Anterior Colporrhaphy (Cystocele Repair)
5724057260wRVU: 12.92 — Combined anteroposterior colporrhaphy (anterior + posterior repair)57285wRVU: 11.31 — Paravaginal defect repair, vaginal approach57284wRVU: 13.97 — Paravaginal defect repair, abdominal approach57250wRVU: 9.83 — Posterior colporrhaphy with perineorrhaphy
Symptomatic anterior vaginal wall prolapse (cystocele), [stage II/III/IV], [central / lateral paravaginal defect]
Same
Anterior colporrhaphy (native tissue cystocele repair)
[Attending name], MD/DO
[Resident/PA name]
[General endotracheal / spinal / MAC]
The patient is a [age]-year-old [female] with symptomatic anterior vaginal wall prolapse [stage ___] presenting with [pelvic pressure / vaginal bulge / incomplete bladder emptying / recurrent UTIs]. Preoperative examination identified a [central / lateral paravaginal] defect. Conservative management with [pessary / pelvic floor physical therapy] has been [failed / declined]. The risks, benefits, and alternatives of native tissue anterior colporrhaphy were discussed and informed consent was obtained.
Examination under anesthesia confirmed [stage ___] anterior vaginal wall prolapse with a [central midline / lateral paravaginal / combined] defect. The vaginal epithelium was [well-estrogenized / atrophic]. The pubocervical fascia was [attenuated in the midline / detached laterally from the arcus tendineus]. [No enterocele was identified.] Uterus [present and well-supported / absent — prior hysterectomy].
The patient was positioned in the dorsal lithotomy position with the legs in [Allen / candy cane] stirrups. A Foley catheter was placed and the bladder drained. The vagina was prepped with [Betadine / chlorhexidine] solution. A surgical timeout was performed.
The anterior vaginal wall was hydrodissected with [20 mL of 0.25% bupivacaine with 1:200,000 epinephrine] to facilitate dissection and reduce bleeding. Allis clamps were placed on the anterior vaginal wall at the level of the bladder neck and at the vaginal apex.
A midline anterior vaginal incision was made from [the level of the bladder neck / midurethra] to [the vaginal apex / cervix]. The vaginal epithelium was sharply dissected off the underlying pubocervical fascia bilaterally using [Metzenbaum scissors / electrocautery], developing the vesicovaginal space. Dissection was carried laterally to the level of the arcus tendineus fasciae pelvis bilaterally.
The pubocervical fascia was identified as a white fibromuscular layer overlying the bladder. [Central defect: The midline fascial defect was plicated with [3-4] interrupted [0-Vicryl / 2-0 PDS] sutures placed in the midline, reducing the cystocele and reapproximating the fascia without tension.] [Lateral defect: see paravaginal repair variant.]
The cystocele was reduced and the bladder base was well-supported. Excess vaginal epithelium was trimmed. The vaginal epithelium was closed with a running [2-0 Vicryl] suture. Hemostasis was confirmed. A vaginal pack was placed and the Foley catheter was left in place.
Cystoscopy was performed with [150 mL / 300 mL] of sterile water in the bladder. Bilateral ureteral jets were visualized confirming ureteral patency. Bladder mucosa was intact with no suture entry noted.
None
None [/ Vaginal epithelium, if sent]
[X] mL
Vaginal pack removed [in PACU / at 24 hours]; Foley catheter removed [at 24 hours / after voiding trial]
The patient was taken to the PACU in stable condition. The vaginal pack was removed at [24 hours]. A voiding trial was performed prior to Foley removal. [The patient voided spontaneously / was discharged with a catheter for home management pending voiding trial at follow-up.]
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Symptomatic anterior vaginal wall prolapse, stage ***, *** defect
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Anterior colporrhaphy, native tissue
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: ***
INDICATIONS: .PTAGE-year-old .PTSEX with stage *** cystocele, *** defect. Failed/declined conservative management. Consent obtained.
FINDINGS: Stage *** anterior prolapse, *** defect pattern. Vaginal epithelium ***. Pubocervical fascia ***. No enterocele.
PROCEDURE:
Dorsal lithotomy. Foley placed, bladder drained. Hydrodissection with bupivacaine/epinephrine. Midline anterior vaginal incision, bladder neck to apex. Vesicovaginal space developed bilaterally to arcus tendineus. Pubocervical fascia identified. Midline fascial plication with *** interrupted 0-Vicryl/2-0 PDS sutures. Cystocele reduced, bladder well-supported. Excess epithelium trimmed. Vaginal epithelium closed running 2-0 Vicryl. Vaginal pack placed.
Cystoscopy: bilateral ureteral jets confirmed. Bladder mucosa intact.
EBL: *** mL
SPECIMENS: None
COMPLICATIONS: None
DRAINS/CATHETERS: Vaginal pack out ***. Foley out after voiding trial.
DISPOSITION: PACU, stable.
Signed: .ME, .MYDEGREE
.TODAYVariants
Paravaginal Defect Repair (Lateral Defect)
Examination confirmed a lateral paravaginal defect with detachment of the pubocervical fascia from the arcus tendineus fasciae pelvis (ATFP) bilaterally [/ on the right / left]. Following development of the vesicovaginal space and identification of the ATFP along the lateral pelvic sidewall, the lateral vaginal sulcus was reattached to the ATFP with [4-5] interrupted [0-Vicryl / 0-PDS] sutures on each side, working from the level of the ischial spine anteriorly to the pubic symphysis. The ATFP was palpable as a firm cordlike structure on the lateral pelvic sidewall. Sutures were placed through the full thickness of the vaginal wall (epithelium and pubocervical fascia) and into the ATFP without incorporating periosteum. This repair corrects lateral displacement of the anterior vaginal wall that would not be corrected by midline plication alone.
Combined Anteroposterior Colporrhaphy
Following completion of the anterior colporrhaphy, a posterior colporrhaphy with perineorrhaphy was performed for concomitant [stage __ rectocele / symptomatic posterior vaginal wall prolapse]. A midline posterior vaginal incision was made from the hymenal ring to [2 cm below the vaginal apex]. The rectovaginal fascia was plicated in the midline with interrupted [2-0 PDS] sutures, reducing the rectocele. The perineal body was reconstructed with [0-Vicryl] sutures. The posterior vaginal wall was closed with running [2-0 Vicryl]. Bill 57260 for the combined repair.
Charting Tips
- Document defect type: central vs. lateral (paravaginal). This determines the operation and the billing code — anterior colporrhaphy (57240) corrects central midline defects; paravaginal repair (57285 vaginal, 57284 abdominal) corrects lateral defects. Performing colporrhaphy for a lateral defect is the most common cause of prolapse recurrence.
- Document cystoscopy findings including bilateral ureteral jets and bladder mucosal integrity. Bladder entry and ureteral kinking are recognized complications of anterior repair; cystoscopy at case end is standard and should be documented with the specific finding of bilateral efflux.
- Note: transvaginal mesh for anterior compartment POP repair was withdrawn from the US market by FDA order in 2019 and is no longer available. Native tissue is the current standard. Do not document mesh use for anterior colporrhaphy unless mesh was placed via an abdominal approach (sacrocolpopexy), which was not affected by the FDA order.
- Document estrogenization status and any preoperative vaginal estrogen use. Atrophic epithelium is associated with higher wound complication and recurrence rates. Preoperative topical estrogen for 4-6 weeks is recommended when feasible.
Billing Tips
- Bill 57240 for anterior colporrhaphy (repair of cystocele, 9.83 wRVU, 90-day global). Note: transvaginal mesh kits for anterior POP repair were withdrawn from the US market by FDA order in 2019. Native tissue repair is the current standard for anterior compartment prolapse.
- Bill 57260 (12.92 wRVU) for combined anteroposterior colporrhaphy when both anterior and posterior repairs are performed at the same session. Do not bill 57240 and 57250 separately when the combined code applies.
- Bill 57285 (11.31 wRVU) for vaginal paravaginal repair and 57284 (13.97 wRVU) for abdominal paravaginal repair. Document the specific defect type (central vs. lateral/paravaginal) to support code selection — these are distinct repairs for distinct defects.
- If a concomitant midurethral sling is placed for coexisting stress urinary incontinence, bill 57288 separately with modifier -51. Document SUI diagnosis and the decision to address both in the same setting.
- 90-day global period: postoperative vaginal packing removal, wound checks, and routine pelvic floor follow-up are bundled. Vault dehiscence requiring OR return uses modifier -78.