Transplant Nephrectomy (Failed Allograft)
5037050360wRVU: 38.88 — Re-transplant at same session (if performed)
Failed renal allograft, [right / left] iliac fossa: [chronic rejection / primary non-function / renal vein thrombosis / chronic allograft nephropathy / recurrent disease]
Same
Transplant nephrectomy, [right / left] iliac fossa, [intracapsular / extracapsular] technique
[Attending name], MD
[Fellow/Resident name]
General endotracheal
Patient presents with failed renal allograft secondary to [chronic rejection / primary non-function / thrombosis / recurrent disease], transplanted [date]. Currently on [hemodialysis / peritoneal dialysis]. [Symptomatic allograft: fevers, pain, hematuria / Asymptomatic but immunosuppression withdrawn.] Decision made to proceed with allograft nephrectomy. Risks including bleeding from collateral vessels and scarred dissection plane, ureteral injury, vascular injury, infection, and prolonged operative time discussed. Consent obtained.
Failed allograft [small and fibrotic / enlarged and necrotic / phlegmonous]. Dissection plane [relatively straightforward / densely scarred / required intracapsular technique due to adherent retroperitoneal fibrosis]. Hilar vessels [easily controlled / required careful dissection from scarred retroperitoneum].
The patient was positioned supine. The prior [right / left] iliac fossa transplant incision was reopened [/ extended]. Retroperitoneal dissection was carried down to the allograft.
[INTRACAPSULAR TECHNIQUE:] The renal capsule was incised and the kidney removed intracapsularly, leaving the capsule and perirenal scar tissue in place. The renal artery and vein stumps were identified within the capsule, suture-ligated with [0-silk / 2-0 Prolene], and divided.
[EXTRACAPSULAR TECHNIQUE:] The kidney was dissected free in the extracapsular plane. Dense adhesions [encountered and carefully lysed]. The renal artery was doubly ligated with [0-silk] ties and divided. The renal vein was similarly suture-ligated and divided. The ureter was ligated and divided proximally.
The allograft was removed and sent to pathology. Hemostasis confirmed. The wound was irrigated copiously. [A closed-suction drain was placed.] Fascia closed with running [0-PDS]. Skin closed with staples. Patient tolerated the procedure well.
None
Failed allograft to pathology
[X] mL
[Closed-suction drain / None]
Patient taken to recovery in stable condition. Admitted for monitoring.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Failed renal allograft, [right / left] iliac fossa: [chronic rejection / primary non-function / thrombosis]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Transplant nephrectomy, [right / left] iliac fossa, [intracapsular / extracapsular] technique
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with failed renal allograft secondary to *** (transplanted ***). Currently on hemodialysis. [Symptomatic: fevers, allograft pain, hematuria.] Risks including hemorrhage from scarred dissection plane, vascular injury, and prolonged dissection discussed. Informed consent obtained.
FINDINGS: Failed allograft [small and fibrotic / enlarged / necrotic]. Dissection [straightforward / densely scarred; intracapsular technique required]. Hilar vessels identified and controlled.
DESCRIPTION OF PROCEDURE:
Patient supine. Prior [right / left] iliac fossa incision reopened. Retroperitoneum entered. [INTRACAPSULAR: Capsule incised; kidney removed intracapsularly; renal artery and vein stumps suture-ligated within capsule.] [EXTRACAPSULAR: Kidney freed in extracapsular plane; adhesions lysed; renal artery doubly ligated and divided; renal vein suture-ligated and divided; ureter ligated and divided.] Allograft removed and sent to pathology. Hemostasis confirmed. Wound irrigated. [Drain placed.] Fascia closed with 0-PDS; skin with staples. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Failed allograft to pathology
COMPLICATIONS: None
DRAINS: [Closed-suction drain / None]
DISPOSITION: Patient to recovery. Admitted for monitoring.
Signed: .ME, .MYDEGREE
.TODAYVariants
Early nephrectomy (within 90-day global, modifier -78)
Append modifier -78 to 50370 if within 90-day global of original transplant. Document complication necessitating return to OR. Payment is reduced.
Concurrent re-transplant
If re-transplanting at same session, bill 50370 + 50360. Place new allograft in contralateral iliac fossa whenever possible to avoid operating in the scarred field of the failed graft.
Charting Tips
- Document indication for nephrectomy (chronic rejection, primary non-function, infection, thrombosis)
- State technique (intracapsular vs. extracapsular) and rationale
- Note extent of adhesions/scarring encountered and management
- Document hilar vessel control technique (suture ligation vs. stapled division)
- If within 90-day global of original transplant, modifier -78 is required. Flag for billing team.
Billing Tips
- Bill 50370 for removal of a transplanted renal allograft (16.40 wRVU, 90-day global). This code applies whether the nephrectomy is performed for chronic rejection, primary non-function, infection, or thrombosis. Document the indication clearly.
- If the transplant nephrectomy is performed within the 90-day global period of the original transplant (50360), modifier -78 (return to OR for related complication) is required. This significantly reduces payment. Document the complication that necessitated early return.
- Concurrent ipsilateral re-transplantation at the same session is separately billable with 50360. Document both procedures and time each separately.
- Intracapsular vs. extracapsular dissection technique affects operative complexity and blood loss but does not change the CPT code. Document technique used and rationale. Intracapsular is faster and less bloody; extracapsular is required for infection or to clear the field for re-transplant.
- 0-day global does not apply here. The 90-day global from 50370 covers postoperative wound care and follow-up.