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Posted By Maria on 12-06-2019, 05:51:45 in Ob-Gyn
Hello Melanie,

Could you please help with CPT codes?

Dr has not given laparoscopic code for radical upper vaginectomy. 57111 I believe this maybe an unlisted laparoscopic code.

Other codes given are 38570 and 58662

As always, thanks for your help.l

66 yo with isolated recurrent uterine cancer to vaginal cuff here for resection
3-4 cm area of tumor on right vaginal cuff (floor side). Enlarged right pelvic lymph node - frozen showed no carcinoma. Right sided pelvic mass.
After assuring informed consent the patient was taken back to the operating suite and induction of general anesthesia was done. The patient was placed in the modified dorsal lithotomy position in Allen stirrups then prepped and draped in the normal sterile fashion. A V-Care was placed inside the vagina with a sterile specimen cup placed between the two V-Care cups in order to delineate a margin around the recurrent disease. Foley catheter was placed. Gloves were changed and attention was then taken to the abdomen.
A supraumbilical skin incision was then made approximately 22 cm above the pubic symphysis and a veress needle was introduced into this incision. Once proper placement was noted by physical examination and sterile water flowing easily into this incision then CO2 gas was insufflated into the abdomen at a maximum pressure of 15 mmHg. A 10/12 blunt trocar was then inserted through this incision and the Robotic camera verified proper placement of this port. Bilateral blunt robotic trocars were then placed 10 cm lateral and 15 degrees inferior lateral from the midline camera port. An additional left flank robotic port was placed 10 cm lateral and 15 degrees upward from the prior robotic port. A 10/12 accessory port was placed beneath the right costal margin. The patient was then placed in steep trendelenberg position and the robot was docked. The monopolar scissors were placed in the right robotic arm; bipolar fenestrated graspers in the left robotic arm and the double fenestrated graspers were placed in the third robotic arm.
Bilateral round ligaments were taken down with monopolar cautery and the retroperitoneal space was opened. Bilateral pararectal and paravesical spaces were then developed. The underlying ureters were visualized. The vesicouterine peritoneum was incised and the bladder was dissected off the superior aspect of the vagina well below the 2 cm margin required for the radical. The bilateral ureters were then dissected off the medial leaves of the broad ligament and careful meticulous ureterolysis was employed into the cardinal ligament tunnel close to the ureterovesical junction. The ureter and bladder was dissected and pushed over the margin needed.
A posterior colpotomy was made at the impression of the sterile specimen cup placed between the V-care cups with a 2 cm margin. This was brought around circumferentially freeing up the upper vagina. The tumor was noted to be in specimen and removed. A right sided pelvic mass was noted and removed as well.
The vaginal cuff was then reapproximated with 0 PDS in a running fashion, starting from either end and tying in the middle. An enlarged right external iliac node was noted. It was dissected out and removed - sent to path and noted to be benign.
The pelvis was then irrigated and the vaginal cuff was noted to be hemostatic. The instruments were then removed and the robot was undocked. The pneumoperitoneum was then evacuated and all trocars were removed. The 12 mm trocar fascia sites were reapproximated with a figure of eight stitch of 0 vicryl. All skin incisions were closed with a 4-0 vicryl subcuticular stitch. Steri-strips were placed as well as bandages. The vagina was examined with sponge sticks x 2 and noted to be hemostatic. Sponge, lap, needle and instrument counts were correct x 2. The patient was taken to the recovery room in awake and stable condition.
Final Pathologic Diagnosis:
Attention:  Malignant

A.  Right external iliac lymph node, excision:
       One lymph node (0/1), negative for metastasis.

B.  Right pelvic side wall, excision:
       Portion of fibrovascular connective tissue.

C.  Upper vagina, excision:
       Clear cell carcinoma, endometrial, recurrent, involving resection
Comments (1)
Posted By Melanie Witt on 12-07-2019, 17:10:24
The two code you were given are correct. And you are correct, there is no laparoscopic code for a radical vaginectomy so use 57111 as your comparison code but report the unlisted code 49329 as being the closest (as you can't use the one for unlisted uterus or ovaries).
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