CPT® Code 58293

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1. Indications

The procedure described by CPT® Code 58293 is indicated for patients presenting with conditions that necessitate the removal of an enlarged uterus, specifically when the uterus weighs more than 250 grams. Common indications for this procedure may include:

• Uterine Fibroids: Benign tumors that can cause significant enlargement of the uterus, leading to symptoms such as heavy menstrual bleeding, pelvic pain, and pressure symptoms.
• Uterine Prolapse: A condition where the uterus descends into the vaginal canal, often requiring surgical intervention to restore normal anatomy and function.
• Endometrial Hyperplasia: A condition characterized by the thickening of the uterine lining, which may lead to abnormal bleeding and increase the risk of endometrial cancer.
• Chronic Pelvic Pain: Persistent pain that may be associated with an enlarged uterus, often requiring surgical evaluation and intervention.

2. Procedure

The procedure involves several detailed steps to ensure the successful removal of the uterus and the performance of the colpo-urethrocystopexy. The steps are as follows:

• Step 1: The surgeon begins by placing tenacula on the cervix to provide traction. This is essential for gaining access to the vaginal canal and the uterus.
• Step 2: An incision is made in the vaginal mucosa around the entire cervix, allowing for the exposure of the underlying structures.
• Step 3: Blunt and sharp dissection techniques are employed to separate the bladder from the uterus, ensuring that the bladder is elevated to expose the peritoneal vesicouterine fold, which is then incised.
• Step 4: The cul-de-sac is exposed, and the peritoneum is incised to access the uterine vessels, which are subsequently ligated to prevent bleeding during the procedure.
• Step 5: The surgeon employs one of the morcellization techniques, such as hemisection, intramyometrial coring, or wedge resection, to remove the uterus in manageable pieces while severing uterine attachments.
• Step 6: As portions of the uterus are exteriorized and removed, the broad ligament is exposed, and the uterosacral ligaments are clamped and divided to facilitate further dissection.
• Step 7: The cardinal ligaments are clamped at the lower uterine segment, incised, and suture ligated to ensure complete removal of the uterus.
• Step 8: The lower portion of the broad ligament is clamped and divided at its attachment to the lower uterine segment, further aiding in the removal process.
• Step 9: The tubo-ovarian round ligaments are exposed, clamped, and incised close to the uterine fundus bilaterally, allowing for the transection of the fallopian tubes.
• Step 10: The entire morcellized uterus is removed, and if the tubes and ovaries are to be excised, the round ligament is cut and tied bilaterally.
• Step 11: Tension is applied to the infundibulopelvic ligament, which is cut to deliver the tubes and ovaries along with the morcellized uterus into the vagina for removal.
• Step 12: The anterior vaginal wall is elevated, and the entire length of the broad ligament is inspected to control any bleeding.
• Step 13: The colpo-urethrocystopexy is performed by placing two sutures through the paravaginal fascia on either side of the urethrovesical junction, which are then passed through the Cooper's ligament, pelvic fascia, or pubic bone and tied to provide necessary support.
• Step 14: If additional suspension is required, a second set of sutures may be placed along the base of the bladder to ensure adequate support.
• Step 15: The surgical site is thoroughly inspected for any bleeding, which is controlled before closing the peritoneum.
• Step 16: The vaginal cuff is left open to allow for drainage of the pelvis, ensuring proper healing and reducing the risk of complications.

3. Post-Procedure

Post-procedure care following a vaginal hysterectomy with colpo-urethrocystopexy includes monitoring for any signs of complications such as bleeding, infection, or urinary retention. Patients are typically advised to rest and avoid strenuous activities for a specified period to promote healing. Follow-up appointments are essential to assess recovery and ensure that the surgical site is healing properly. Patients may also receive instructions regarding pelvic floor exercises to support recovery and improve urinary function. It is important for healthcare providers to provide clear guidance on signs of complications that patients should report, such as increased pain, fever, or unusual discharge.