Question

1.   Operative Report

PREOPERATIVE DIAGNOSIS: Right proximal ureteral calculi.

POSTOPERATIVE DIAGNOSIS: Right proximal ureteral calculi.

OPERATIONS   PERFORMED:

1.Cystoscopy 2.Right ureteroscopy 3.Laser lithotripsy of ureteral   stone and basketing stone fragments 4.Placement of double-J   stent

ANESTHESIA::General.

 

INDICATIONS: The patient is a 59-year-old male with a history of stone disease, who has severe right flank pain and was found to have an obstructing large right proximal ureteral stone.

 

DESCRIPTION OF OPERATION: After induction of general anesthesia, the patient was placed in the lithotomy position. Genitalia were prepped and draped in the usual sterile fashion. A # 21-French cystoscope was inserted under camera vision. The urethra was unremarkable. Prostate revealed early benign BPH, nonobstructive in nature. The scope was passed into the bladder. The bladder mucosa was normal throughout.

Under fluoroscopic control, a guidewire was placed up the right ureter and bypassed the stone. This was difficult at first, but the guidewire was eventually manipulated around the stone into the proximal collecting system. A rigid ureteroscope was then negotiated up the right ureter alongside the guidewire up to the stone, which was at approximately the junction of the upper third and the middle two-thirds of the ureter. The stone was quite large and occupied the entire lumen of the ureter.

Laser lithotripsy was then performed under camera vision. Using the Holmium laser, the stone was fragmented into multiple fragments, all of which were then individually basketed. Some of the stones were sent for analysis. Further ureteroscopy up to the kidney failed to reveal any significant sized fragments. Therefore, the ureteroscope was removed and a 24 cm length, #6 French diameter double-J stent was negotiated over the guidewire into the ureter and the guidewire was removed. The stent was seen curled in good position on cystoscopy. The procedure was well tolerated by the patient without complications. The patient was taken to the recovery room in stable condition.

Intent of Procedure: _________________________________________________________________________

Root Operation: ________________________________________________________(Index Main Term)

Where: Major—(Body System): ___________________________________________________________________

Minor—(Body Part): __________________________________________________(Index Sub-Term)

Approach: _________________________________________________________________________________   (See Approach Decision Tree)

Device: ____________________________________________________________________________________ Yes—See Table, No—Z

Qualifier: __________________________________________________________________________________ Yes—See Table, No—Z

Code the Procedure (Hint: Some cases may have more than one code):
____________________________________________________________________________________

Rationale (How you arrived at the root operation, body part and the code or codes if applicable):
____________________________________________________________________________________

Guidelines pertinent to the coding of this case:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________