CPT® Code 52281

Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female

CPT® Code 52281 refers to a procedure known as cystourethroscopy, which involves the examination of the urethra and bladder using a specialized instrument called a cystourethroscope. This procedure is specifically performed to address urethral stricture or stenosis, conditions characterized by the narrowing of the urethra that can impede the flow of urine. Urethral calibration is a critical component of this procedure, as it entails measuring the diameter of the narrowed segment of the urethra. The calibration and/or dilation process is typically indicated when the stricture is located at the distal aspect of the urethra or at the urethral opening, known as the urethral meatus. During the procedure, the physician utilizes a series of cone-shaped instruments, referred to as bougies, which vary in diameter. The physician begins with the smallest bougie, usually an 8 French size, and advances it into the urethra. If this initial size can be easily inserted and withdrawn, larger bougies are subsequently introduced until resistance is encountered, allowing the physician to determine the maximum diameter that can be accommodated by the narrowed segment. Following this calibration, the cystourethroscope is employed to visualize the urethra, enabling the physician to assess the stricture and decide on the most appropriate treatment approach. Treatment options may include dilation of the stricture using progressively larger sounds, filiforms, or balloon catheters, as well as performing a meatotomy, which involves incising the urethral meatus to alleviate the narrowing. Additionally, contrast material may be injected through the urethra for cystography, which can be reported separately. This comprehensive approach ensures that the underlying issues causing the stricture are effectively addressed, facilitating improved urinary function for the patient.