Ureteral Reimplantation (Ureteroneocystostomy)

CPT 50780
Approach Open
Add-on / Variant CPTs
  • 50782 — Ureteroneocystostomy, with bladder flap (Boari)
  • 50785 — Ureteroneocystostomy, with vesico-psoas hitch
Preoperative Diagnosis:

Right [left] distal ureteral [stricture / injury / iatrogenic division / ureteral cancer] — requiring ureteral reimplantation

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] ureteroneocystostomy [with psoas hitch / Boari flap] — [open / laparoscopic / robotic]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal

Indications:

The patient is a [age]-year-old [male/female] with right [left] distal ureteral [stricture / injury] secondary to [pelvic surgery / radiation / ureteral cancer excision]. The ureteral defect was [X] cm in length. Direct repair or ureteroureterostomy was not feasible given [defect length / distal ureteral quality]. Ureteral reimplantation [with psoas hitch] was planned. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The right [left] ureter was identified and traced to the level of the injury/stricture at [X] cm from the bladder. The ureter was divided at the [normal / injured] segment and the proximal ureteral end was [healthy / viable / with [good caliber / adequate peristalsis visible]. The bladder was [mobile / could be mobilized to the right / required psoas hitch / required Boari flap] to bridge the defect without tension.

Description of Procedure:

The patient was positioned supine. A midline [/ Pfannenstiel] incision was made. The retroperitoneum was entered. The right [left] ureter was identified at the pelvic brim and dissected distally to the site of [injury / stricture].

The ureter was transected [X] cm above the normal-appearing proximal ureteral tissue. The proximal ureteral end was spatulated [1 cm] on its medial/anterior surface. A [5 Fr] pediatric feeding tube was used to confirm ureteral caliber and patency.

The bladder was mobilized by dividing the contralateral [right / left] superior vesical pedicle and dissecting the bladder off the pelvic sidewall. [Psoas hitch: the bladder was sutured to the psoas tendon (not the psoas muscle — avoid genitofemoral nerve) with [2] non-absorbable [2-0 Prolene / 0-Vicryl] sutures, bringing the bladder [4–6] cm toward the ureter.]

A [2]-cm cystotomy was made in the posterolateral bladder wall on the ipsilateral side. A [2]-cm submucosal tunnel was created. The ureter was brought through the tunnel submucosally (extravesical Lich-Gregoir technique) [/ passed through the cystotomy]. The ureterovesical anastomosis was constructed with [5-0 Vicryl] interrupted and running sutures. A [6 Fr × 26-cm] DJ stent was placed [antegrade / retrograde].

The cystotomy was closed with [3-0 Vicryl]. A [16 Fr] urethral catheter and [19 Fr] pelvic drain were placed. The wound was closed in layers.

Complications:

None

Specimens:

[Excised ureteral segment — sent to pathology]

Estimated Blood Loss:

[X] mL

Drains:

Double-J ureteral stent; [19 Fr] pelvic drain; [16 Fr] urethral catheter

Disposition:

The patient was taken to the PACU in stable condition. The drain was removed when output was [<50 mL/day] with low creatinine [confirming no anastomotic leak]. The urethral catheter was removed at [5–7 days]. The DJ stent was removed cystoscopically at [6 weeks].

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Right/Left distal ureteral *** — requiring reimplantation
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left ureteroneocystostomy with psoas hitch/Boari/direct
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General

INDICATIONS: .PTAGE-year-old .PTSEX with right/left ureteral *** at *** cm from bladder. Defect *** cm. Consent obtained.

FINDINGS: Ureter divided *** cm above injury. Proximal end viable, good caliber. Bladder mobile/*** — psoas hitch/Boari/direct reimplant feasible.

PROCEDURE:
Supine. *** incision. Retroperitoneum entered. Ureter dissected to ***. Transected *** cm above normal tissue. Spatulated *** cm. [Psoas hitch: bladder mobilized, sutured to psoas tendon with *** sutures.] Cystotomy *** cm. Submucosal tunnel *** cm. Ureter passed *** technique. Anastomosis 5-0 Vicryl. DJ stent *** Fr placed. Cystotomy closed 3-0 Vicryl. Foley *** Fr. Drain ***. Closed.

EBL: *** mL
COMPLICATIONS: None
DISPOSITION: PACU. Drain out when <50 mL creatinine-negative. Foley out day ***. Stent out 6 weeks.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Boari Flap for Long Ureteral Defects

Given a [10–15]-cm ureteral defect that could not be bridged by psoas hitch alone, a Boari flap was constructed. A [4 × 3]-cm anterior bladder flap was outlined, based on a posterior pedicle with superior vesical artery supply. The flap was tubularized over a stent with a [3-0 Vicryl] running suture to form a neo-ureter. The flap was sutured to the proximal native ureter end-to-end with [5-0 Vicryl]. Boari flaps can bridge defects up to 15 cm; for longer defects, ileal ureter interposition or renal autotransplantation should be considered.

Charting Tips
  • Document psoas hitch suture placement with care to avoid the genitofemoral nerve. The genitofemoral nerve runs on the anterior surface of the psoas muscle and is commonly injured by sutures placed too laterally or too deeply. Document 'sutures placed in the psoas tendon, avoiding the genitofemoral nerve.'
  • Document anti-reflux technique. Submucosal tunnel length of 3–4:1 (tunnel length to ureteral diameter) is required for anti-reflux protection. Document the tunnel length and the technique used (Lich-Gregoir extravesical, Politano-Leadbetter intravesical). Primary anastomosis without anti-reflux is acceptable for benign strictures in adults.
  • Document drain creatinine level before removal. Pelvic drain output with elevated creatinine (>2× serum creatinine) indicates urinoma from anastomotic leak. Document drain creatinine before removal to confirm the drain fluid is serosanguinous, not urinary.
Billing Tips
  • 50780 (ureteroneocystostomy, anastomosis of single ureter, 19.45 wRVU) is the primary code for standard ureteral reimplantation into the bladder.
  • Code selection by complexity: 50782 (obstructed ureter, 19.17 wRVU), 50783 (extensive ureteral dissection, 20.18 wRVU), 50785 (with bladder flap/psoas hitch/Boari flap, 21.67 wRVU). Document which reconstructive technique was used.
  • Bilateral reimplantation: bill each side separately with -RT/-LT modifiers; bilateral reimbursement is 150% of the higher-valued procedure.
  • Psoas hitch (cystotomy for bladder mobilization) and Boari flap are included in 50785. Do not bill cystotomy separately.
  • Ureteral stent placement at the same session is bundled. Do not separately bill 52332.
  • Global period is 90 days. Post-op stent removal and urogram within the global are bundled unless performed at a separate session with a distinct clinical purpose.
  • Document: indication (ureteral injury, stricture, VUR grade), side, technique (extravesical/Lich-Gregoir vs intravesical/Politano-Leadbetter), need for tapering, and stent placed. These details support medical necessity and coding tier.