OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Recurrent bladder cancer. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Cystourethroscopy with bladderbiopsies and fulguration.
Question:
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Recurrent bladder cancer.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: Cystourethroscopy with bladderbiopsies and fulguration.
ANESTHESIA: General.
INDICATIONS FOR PROCEDURE: The patient has priortransitional cell carcinoma of the bladder and also carcinoma insitu. He has received MVAC chemotherapy and BCG. Surveillance cystoscopy demonstrated erythema of the bladderwall. He is currently being admitted for cystoscopy, bladderbiopsy, and fulguration. Procedure, reasons, risks andcomplications were reviewed and consent was granted.
DESCRIPTION OF PROCEDURE: He was brought to the operating room under general anesthesia, placed in the dorsolithotomyposition, and prepped and draped in a sterile manner. A21-French cystoscope was inserted, urethra was normal, verumontanumintact. Prostate examination revealed evidence of priortransurethral resection and moderate outlet obstructoin. There were erythematous areas throughout the bladder, anda 0.5 cm leison wasfulgurated. Both ureteric orifices were normalsize, shape and caliber with clear efflux. The erythematous areas were then biopsied with flexiblebiopsy forceps. After obtaining biopsies, the area was thenfulgurated with a Bugbee electrode. Reinspection was carried out;no gross bleeding was noted. The bladder was drained,cystoscope was withdrawn, and the patient was transferred to therecovery room in satisfactory condition with all vital signsstable.
PATHOLOGICAL DIAGNOSIS:
1. Urothelial carcinoma in situ, focal.
2. Chronic nonspecific cystitis.
What are the correct CPT codes for this procedure. You will need 2 of them.
Introductory Statistics Exploring The World Through Data
ISBN: 9780135163146
3rd Edition
Authors: Robert Gould, Rebecca Wong, Colleen N. Ryan