Procedure Ke
For each CPT code, report the diagnosis codes that support it.
PREOPERATIVE DIAGNOSIS: Urinary retention.
POSTOPERATIVE DIAGNOSIS: Recurrent prostatic hyperplasia.
PROCEDURE PERFORMED: Cystoscopy and transurethral resection of the prostate.
SURGEON: Edith Hopkins, MD
ANESTHESIA: Spinal.
CLINICAL NOTE: This is a 75-year-old gentleman who underwent right hip arthroplasty. This gentleman had undergone a right transurethral resection of the prostate for urinary retention 4 months ago and has again developed urinary retention. He has had several trials of voiding with both alpha blockade and bethanechol. Cystoscopy revealed recurrent prostatic hyperplasia. There is a large piece of tissue acting as a ball valve.
PROCEDURE: The patient was given a spinal anesthetic, prepped, and draped in the lithotomy position. A 28-French resectoscope was passed under direct vision. Again, the prostate shows irregular ingrowth and obstruction. The bladder shows mild to moderate trabeculation. The prostate was thoroughly resected on the left and chips evacuated from the bladder and hemostasis achieved. A 22-French three-way catheter was inserted into the bladder and placed at continuous bladder irrigation. The patient tolerated the procedure well and was transferred to the recovery room in good condition.
Procedure Key Terms: transurethral resection
ICD-10-CM Key Terms: recurrent hyperplasia, urinary retention
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