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A urethrovaginal fistula is a pathological connection between the urethra and the vagina, often resulting from surgical trauma during procedures such as anterior vaginal repair or from obstetrical trauma during vaginal delivery. The closure of this type of fistula, as described by CPT® Code 57310, involves a surgical procedure where the fistula is carefully exposed. The process begins with an incision of the vaginal mucosa, extending from the urethral meatus to the site of the fistula. This allows for the development and mobilization of fascial flaps on either side of the urethra, which are essential for the closure of the fistula. The surgical technique includes suturing the urethral mucosa to effectively close the fistula. Following this, the fascial flap on one side is sutured to the base of the flap on the opposite side, creating a secure closure. The procedure concludes with the closure of the vaginal mucosa, ensuring that the anatomical integrity is restored. This surgical intervention is critical for patients suffering from the complications associated with urethrovaginal fistulas, as it aims to restore normal function and alleviate symptoms associated with this condition.
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The closure of a urethrovaginal fistula, as indicated by CPT® Code 57310, is performed in specific clinical scenarios. The following conditions typically warrant this surgical intervention:
The procedure for the closure of a urethrovaginal fistula involves several critical steps, each designed to ensure effective repair and restoration of normal anatomy. The following outlines the procedural steps:
After the closure of the urethrovaginal fistula, specific post-procedure care is essential for optimal recovery. Patients are typically monitored for any signs of complications, such as infection or recurrence of the fistula. It is common practice to place a suprapubic catheter to allow the urethra to heal properly without undue stress. This catheterization helps maintain urinary function while the surgical site recovers. Patients may also receive instructions regarding activity restrictions and follow-up appointments to ensure proper healing and assess the success of the procedure.
| Short Descr | REPAIR URETHROVAGINAL LESION | Medium Descr | CLOSURE URETHROVAGINAL FISTULA | Long Descr | Closure of urethrovaginal fistula; | 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 | ASC Payment Indicator | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | 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). | 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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| 2010-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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