How to safeguard the ureter and repair surgical injury
Under certain circumstances, ureteral injury may not only be likely—it is unavoidable. Here’s what you need to know to minimize the risk and ensure recovery.
IN THIS ARTICLE
Postoperative management
After repair of a ureteral injury, leave a closed-suction pelvic drain in place for 2 to 3 days so that any major urinary leak can be detected; it also enhances spontaneous closure and helps prevent potentially infected fluid from accumulating in the region of anastomosis.
The cystotomy performed during ureteroneocystostomy generally heals quickly with a low risk of complications.
Leave a large-bore (20 or 22 French) urethral Foley catheter in place for 2 weeks.
I recommend that a 6 French double-J ureteral stent be left in place for 6 weeks. Potential benefits of the stent include:
- prevention of stricture
- stabilization and immobilization of the ureter during healing
- reduced risk of extravasation of urine
- reduced risk of angulation of the ureter
- isolation of the repair from infection, retroperitoneal fibrosis, and cancer.
I perform IVP approximately 1 week after stent removal to ensure ureteral patency.
CASE RESOLVED
Exposure is improved by widening the incision and dividing the tendonous insertions of the rectus abdominus muscles. The surgeon then removes the mass, preserving the distal ureter, which is estimated to be 12 cm in length and to have intact adventitia.
The surgeon performs a double-spatulated end-to-end ureteroureterostomy over a 6 French double-J ureteral stent that has been passed proximally into the renal pelvis and distally into the bladder. The stent is removed 6 weeks postoperatively, and an IVP the following week demonstrates excellent patency.
The majority of payers consider ureterolysis integral to good surgical technique, but there can be exceptions when documentation supports existing codes. Three CPT codes describe this procedure:
50715 Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis
50722 Ureterolysis for ovarian vein syndrome
50725 Ureterolysis for retrocaval ureter, with reanastomosis of upper urinary tract or vena cava
The key to getting paid will be to document the existence of the condition indicated by each of the codes.
The ICD-9 code for both retroperitoneal fibrosis and ovarian vein syndrome is the same, 593.4 (Other ureteric obstruction). If the patient requires ureterolysis for a retrocaval ureter, the code 753.4 (Other specified anomalies of ureter) would be reported instead. Note, however, that these procedure codes cannot be reported if the ureterolysis is performed laparoscopically. In that case, the most appropriate code is 50949 (Unlisted laparoscopy procedure, ureter).
When repair is necessary, you have several codes to choose from, but the supporting diagnosis code 998.2 (Accidental puncture or laceration during a procedure) must be indicated. If a Medicare patient is involved, the surgeon who created the injury would not be paid additionally for repair.
50780 Ureteroneocystostomy; anastomosis of single ureter to bladder
50782 Ureteroneocystostomy; anastomosis of duplicated ureter to bladder
50783 Ureteroneocystostomy; with extensive ureteral tailoring
50785 Ureteroneocystostomy; with vesico-psoas hitch or bladder flap
50760 Ureteroureterostomy; fusion of ureters
50770 Transureteroureterostomy, anastomosis of ureter to contralateral ureter—MELANIE WITT, RN, CPC-OBGYN, MA
