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The procedure described by CPT® Code 53415 refers to a urethroplasty performed through a transpubic or perineal approach, specifically designed as a one-stage operation for the reconstruction or repair of the prostatic or membranous urethra. This surgical intervention is typically indicated in cases of injury or trauma, such as those resulting from pelvic fractures, which can compromise the integrity of the posterior urethra. The posterior urethra consists of two main segments: the prostatic urethra, which runs through the prostate gland, and the membranous urethra, which extends from the prostatic apex to the perineal membrane, ultimately connecting to the anterior urethra at the bulbar segment. The procedure involves a midline incision in the perineum, allowing for direct access to the urethra. Through careful dissection, the surgeon exposes the urethra, identifies points of obstruction, and mobilizes the urethral segments to facilitate reconstruction. The goal of this procedure is to restore normal urethral function and anatomy, thereby improving urinary flow and reducing complications associated with urethral injuries.
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The procedure is indicated for the following conditions:
The urethroplasty procedure begins with a midline incision in the perineum, which is bifurcated at the posterior end to provide access to the underlying structures. The surgeon then dissects through the bulbospongiosum muscle to expose the corpus spongiosum, allowing for the identification and mobilization of the urethra. As the dissection progresses towards the bulbar urethra, the proximal point of any obstruction is located using a catheter, while the distal point is assessed as far as the suspensory ligament of the penis. A sound is then passed through a previously created suprapubic cystotomy tract into the prostatic urethra, facilitating further evaluation and manipulation.
Next, the surgeon separates the right and left corporal bodies in the midline for a distance of 4-5 cm, which allows the urethra to be repositioned upwards, effectively shortening the distance between the urethral ends. If tension remains on the urethra after this separation, the surgeon may need to displace or ligate the penile vessels laterally to relieve the tension further. To create additional space for the urethra, a wedge of bone is removed from the inferior aspect of the pubis using bone rongeurs or an osteotome, which creates a groove for the urethra and adds 1-2 cm of length to the urethra.
If anastomosis of the urethra is still not feasible due to persistent tension, the procedure may involve rerouting the urethra around the corporal body through a larger resection of the pubic bone. This is accomplished by circumferentially mobilizing one of the corporal bodies proximal to the suspensory penile ligament. The distal urethral stump is then spatulated and brought down from a 12-o'clock position, while the proximal urethral stump is spatulated and lifted from the 6-o'clock position. Healthy tissue is identified, including the seminal ducts located in the verumontanum of the prostatic urethra. Finally, the anastomosis of the two urethral ends is performed by placing 8-10 sutures through the urethral mucosa, ensuring a secure connection. A fenestrated French catheter is placed transurethrally to facilitate drainage, and the incision is subsequently closed in layers. The suprapubic catheter is then replaced to maintain urinary function during the recovery period.
Post-procedure care involves monitoring the patient for any complications related to the surgery, such as infection or urinary retention. Patients are typically advised to follow up with their healthcare provider to assess the healing process and the functionality of the urethra. The presence of a suprapubic catheter may require specific care instructions to prevent infection and ensure proper drainage. Patients may also need to adhere to activity restrictions during the recovery period to promote healing and avoid undue stress on the surgical site. Regular follow-up appointments are essential to evaluate the success of the urethroplasty and to address any potential complications that may arise.
| Short Descr | RECONSTRUCTION OF URETHRA | Medium Descr | URTP TRANSPUBIC/PRNL 1 STG RCNSTJ/RPR URT | Long Descr | Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra | 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 | 109 - Procedures on the urethra |
| 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). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) 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. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 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 | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | KX | Requirements specified in the medical policy have been met | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2009-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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