Reporting Transurethral resection of bladder tumor with gemcitabine
- Medycoding Expert
- Jun 30
- 2 min read
Why Does the Physician Instill Gemcitabine or Mitomycin C After TURBT?
After a Transurethral Resection of Bladder Tumor (TURBT), microscopic tumor cells may remain attached to the bladder lining or become dislodged during tumor resection. The physician may instill Gemcitabine or Mitomycin C directly into the bladder through a Foley catheter.
This is called intravesical chemotherapy.
The physician performs an intravesical chemotherapy instillation immediately after resection to
Destroy any remaining cancer cells
Reduce the risk of tumor recurrence.
The medicine is usually instilled within 24 hour.
Is intravesical chemotherapy included in TURBT?
If given in the same operative session
Yes, dont code 51720 with any of bladder Tumor resection 52234/52235/52240.
If given in the postoperative care unit by other anesthesologist
Report 51720 with any of bladder Tumor resection 52234/52235/52240.
Preoperative Diagnosis :Bladder tumor
Postoperative Diagnosis :Bladder tumor (5.5 cm)
Procedure Performed
Cystoscopy
Transurethral fulguration of bladder tumor (5.5 cm)
Intravesical instillation of Mitomycin C
Operative Report
After induction of general anesthesia, the patient was placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion.
A 26-French resectoscope was introduced through the urethra into the bladder. Cystoscopic examination revealed a 5.5 cm papillary bladder tumor located on the left lateral wall. No additional tumors were identified.
The tumor was completely fulgurated using a bipolar loop electrode until all visible tumor tissue was destroyed. Excellent hemostasis was achieved. Final cystoscopic inspection demonstrated complete treatment of the lesion without evidence of bladder perforation.
A 20-French Foley catheter was inserted. Immediately following completion of the procedure, while the patient remained in the operating room, 40 mg of Mitomycin C diluted in sterile saline was instilled into the bladder through the Foley catheter. The catheter was clamped to allow the medication to dwell in the bladder.
The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
Report : 52240 only
Preoperative Diagnosis : Bladder tumor
Postoperative Diagnosis :Bladder tumor (5.5 cm)
Procedure Performed
Cystoscopy
Transurethral fulguration of bladder tumor (5.5 cm)
Operative Report
After induction of general anesthesia, the patient was placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion.
A 26-French resectoscope was inserted through the urethra. Cystoscopy demonstrated a 5.5 cm papillary bladder tumor involving the left lateral wall.
The lesion was completely fulgurated using bipolar electrocautery. Careful inspection confirmed complete destruction of the tumor. Hemostasis was excellent, and there was no evidence of bladder perforation.
A 20-French Foley catheter was left in place for postoperative bladder drainage. The patient tolerated the procedure well and was transferred to the Post-Anesthesia Care Unit (PACU) in stable condition.
Postoperative Care Unit Note
Approximately one hour after surgery, following confirmation of stable vital signs and absence of significant hematuria, 40 mg of Mitomycin C diluted in sterile saline was instilled into the bladder through the existing Foley catheter in the PACU. The catheter was clamped for one hour to allow adequate intravesical exposure before being reopened for drainage.
Report : 52240, 51720-59
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