Retroperitoneal Sarcoma Resection
4919050230wRVU: 23.21 — Radical nephrectomy open (23.21 wRVU) — correct code when kidney is removed inside Gerota's fascia with perinephric fat as part of compartmental RPS resection; 50220 (simple nephrectomy, 18.21 wRVU) is not appropriate for this oncologic extent44160wRVU: 20.37 — Colectomy (if colon removed en bloc)38100wRVU: 19.06 — Splenectomy (if involved)35221wRVU: 25.95 — Repair of blood vessel, intra-abdominal, direct (if IVC involved; use 35251 with vein graft)
[Retroperitoneal well-differentiated liposarcoma (WDLPS) / dedifferentiated liposarcoma (DDLPS) / leiomyosarcoma / solitary fibrous tumor / MPNST], [X] cm, [right / left retroperitoneum]
Same
En bloc resection of retroperitoneal sarcoma with [ipsilateral kidney / right colon / spleen / no organ resection], [R0 / R1 margins]
[Attending name], MD
[Fellow/Resident name]
General endotracheal. Arterial line, CVP, cell saver. [Preoperative radiation [X Gy] completed [date].]
Patient presents with [retroperitoneal liposarcoma] measuring [X] cm on staging CT. [No metastatic disease.] [Neoadjuvant radiation [X Gy] completed [date].] Multidisciplinary tumor board review recommended surgical resection. Plan for en bloc resection with [ipsilateral kidney / right colon]. Risks including major hemorrhage, adjacent organ injury, vascular injury, local recurrence, and perioperative morbidity discussed. Consent obtained.
[Well-differentiated liposarcoma / dedifferentiated liposarcoma / leiomyosarcoma] [X] cm. [Abutting / encasing] [right kidney / right colon / IVC / psoas]. Tumor [did not / did] involve [vessel / organ]. [Plane between tumor and [IVC / aorta] developed bluntly: [vessel wall not entered / small venous tributary ligated].] R[0/1] resection achieved.
The patient was positioned supine [/ in right lateral decubitus]. A [midline / right flank / left flank] incision was made. The abdomen was explored. No peritoneal implants or liver metastases were identified. The retroperitoneum was entered.
[RIGHT-SIDED TUMOR: The right colon was reflected medially (Cattell-Braasch maneuver — right medial visceral rotation; mobilizes right colon, duodenum, and small bowel to expose the right retroperitoneum and IVC).]
[LEFT-SIDED TUMOR: The left colon was reflected medially (Mattox maneuver — left medial visceral rotation; mobilizes descending colon, spleen, tail of pancreas, and left kidney to expose the left retroperitoneum and aorta).]
The tumor was identified in the [right / left] retroperitoneum. Compartmental resection was performed: the tumor was resected en bloc with the ipsilateral retroperitoneal soft tissue, Gerota's fascia, perinephric fat, [and ipsilateral kidney / colon / adrenal gland] to achieve a soft-tissue margin regardless of direct organ abutment (per TARPSWG compartmental resection principles). The plane of dissection was developed along the psoas muscle posteriorly, the mesocolon anteriorly, the [IVC / aorta] medially, and the iliac vessels inferiorly.
[En bloc nephrectomy was performed. The kidney was taken with the tumor due to [involvement / proximity / inability to separate the plane safely]. The renal vessels were individually ligated and divided.]
[En bloc right colon resection; see concurrent bowel resection note.]
The specimen was freed and removed. Hemostasis confirmed. The retroperitoneum was inspected; [no residual gross tumor / minimal residual at [IVC / psoas, R1]]. [Drains placed in the retroperitoneal space.] Fascia closed. Skin closed. Patient tolerated the procedure well.
None
Retroperitoneal sarcoma specimen to pathology with orientation sutures and margins labeled
[X] mL
[Retroperitoneal closed-suction drain / None]
Patient taken to surgical ICU / floor in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Retroperitoneal [liposarcoma / leiomyosarcoma], *** cm, [right / left retroperitoneum]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: En bloc retroperitoneal sarcoma resection with [kidney / colon / spleen / no organ], [R0 / R1]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; arterial line; cell saver; [neoadjuvant RT *** Gy completed ***]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with retroperitoneal [liposarcoma / leiomyosarcoma] *** cm. No metastatic disease. [Neoadjuvant RT complete.] MTB review recommended resection. En bloc plan includes [kidney / right colon]. Risks including major hemorrhage, vascular injury, and local recurrence discussed. Informed consent obtained.
FINDINGS: [Well-differentiated / dedifferentiated liposarcoma / leiomyosarcoma] *** cm. [Abutting / encasing] ***. [Plane developed from IVC/aorta; vessel wall not entered.] R[0/1] resection.
DESCRIPTION OF PROCEDURE:
Patient supine. [Midline / flank] incision. Abdomen explored; no peritoneal implants. Retroperitoneum entered. [Right-sided: right colon reflected medially (Cattell-Braasch maneuver).] [Left-sided: left colon reflected medially (Mattox maneuver).] Compartmental resection: tumor with ipsilateral retroperitoneal soft tissue, Gerota's fascia, perinephric fat, [and kidney / colon / adrenal] en bloc. Dissection along psoas posteriorly, mesocolon anteriorly, IVC/aorta medially, iliac vessels inferiorly. [En bloc radical nephrectomy (50230); renal vessels ligated and divided.] [En bloc colon resection; see concurrent note.] Specimen removed. Hemostasis confirmed. R[0/1] resection. [Retroperitoneal drain placed.] Fascia and skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Sarcoma specimen to pathology (oriented, margins labeled)
COMPLICATIONS: None
DRAINS: [Retroperitoneal drain / None]
DISPOSITION: Patient to [SICU / floor] in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
IVC involvement
IVC resection and reconstruction is required for intraluminal tumor extension or tight adherence. Document whether IVC was reconstructed (PTFE graft) or ligated (if contralateral renal vein and collaterals adequate). Vascular surgery involvement common.
Neoadjuvant radiation
The STRASS trial (EORTC-62092, Lancet Oncol 2020) showed no overall survival benefit from neoadjuvant RT for RPS overall, with a trend toward benefit in the WDLPS/low-grade DDLPS subgroup on abdominal recurrence-free survival. Neoadjuvant RT is not standard of care for RPS; it is considered for selected histologies (primarily WDLPS) at high-volume sarcoma centers following multidisciplinary tumor board review. Document RT dose, completion date, and impact on tissue planes in the operative note. Modifier -22 applies when post-radiation planes substantially increase operative complexity.
Recurrent retroperitoneal sarcoma
Higher complexity due to obliterated surgical planes, prior radiation changes, and frequent dedifferentiation in recurrent WDLPS. Local recurrence rates for RPS are high (up to 50% at 5 years for WDLPS, more rapid for high-grade DDLPS). Document complexity, prior treatments, histologic grade at recurrence, and distinction from primary resection. Modifier -22 applies if substantially more complex than standard.
Charting Tips
- Document tumor size, location, and histologic subtype (WDLPS, DDLPS, leiomyosarcoma, etc.) — subtype drives prognosis, recurrence pattern, and systemic treatment decisions
- {'State resection margins': 'R0 (negative), R1 (microscopically positive), R2 (macroscopic residual) — R2 should be documented when it occurs'}
- {'Document the compartmental resection approach': 'which structures were removed en bloc and why (proximity, adherence, or planned compartmental clearance per TARPSWG principles) — this supports multivisceral resection billing and oncologic documentation'}
- {'Specify approach maneuver used': 'Cattell-Braasch (right-sided) or Mattox (left-sided) — never apply the wrong eponym to the wrong side'}
- Document retroperitoneal dissection planes (psoas, IVC/aorta, iliac vessels) and whether vessel wall was entered
- Orient specimen and mark relevant margins for pathology; label any areas of concern (R1 or close margin)
- Blood product use is common; document transfusions
Billing Tips
- Bill 49186-49190 for excision of retroperitoneal/intra-abdominal tumor (replaced deleted codes 49203-49205 effective 2025). Code selection is based on the sum of the maximum length of each tumor/cyst excised: 49186 sum <=5 cm (21.45 wRVU); 49187 5.1-10 cm (27.93 wRVU); 49188 10.1-20 cm (33.15 wRVU); 49189 20.1-30 cm (39.00 wRVU); 49190 >30 cm (48.75 wRVU). Retroperitoneal liposarcoma is typically large; most cases qualify for 49189 or 49190. Document tumor dimensions (measured in situ) in the operative note. 90-day global.
- En bloc resection of adjacent organs (kidney, colon, spleen) is separately billable alongside 49186-49190. Document every organ removed en bloc and the reasoning. Important: the CPT parenthetical note for 49186-49190 restricts their use when the tumor arises directly from a separately reportable organ or soft tissue. For retroperitoneal sarcoma arising from retroperitoneal soft tissue (not from the kidney or colon itself), simultaneous billing of 49186-49190 plus organ resection codes is the standard interpretation, but NCCI edits may apply to specific combinations — verify with your institutional coding team before submitting. Document that the sarcoma arose from retroperitoneal soft tissue, not from the adjacent organ, to support the claim.
- IVC involvement: CPT 35221 (direct repair, intra-abdominal vessel) and 35251 (with vein graft) are injury-repair codes and are not cleanly appropriate for planned oncologic IVC resection and reconstruction. For planned IVC resection with PTFE or allograft reconstruction as part of tumor removal, many centers use 37799 (unlisted vascular surgery procedure) with a comparison code letter and operative note, billed with vascular surgery. Consult vascular surgery billing for the reconstruction component. Modifier -22 (increased complexity) is appropriate for post-radiation tissue planes, encased vessels, or multi-organ resection requiring substantially greater work — document the specific factors that increased complexity.
- 90-day global: drain management, wound care, and routine follow-up are bundled. Recurrence surgery within 90 days uses modifier -78 (unlikely given biology, but documented for completeness).
- Preoperative radiation (neoadjuvant RT) does not affect the surgical CPT coding but should be documented. It affects operative complexity, tissue planes, and risk.
General coding reference. Verify with your institution’s billing department before submitting claims.