in women, particularly when this condition is associated with vaginal wall prolapse. This procedure is also known by various names, including the Stamey, Raz, or modified Pereyra procedures, and it can be performed with or without the assistance of endoscopic control. The primary goal of this surgery is to provide support to the bladder neck, thereby improving urinary continence. The procedure involves making incisions in both the abdominal and vaginal areas to access the necessary anatomical structures. The modified Pereyra technique specifically involves a transverse incision at the distal urethra and a vertical incision in the vagina, allowing for the dissection of the vaginal epithelium and exposure of the pubourethral ligaments. Heavy, nonabsorbable sutures are then utilized to secure these ligaments to the endopelvic fascia, which is crucial for restoring the anatomical position of the bladder. The Raz and Stamey procedures offer alternative approaches, each with distinct incision patterns and techniques for suspending the bladder. Overall, this procedure is a critical option for women suffering from incontinence due to pelvic support deficiencies, aiming to enhance their quality of life through improved bladder control.
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The abdomino-vaginal vesical neck suspension procedure (CPT® Code 51845) is indicated for the treatment of anatomical incontinence in women, particularly when this condition is a result of vaginal wall prolapse. This surgical intervention is typically considered when conservative management options have failed or are not appropriate, and the patient experiences significant urinary incontinence that affects her quality of life.
The abdomino-vaginal vesical neck suspension procedure involves several detailed steps to ensure proper suspension of the bladder neck. The modified Pereyra technique begins with the surgeon making a small transverse incision at the distal urethra. Following this, a second vertical incision is created in the vagina, which is extended until it intersects with the initial incision at the distal urethra. This allows for the dissection of the vaginal epithelium down to the pubic rami. The endopelvic fascia is then perforated, exposing the pubourethral ligaments. Heavy, nonabsorbable suture material is utilized to secure these ligaments to the endopelvic fascia, providing the necessary support to the bladder neck.
Next, a small suprapubic incision is made above the pubic bone. A ligature carrier is passed through this incision and advanced through the vaginal incision. The sutures on either side of the urethra are threaded through the eye of the ligature carrier and subsequently transferred to the abdominal wall. This step may be performed with cystoscopic control to minimize the risk of bladder injury. After the vaginal incisions are closed, the left and right sutures are accessed via the suprapubic incision and tied to effectively suspend the bladder. Finally, the suprapubic incision is closed.
In the Raz procedure, the approach differs slightly as the retropubic space is entered to facilitate the passage of the needle. The vaginal wall, excluding the vaginal mucosa, is anchored to the endopelvic fascia to provide support. Conversely, the Stamey procedure employs two transverse suprapubic incisions, one on each side of the symphysis pubis, exposing the rectus fascia. A T-shaped vaginal incision is made below the urethral meatus, and the Stamey needle is introduced through one of the suprapubic incisions, passing through the vaginal incision at the bladder neck level. A suture is placed through the needle and withdrawn through the suprapubic incision. The needle is then passed through the same suprapubic incision, just lateral to the original entry site, and carried into the vagina at a point just distal to the original entry site. The suture is passed through a small synthetic tube that acts as a buttress for the vaginal loop, capturing a large loop of vaginal tissue. This process is repeated on the opposite side, and the vaginal incision is subsequently closed. Using cystoscopic control, tension is applied to the sutures via the suprapubic incisions to suspend the bladder, and the sutures are tied before closing the suprapubic incisions.
Post-procedure care following an abdomino-vaginal vesical neck suspension involves monitoring the patient for any immediate complications, such as bleeding or infection. Patients are typically advised to avoid strenuous activities and heavy lifting for a specified period to allow for proper healing. Follow-up appointments are essential to assess the surgical site and ensure that the bladder suspension is functioning as intended. Patients may also receive guidance on pelvic floor exercises to strengthen the pelvic muscles and support recovery. It is important for healthcare providers to educate patients about signs of complications, such as increased pain, changes in urinary patterns, or any unusual symptoms that may arise during the recovery phase.
| Short Descr | REPAIR BLADDER NECK | Medium Descr | ABDOMINO-VAG VESICAL NCK SSP W/WO NDSC CTRL | Long Descr | Abdomino-vaginal vesical neck suspension, with or without endoscopic control (eg, Stamey, Raz, modified Pereyra) | 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 | Hospital Part B services paid through a comprehensive APC | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 106 - Genitourinary incontinence procedures |
| 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). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| Pre-1990 | Added | Code added. |
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