CPT® Code 55812

1. Indications

The perineal radical prostatectomy with lymph node biopsy, as described by CPT® Code 55812, is indicated for the following conditions:

• Prostate Cancer The primary indication for this procedure is the presence of prostate cancer, particularly when there is a need to remove the prostate gland and assess lymph node involvement.
• Suspicion of Lymph Node Metastasis This procedure is performed when there is a clinical suspicion that cancer may have spread to the pelvic lymph nodes, necessitating a biopsy to evaluate the extent of the disease.

2. Procedure

The procedure for CPT® Code 55812 involves several detailed steps, which are as follows:

• Step 1: Lymph Node Biopsy If lymphadenectomy is indicated, the procedure begins with an incision in the lower abdomen to explore the pelvic lymph nodes on one side. Care is taken to avoid opening the peritoneum. The fatty tissue surrounding the common iliac and external iliac vessels is carefully stripped away to access the iliac, hypogastric, and obturator nodes, which are biopsied and sent for separate frozen section analysis.
• Step 2: Radical Perineal Prostatectomy Following the lymph node biopsy, an inverted-U incision is made in the perineum above the anal opening. The incision is deepened to the ischiorectal fossa, and the central tendon is divided on both sides. The fibrous confluence is dissected posterior to the raphe of the bulbospongiosus muscle, which is also divided to expose the rectourethralis and levator ani muscles.
• Step 3: Mobilization of the Prostate The rectourethralis muscle is divided, allowing for the rectum and urethra to be exposed. The rectum is mobilized posteriorly from the prostatic apex, and the Denonvilliers fascia is revealed. The prostate gland is then mobilized toward the perineum while the rectum is moved away from the prostate.
• Step 4: Dissection of the Vas Deferens and Seminal Vesicles A transverse incision is made through the Denonvilliers fascia between the vas deferens and seminal vesicles. Each vas deferens is freed, ligated, and divided. The seminal vesicles are retracted medially, exposing their lateral aspects, which are also ligated and divided.
• Step 5: Nerve-Sparing vs. Non-Nerve-Sparing Approach In a nerve-sparing approach, the Denonvilliers aponeurosis is incised, and the cavernosal nerve bundles are separated from the prostate. In a non-nerve-sparing approach, the periprostatic tissue is dissected from the levator muscles and excised along with the prostate.
• Step 6: Division of Prostate Attachments The puboprostatic ligaments anterior to the prostate are divided, and the attachments anterior to the bladder neck are exposed and severed. A dissection plane is created between the bladder neck and the base of the prostate, allowing for the urethra to be exposed at its junction with the prostate.
• Step 7: Removal of the Prostate The urethra is dissected from surrounding tissue and divided approximately 1 cm below the bladder neck. The prostate is then removed, and the urethral ends are anastomosed. If the bladder neck cannot be preserved, it is excised, and the bladder opening is reduced to facilitate the anastomosis of the urethra.
• Step 8: Closure and Catheter Placement A catheter is placed transurethrally into the bladder, and the bladder is irrigated to clear any clots. Finally, the perineal incision is closed.

3. Post-Procedure

Post-procedure care following a perineal radical prostatectomy with lymph node biopsy includes monitoring for complications such as bleeding, infection, and urinary retention. Patients may require a catheter for a period to facilitate urinary drainage while the surgical site heals. Follow-up appointments are essential to assess recovery and to evaluate the results of the lymph node biopsies. Patients are typically advised on activity restrictions and signs of complications to watch for during their recovery period.