AUDIT REPORT T10.2 OPERATIVE REPORT, PROSTATECTOMY

AUDIT REPORT T10.2 OPERATIVE REPORT, PROSTATECTOMY
CLINICAL NOTE: This gentleman was found to have adenocarcinoma of the prostate after presenting with a rising PSA and abnormal digital rectal examination.
OPERATIVE NOTE: The patient was given an epidural anesthetic. Unfortunately, analgesia was incomplete, and therefore he was converted to a general endotracheal anesthetic. A 20-French catheter was inserted into the bladder and a lower abdominal midline incision made. The Omni retractor was used for exposure. Bilateral pelvic lymphadenectomy was performed. The obturator nerves were identified and spared. There was no gross abnormality of the lymph nodes, and therefore they were sent for permanent section. The superficial venous complex was identified, cauterized, and divided. The endopelvic fascia was opened bilaterally. The puboprostatic ligaments were divided sharply. The dorsal venous complex was then surrounded with a McDougal clamp, ligated distally with #1 silk and oversewn proximally with 2-0 chromic. It was then divided using electrocautery. The urethra was incised anteriorly, the catheter withdrawn, clamped, divided and the urethra divided posteriorly. A left nerve-sparing procedure was performed, and the nerves were dissected off the prostate under direct visual guidance. The right neurovascular bundle was taken widely using clips and chromic ties. Lateral pedicles were taken with 0 chromic ties. The bladder neck was opened anteriorly, then divided posteriorly after the ureteric orifices were identified. The seminal vesicles were clipped and divided near their bases. A small amount of seminal vesicle tissue was left on the right-hand side. The ampullae of the vas were also clipped and divided. Hemostasis was achieved with 2-0 chromic suture ligatures. The bladder neck was then closed in a tennis racquet fashion using 2-0 chromic and the mucosa everted using 4-0 chromic. The urethra was re-anastomosed to the bladder neck using 2-0 Monocryl sutures over a 20-French Foley catheter in the usual fashion. A Jackson-Pratt drain was left through a left lower quadrant stab wound and sutured to the skin with 2-0 Prolene. The fascia was closed with #1 Vicryl, subcutaneous tissue with 3-0 Vicryl, and skin with 4-0 subcuticular Dexon and Dermabond. Estimated blood loss was 750 cc. Sponge and needle counts were reported as correct. The patient remained hemodynamically stable intraoperatively.
PATHOLOGY REPORT LATER INDICATED: Malignant, primary prostate cancer
T10.2:
SERVICE CODE(S): 55840, 51800-51, 38770-51-50
ICD-10-CM DX CODE(S): D07.5______________
INCORRECT/MISSING CODE(S): ______________________________________