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Posterior repair with vault reduction, sacrospinous ligament fixation

Yolanda Posted Fri 19th of March, 2010 21:26:09 PM

Which code is appropiate '57250' or '57260' for the 'posterior repair' what about the 'sacrospinous ligament fixation?

POSTOPERATIVE DIAGNOSIS: Rectocele, cystocele, stress urinary incontinence,history of bladder cancer.

PROCEDURE: Posterior repair with vault reduction, sacrospinous ligament fixation, pubovaginal sling cystourethropexy with cystocele repair,cystoscopy.

female who presented to the office with a history of some hematuria and urinary incontinence with leakage lifting,
laughing, sneezing-type maneuvers. On cystoscopic examination, she was found to have a bladder tumor and subsequently underwent a transurethral resection. This was a noninvasive papillary-type lesion. Following that, she requested further evaluation and repair of vaginal wall relaxation including posterior rectocele, cystocele, and urinary incontinence. The risks, benefits, and
alternative of all of these were carefully discussed and the patient was seen at this time for further management.
Specific complications of urinary retention, need for Foley catheter, both long-term and short-term, damage to internal organs, damage to bladder, failure to control incontinence, sling erosion, cuff erosion, mesh erosion, fistula formation were all carefully reviewed.

OPERATIVE SUMMARY: Patient was prepped and draped in the dorsal lithotomy
position. With the patient relaxed, a vaginal speculum was placed. There was
a significant amount of rectocele present, but glaringly a very short vaginal
stump was noted. A Foley catheter was placed. The posterior repair was then
undertaken by grasping the posterior vaginal tissue and infiltrating the
midline with a combination of 1% lidocaine and epinephrine. A midline
incision was then created overlying the rectum and the rectum was dissected
free bilaterally. The perirectal fossa was then entered on both sides and the
ischial spine of the pubis was carefully identified and the sacrospinous
ligaments inferior and medial to this was palpated and cleared on both sides
for approximately 2 to 3 cm. At this point, the Elevate needle was passed on
the patient's left side and the mesh connector was secured into the
sacrospinous ligament under direct contact. Similar procedure was carried out
on the opposite side and the mesh material was then placed overlying the
eyelids. The mesh was then brought posterior effectively reducing the
cystocele and the grommets were then placed and the sling secured in its final
position by releasing the grommets onto the mesh. The redundant portion of
the long connectors were then cut off, placing the sling in an excellent
position. It was secured to the midline of the cuff with a single Vicryl
suture. Next, the distal portion of the mesh was then secured to the levator
muscles laterally, 1 suture of 2-0 Vicryl on each side and the very distal
portion of the mesh was secured just lateral to the perineal body. Effective
reduction of the rectocele was noted. There was some redundant vaginal
tissue, which was carefully excised and the vagina was then closed posteriorly
with a 2-0 Vicryl suture. Inspection of the anterior wall revealed that
reduction posteriorly had taken care of much of the relaxation, therefore it
was decided that the pubovaginal sling would likely be enough to reduce both
her incontinence and the effective portion of the cystocele. A midline
incision was then created overlying the urethra and this was carried down to
the periurethral fascia on both sides. The bladder was then drained. The
MiniArc needle was then passed on both sides and secured into the obturator
internus inferior to the pubic bone. Excellent position of the sling was
noted. The Foley catheter was then removed and routine cystoscopy was
performed using a 17-French cystoscope with 30 and 70 degrees lenses. Within
the bladder, there were no obvious tumors. A previous biopsy site could be
noted near the posterior wall, otherwise no injuries, lesions, sutures or
other abnormalities were appreciated. The scope was removed and the Foley
catheter was reinserted. Laterally, reduction of the cystocele was effective
with the sling. Therefore, the vaginal epithelium was closed with a 2-0
Vicryl suture. The vagina was then packed with Premarin-soaked vaginal
packing and the Foley catheter left to gravity drainage. Patient will be
admitted to the hospital overnight. The vaginal packing will be removed in
the morning and the Foley catheter will be left in place until next week.

SuperCoder Answered Mon 22nd of March, 2010 10:09:22 AM

The sacrospinous ligament fixation can be coded using 57282. And from the OP notes it seems that the repair should be 57260 in this case (though the direct code for "posterior repair" is 57250).

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