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The procedure described by CPT® Code 45126 is known as pelvic exenteration for colorectal malignancy, which is a complex surgical intervention aimed at treating bulky, locally advanced primary or recurrent colorectal cancer that has metastasized to adjacent organs. This extensive operation involves the removal of the entire large bowel, rectum, and bladder, along with the potential removal of reproductive organs such as the uterus, cervix, fallopian tubes, and ovaries in women, or the prostate in men. The procedure is indicated when cancer has spread significantly, necessitating a wide surgical approach to ensure complete excision of malignant tissues. The surgical technique involves a midline abdominal incision to provide wide exposure of the abdominal cavity, allowing the surgeon to assess the extent of cancer involvement in surrounding structures. The operation includes a series of meticulous steps, such as the transection of the inferior mesenteric artery, mobilization of the sigmoid colon, and dissection of the pelvic region, ultimately leading to the removal of all affected organs in a single en bloc procedure. The ureters are then transplanted to a segment of the isolated ileum, which is exteriorized to create an incontinent ileal conduit, or a colonic reservoir may be fashioned for a continent urinary conduit. This procedure is significant not only for its complexity but also for its potential to improve survival outcomes in patients with advanced colorectal malignancies.
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The procedure is indicated for the treatment of bulky, locally advanced primary or recurrent colorectal cancer with metastases to adjacent organs. This includes cases where the cancer has spread significantly, necessitating extensive surgical intervention to remove all affected tissues and organs.
The procedure begins with a midline abdominal incision, which allows for wide exposure of the abdominal cavity. This is crucial for the surgeon to explore and assess the extent of cancer involvement in adjacent organs. The pelvic dissection initiates at the level of the aortic bifurcation, where the inferior mesenteric artery is transected at its origin. Following this, a wide lymphadenectomy is performed to remove lymph nodes that may harbor cancerous cells. The sigmoid colon is then mobilized and transected to facilitate access to the rectum and bladder. The dissection continues by separating the fascia of the mesorectum from the endopelvic fascia, extending as far distally as possible to ensure complete removal of affected tissues.
Next, the ureters are located and traced both proximally and distally to prepare for their transplantation. The bladder is mobilized, and its superior and inferior pedicles are ligated and transected. In male patients, the procedure involves dividing the puboprostatic ligaments, the dorsal vein of the penis, and the urethra, while in female patients, the ovaries and ureters are mobilized for removal. Once the abdominal dissection is completed, a perineal dissection is performed, which involves dissecting the entire sphincter musculature and the urogenital diaphragm up to the abdominal dissection plane. At this point, all mobilized contents of the perineum, pelvis, and abdomen are removed en bloc.
After the removal of the affected organs, a segment of distal ileum is isolated, and the ureters are anastomosed directly into this segment, which is then exteriorized and sutured to the skin to create an incontinent ileal conduit. Alternatively, a colonic reservoir may be fashioned to create a continent urinary conduit. If a colostomy is necessary, a separate incision is made to create a stoma, through which the proximal segment of the colon is exteriorized. The colon is then everted and sutured to the skin and subcutaneous tissue. To reconstruct the pelvic floor, materials such as mesh, AlloDerm, omentum, or other tissues from the patient may be used. Finally, the pelvic dead space is filled using myocutaneous flaps, drains are placed, and both the perineal and abdominal incisions are closed.
Post-procedure care involves monitoring the patient for complications related to the extensive surgical intervention. Patients may require pain management and close observation for signs of infection or other postoperative complications. Recovery may involve a prolonged hospital stay due to the complexity of the surgery and the need for potential rehabilitation. Follow-up care is essential to assess the surgical site, manage any drains, and monitor for any signs of recurrence of cancer. The patient may also need support for adjustments related to changes in bowel and urinary function following the procedure.
| Short Descr | PELVIC EXENTERATION | Medium Descr | PELVIC EXENTERATION COLORECTAL MALIGNANCY | Long Descr | Pelvic exenteration for colorectal malignancy, with proctectomy (with or without colostomy), with removal of bladder and ureteral transplantations, and/or hysterectomy, or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), or any combination thereof | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 78 - Colorectal resection |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| 1999-01-01 | Added | First appearance in code book in 1999. |
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