CPT® Code 51940

Official Description

Closure, exstrophy of bladder

Common Language Description

Bladder exstrophy is a congenital condition characterized by a malformation where the bladder is flattened and positioned outside the body, rather than being contained within the abdominal cavity. This defect not only impacts the bladder but also involves the abdominal wall, pelvic bones, bladder neck, perineum, urethra, and external genitalia. In individuals with this condition, the abdominal wall is open, leading to a significant separation of the symphysis pubis at the midline, which is accompanied by bony deficits at the anterior pubic rami. Additionally, there is an anterior rotation of both the posterior and anterior aspects of the pelvis. The distance between the umbilicus and the anus is reduced due to the shortening and broadening of the perineum, which also affects the musculature at the bladder neck, resulting in difficulties with bladder control. In females, the anatomical alterations include a shorter urethra and vagina, along with widely separated labia and a bifid clitoris. In males, the penis may appear shorter than normal because its base remains attached to the pubic bones internally, a consequence of the failure of the pubic bones to fuse, which causes the base of the penis to spread apart. The surgical procedure coded as CPT® 51940 involves the closure of this exstrophy, beginning with the alignment of the pelvic bones. Depending on the degree of separation, techniques such as medial rotation of the greater trochanters or osteotomy may be employed to bring the pubic bones together. The procedure also entails closing the bladder, posterior urethra, and abdominal wall, which involves several intricate steps to ensure proper anatomical restoration and function.

1. Indications

The procedure coded as CPT® 51940, which involves the closure of bladder exstrophy, is indicated for patients presenting with the following conditions:

Bladder Exstrophy A congenital defect where the bladder is exposed outside the body, requiring surgical intervention to restore normal anatomy.
Separation of Pelvic Bones Significant separation of the pubic bones that may necessitate surgical correction to align the pelvic structure.
Abnormal Urethral and Genital Development Conditions affecting the urethra and external genitalia that require reconstruction as part of the closure procedure.

2. Procedure

The closure of bladder exstrophy involves several detailed procedural steps to restore the anatomy and function of the affected areas:

Step 1: Pelvic Bone Alignment The procedure begins with the alignment of the pelvic bones. If there is minor separation, medial rotation of the greater trochanters is performed to bring the pubic bones together at the midline. In cases of significant separation, an osteotomy may be necessary to correct the alignment.
Step 2: Osteotomy For patients with widely separated pelvic bones, bilateral transverse anterior innominate bone and anterior vertical iliac bone osteotomies are conducted. Pins are placed to secure the closure of the separation at the symphysis pubis.
Step 3: Incision and Bladder Separation An incision is made around the umbilicus and bladder, extending down to the urethral plate. The umbilical vessels are doubly ligated and transected, allowing for the separation of the bladder dome from the peritoneum.
Step 4: Development of Retropubic Space The retropubic space is developed, and the bladder is carefully separated from the rectus sheath and muscle. In male patients, the prostate is also freed from the rectus muscle during this step.
Step 5: Incision of Urogenital Diaphragm The upper border of the urogenital diaphragm fibers between the bladder neck, posterior urethra, and pubic bone is sharply incised and separated down to the pelvic floor. In males, a deep incision is made to free the prostate and anterior corpus from the pubis.
Step 6: Ureteral Stent Placement Ureteral stents are placed to ensure proper drainage, and the bladder neck and urethra are reconstructed as necessary to restore function.
Step 7: Closure of Bladder Wall The bladder wall is then closed, and the pubic bones are approximated using nylon sutures placed between the fibrous cartilages of the pubic rami.
Step 8: Drain Placement and Abdominal Closure A drain is placed near the umbilicus to facilitate fluid management, and the abdominal wall is closed in layers to complete the procedure.

3. Post-Procedure

Post-procedure care following the closure of bladder exstrophy includes monitoring for complications such as infection or improper healing of the surgical site. Patients may require pain management and should be observed for any signs of urinary obstruction or dysfunction. Follow-up appointments are essential to assess the healing process and the functionality of the bladder and urethra. Additional interventions may be necessary based on the individual recovery and any complications that arise during the healing period.

Short Descr	CORRECTION OF BLADDER DEFECT
Medium Descr	CLOSURE EXSTROPHY BLADDER
Long Descr	Closure, exstrophy of bladder
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