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Official Description

Laparoscopy, surgical prostatectomy, simple subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy), includes robotic assistance, when performed

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Laparoscopic simple subtotal suprapubic prostatectomy is a minimally invasive surgical procedure performed to alleviate symptomatic obstruction caused by an enlarged prostate, also known as benign prostatic hyperplasia (BPH). This procedure is typically indicated for patients experiencing significant urinary difficulties due to the enlargement of the prostate gland. The surgery is conducted under general anesthesia, ensuring the patient is completely unconscious and pain-free during the operation. The patient is positioned in maximum Trendelenburg position, which involves tilting the body so that the head is lower than the feet, facilitating better access to the pelvic region. A urinary catheter is inserted to manage urine flow during the procedure. The surgical approach begins with a suprapubic incision, allowing access to the bladder. Pneumoperitoneum, the process of inflating the abdominal cavity with gas, is established to create a working space for the surgeon. A trocar, a specialized surgical instrument, is inserted to facilitate the introduction of a camera and other surgical instruments into the abdominal cavity. The procedure involves careful dissection and manipulation of the prostate and surrounding structures, including the bladder and urethra, to remove the obstructive prostate tissue while preserving surrounding anatomy. Robotic assistance may be utilized to enhance precision during the surgery. Postoperatively, the patient is monitored for urine output and any complications, ensuring a safe recovery process.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The laparoscopic simple subtotal suprapubic prostatectomy is indicated for patients experiencing significant urinary obstruction due to an enlarged prostate. The following conditions may warrant this procedure:

  • Symptomatic Obstruction Patients suffering from urinary difficulties, such as weak urine flow, urgency, frequency, or incomplete bladder emptying, due to benign prostatic hyperplasia (BPH).

2. Procedure

The laparoscopic simple subtotal suprapubic prostatectomy involves several key procedural steps that ensure the effective removal of obstructive prostate tissue while minimizing recovery time and complications.

  • Step 1: Anesthesia and Positioning The procedure begins with the patient being placed under general anesthesia to ensure comfort and immobility during the surgery. The patient is then positioned in maximum Trendelenburg position, which tilts the body so that the head is lower than the feet, optimizing access to the pelvic area.
  • Step 2: Catheter Placement and Incision A urinary catheter is inserted to facilitate urine drainage during the procedure. Following this, a suprapubic incision is made to access the bladder. A needle is inserted to establish pneumoperitoneum, which inflates the abdominal cavity with gas, creating a working space for the surgical instruments.
  • Step 3: Trocar Insertion and Camera Introduction A trocar is placed in the midline of the abdomen, allowing for the introduction of a camera. This camera provides visualization of the surgical field, enabling the surgeon to inspect the pelvis and place additional trocars for the introduction of surgical instruments.
  • Step 4: Robotic Assistance Setup If robotic assistance is utilized, the robotic arms are docked and prepared at the console, enhancing the precision of the surgical procedure.
  • Step 5: Bladder Mobilization and Prostate Dissection The laparoscope is introduced, and the colon is mobilized away from the bladder. An incision is made in the posterior bladder wall, with stay sutures placed to expose the bladder base. The ureteral openings are identified, and the median lobe of the prostate is located. An incision is made at the junction of the prostate and bladder neck, which is then carried around the prostatic capsule.
  • Step 6: Prostate Removal The prostate is carefully moved back and forth to facilitate dissection along the pedicle to the posterior apex. The remaining attachments are cut, and the prostate specimen is placed in an endobag to prevent spillage of tissue.
  • Step 7: Bladder Reconstruction The bladder neck is advanced to the urethral mucosa and sutured in place. The posterior bladder wall is then closed, and the integrity of the bladder suture is tested by filling it with saline to ensure there are no leaks.
  • Step 8: Drain Placement and Incision Closure A drain is placed through a side port to facilitate fluid management. After inspecting the trocar sites, all trocars are removed. The prostate specimen is extracted through an enlarged midline incision, and the rectus fascia is closed. Finally, all incisions are sutured closed, dressings are applied, and the urinary catheter is secured to the thigh.

3. Post-Procedure

Postoperatively, the patient is monitored closely for urine output and any potential complications. The urinary catheter remains in place for a specified duration to ensure proper drainage and healing. Patients are typically advised on activity restrictions and signs of complications to watch for during recovery. Follow-up appointments are scheduled to assess healing and address any ongoing symptoms related to urinary function.

Short Descr LAPS SURG PRST8ECT SMPL STOT
Medium Descr LAPS SURG PRST8ECT SMPL STOT ROBOTIC ASSISTANCE
Long Descr Laparoscopy, surgical prostatectomy, simple subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy), includes robotic assistance, when performed
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 Hospital Part B services paid through a comprehensive APC
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) none
MUE 1
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
GC This service has been performed in part by a resident under the direction of a teaching physician
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
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).
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
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.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
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.)
81 Minimum assistant surgeon: minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number.
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).
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
KX Requirements specified in the medical policy have been met
RT Right side (used to identify procedures performed on the right side of the body)
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
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2023-01-01 Added Code added.
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