CPT® Code 54650

1. Indications

The procedure described by CPT® Code 54650 is indicated for the surgical correction of an intra-abdominal testis, which is a testis that has not descended into the scrotum. The following conditions may warrant this procedure:

• Cryptorchidism - A condition where one or both testicles are undescended, which can lead to complications such as infertility or testicular cancer if not addressed.
• Testicular torsion risk - An undescended testis may be at increased risk for torsion, which is a medical emergency that can result in loss of the testis.
• Hormonal imbalances - The absence of a testis in the scrotum can affect hormonal levels and development during puberty.

2. Procedure

The orchiopexy procedure using CPT® Code 54650 involves several detailed steps to ensure the successful mobilization of the testis to the scrotum:

• Step 1: Incision - A midline skin incision is made from the pubis to just below the umbilicus. This incision is carried down through the rectus muscle, allowing access to the peritoneal cavity.
• Step 2: Accessing the Peritoneal Cavity - The peritoneum is opened, and the intestines are carefully moved aside to visualize the internal structures, including the testis and spermatic cord.
• Step 3: Dissection of Spermatic Vessels - The spermatic vessels are dissected free, and vascular clips are applied to control blood flow. This step is crucial for the subsequent mobilization of the testis.
• Step 4: Gubernaculum Transection - The peritoneum is excised around the internal inguinal ring, and the gubernaculum is transected distally, ensuring some testicular tissue remains attached for proper blood supply.
• Step 5: Incision Over Spermatic Vessels - The peritoneum is incised laterally and medially over the spermatic vessels, with the incisions joined proximally to facilitate further dissection.
• Step 6: Mobilization of the Testis - Dissection continues until sufficient length is obtained in the spermatic cord, allowing the testis to be mobilized to the scrotum.
• Step 7: Single-Stage Procedure - In a single-stage procedure, the spermatic vessels are divided between the vascular clips, and a scrotal incision is made on the same side as the testis. A pouch is developed in the dartos tissue, and a neo-inguinal ring is created to facilitate the descent of the testis.
• Step 8: Mobilization to the Scrotum - The testis is grasped with forceps and gently mobilized through the tunnel created to the scrotum. The spermatic cord is inspected for any tension or torsion.
• Step 9: Anchoring the Testis - To prevent the testis from migrating back to the abdomen, it may be anchored to the scrotal septum with sutures.
• Step 10: Closure of Incisions - The scrotal incision is closed, and the abdominal incision is checked for bleeding. Hemostasis is obtained using electrocautery, and the intestines are returned to their original position before closing the abdominal incision in layers.
• Step 11: Two-Stage Procedure - If a two-stage procedure is performed, the incision is closed after the initial mobilization of the testis, allowing approximately six months for the development of collateral vascular circulation before the second stage of the procedure.

3. Post-Procedure

Post-procedure care following an orchiopexy involves monitoring for any complications such as infection or bleeding. Patients are typically advised to avoid strenuous activities for a specified period to ensure proper healing. Follow-up appointments are essential to assess the position of the testis and the integrity of the surgical site. In the case of a two-stage procedure, the patient will return for a second surgery after approximately six months to complete the mobilization of the testis to the scrotum. It is important to monitor the testis for proper blood supply and function during the recovery period.