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Official Description

Urethrorrhaphy, suture of urethral wound or injury; perineal

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 53510 refers to urethrorrhaphy, which is the surgical repair of a wound or injury to the urethra, specifically targeting the bulbar urethra. This procedure is typically indicated in cases of trauma or injury to the urethra, which may occur due to various reasons, including penetrating injuries. The surgical approach involves making a midline incision in the perineal area, allowing access to the urethra. During the procedure, the bulbocavernosus muscle is divided to facilitate entry into the corpus spongiosum, where the injury is located. The surgical team cleans the wound and may perform debridement of the corpus spongiosum if necessary to ensure a clean repair. The urethra is then carefully examined, and the repair technique employed is akin to that used in urethroplasty for strictures. For defects measuring less than 25 mm, the repair is achieved through anastomosis, while longer defects require additional dissection to maximize the length of the urethra for proper alignment. The suturing technique involves a single layer of sutures on the dorsal surface and two layers on the ventral surface to ensure a secure closure. Post-operative care may include the placement of drains if the wound is large or contaminated, and a catheter may be inserted transurethrally into the bladder to facilitate healing and drainage.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The procedure of urethrorrhaphy, as described by CPT® Code 53510, is indicated for the surgical repair of injuries to the bulbar urethra. The following conditions may warrant this procedure:

  • Penetrating Urethral Injury - This includes injuries resulting from trauma, such as gunshot or stab wounds, that compromise the integrity of the urethra.
  • Urethral Wound - Any laceration or wound to the urethra that requires surgical intervention to restore normal function and anatomy.
  • Urethral Defect - Defects in the urethra, particularly those measuring less than 25 mm, which can be repaired through anastomosis.

2. Procedure

The surgical procedure for urethrorrhaphy involves several critical steps to ensure effective repair of the urethral injury:

  • Step 1: Incision - A midline perineal incision is made to access the bulbar urethra. This approach allows the surgeon to directly visualize and address the injury.
  • Step 2: Muscle Division - The bulbocavernosus muscle is divided to gain entry into the corpus spongiosum at the site of the urethral injury. This step is essential for proper exposure of the urethra.
  • Step 3: Wound Cleaning and Debridement - The wound is meticulously cleaned, and if necessary, debridement of the corpus spongiosum is performed to remove any devitalized tissue, ensuring a healthy environment for repair.
  • Step 4: Urethral Examination - The urethra is exposed and thoroughly examined to assess the extent of the injury and determine the appropriate repair technique.
  • Step 5: Repair Technique - For urethral defects measuring less than 25 mm, anastomosis is performed. For longer defects, the urethra is dissected distally from the corpus spongiosum to maximize length, with the distal end spatulated dorsally and the proximal end ventrally.
  • Step 6: Suturing - The anastomosis of the urethral ends is accomplished using a single layer of sutures through the urethral mucosa and spongiosal adventitia on the dorsal surface, and two layers of sutures on the ventral surface to ensure a secure closure.
  • Step 7: Closure - After the urethra is repaired, the corpus spongiosum is closed, followed by the closure of the bulbocavernosus muscle and the skin.
  • Step 8: Catheter Placement - At the conclusion of the procedure, a catheter may be placed transurethrally into the bladder to facilitate drainage and healing.

3. Post-Procedure

Post-procedure care following urethrorrhaphy includes monitoring for any signs of complications such as infection or urinary retention. Patients may require a catheter for a specified duration to ensure proper healing and drainage of urine. The surgical site should be kept clean and dry, and any drains placed during the procedure should be monitored for output. Follow-up appointments are essential to assess the healing process and to remove the catheter when appropriate. Patients should be advised on activity restrictions to prevent undue stress on the surgical site during the recovery period.

Short Descr REPAIR OF URETHRA INJURY
Medium Descr URETHRORRHAPHY SUTR URETHRAL WOUND/INJ PERINEAL
Long Descr Urethrorrhaphy, suture of urethral wound or injury; perineal
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
ASC Payment Indicator Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P5E - Ambulatory procedures - other
MUE 1
CCS Clinical Classification 109 - Procedures on the urethra
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
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.
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.
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
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
GW Service not related to the hospice patient's terminal condition
SA Nurse practitioner rendering service in collaboration with a physician
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