Open Nephrectomy
5022050225wRVU: 21.33 — Open nephrectomy, complicated (prior surgery, adhesions, large tumor)50230wRVU: 23.21 — Open radical nephrectomy with regional lymph node dissection (23.21 wRVU)50240wRVU: 23.6 — Open partial nephrectomy
Right [left] [non-functioning kidney / renal cell carcinoma / chronic pyelonephritis / renovascular hypertension / ureteral obstruction with renal atrophy]
Same
Right [left] open [simple / radical] nephrectomy via [flank / transperitoneal] approach
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with [indication] of the right [left] kidney presenting for open nephrectomy. [Preoperative imaging demonstrated a [X]-cm [mass / non-functioning kidney / hydronephrotic kidney].] Contralateral kidney function was [adequate on split renal function study / normal on imaging]. The risks, benefits, and alternatives were discussed and informed consent was obtained.
The [right / left] kidney measured approximately [X] cm and was [mobile / adherent to surrounding retroperitoneal structures / surrounded by perinephric fat stranding]. [A mass was identified at the [upper / lower / mid] pole measuring [X] cm.] The renal hilum was [well-defined / with enlarged hilar lymph nodes]. The adrenal gland was [separate and preserved / adherent and removed en bloc]. The ureter was identified and divided at [the level of the iliac vessels / pelvic brim].
[FLANK APPROACH:]
The patient was positioned in the lateral decubitus position with the operative side up and the table flexed at the waist to open the space between the iliac crest and the costal margin. A flank incision was made [over the 11th rib / between the 11th and 12th ribs / over the 12th rib]. The rib was [resected / preserved with periosteal dissection]. The retroperitoneal space was entered by incising the transversalis fascia and lumbodorsal fascia. Care was taken to avoid the peritoneum anteriorly. The retroperitoneal fat was swept anteriorly to expose Gerota's fascia.
Gerota's fascia was incised. The kidney was mobilized within its fascial envelope. [For radical nephrectomy: the kidney and perinephric fat were mobilized as a unit within Gerota's fascia.] [For simple nephrectomy: the kidney was mobilized within Gerota's fascia and the perinephric fat was left in the retroperitoneum.]
[RIGHT SIDE:] The renal hilum was dissected. The renal artery was identified posterior and superior to the renal vein. The renal artery was doubly ligated with [0-silk ties] and divided. The renal vein was then ligated and divided.
[LEFT SIDE:] The renal hilum was dissected. The gonadal vein draining into the left renal vein was ligated and divided. The adrenal vein was [identified and preserved / ligated and divided for adrenalectomy]. The renal artery was ligated and divided posterior to the vein. The renal vein was then ligated and divided.
The ureter was identified in the retroperitoneum, doubly clipped, and divided distally at [the level of the iliac vessels / pelvic brim]. The kidney was removed from the retroperitoneal space. Hemostasis was confirmed.
The wound was irrigated. The lumbodorsal fascia and transversalis fascia were closed with [0-PDS]. [The rib periosteum was approximated with absorbable sutures.] The muscle layers were closed in sequence with [0-Vicryl]. The subcutaneous tissue was closed with [3-0 Vicryl]. The skin was closed with [staples / 4-0 Monocryl].
None
Right [left] kidney [with perinephric fat] sent to pathology. [Adrenal gland sent separately.]
[X] mL
None / [Jackson-Pratt drain in renal fossa]
The patient was taken to the PACU in stable condition. Ambulation was initiated on postoperative day 1. Diet was advanced as tolerated.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left open [simple/radical] nephrectomy, flank/transperitoneal approach
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General
INDICATIONS: .PTAGE-year-old .PTSEX with *** kidney, ***. Contralateral function ***. Consent obtained.
FINDINGS: Kidney *** cm, ***. Hilum ***. Adrenal ***. Mass: ***.
PROCEDURE:
Lateral decubitus, *** up, table flexed. Flank incision over ***. Retroperitoneum entered. Peritoneum avoided. Gerota's fascia incised. Kidney mobilized [within Gerota's for radical / within fascia for simple]. Renal artery identified posterior to vein, doubly ligated and divided. Renal vein ligated and divided. [Left: gonadal vein ligated; adrenal vein ***.] Ureter clipped and divided at iliac vessels. Kidney removed. Hemostasis confirmed. Wound irrigated. Fascia closed in layers.
EBL: *** mL
SPECIMENS: Kidney [+ adrenal] to pathology
COMPLICATIONS: None
DISPOSITION: PACU stable. Ambulate POD 1.
Signed: .ME, .MYDEGREE
.TODAYVariants
Transperitoneal Approach
A transperitoneal approach was used given [large tumor / prior retroperitoneal surgery / need for simultaneous intraabdominal procedure]. A midline or subcostal incision was made. The colon was reflected medially by incising the white line of Toldt. [Right: the duodenum was mobilized (Kocher maneuver) to expose the IVC and right renal hilum.] [Left: the descending colon was reflected medially; the spleen was mobilized as needed.] The renal hilum was identified and the vessels were ligated as described above. The kidney was mobilized and removed within Gerota's fascia.
Living Donor Nephrectomy
Open donor nephrectomy was performed for living related [unrelated] kidney transplantation. The left kidney was preferred given the longer renal vein. The renal artery was divided close to its aortic origin. The renal vein was divided at the IVC with a vascular stapler to maximize vein length. Cold ischemia was initiated immediately upon extraction; the kidney was flushed with [University of Wisconsin / HTK] preservation solution on the back table and transferred to the transplant team. Warm ischemia time: [X] minutes.
Charting Tips
- Document the dissection plane: simple vs radical nephrectomy is defined by the dissection plane — perinephric (within Gerota's fascia, kidney removed with surrounding fat) vs. perifascial (outside Gerota's). This determines the correct CPT code and is an oncologic distinction for renal cell carcinoma.
- Document artery-before-vein sequence. The renal artery must be ligated before the vein to prevent venous engorgement, renal swelling, and increased bleeding. Document 'renal artery was identified and divided before the renal vein' explicitly.
- Document contralateral kidney assessment. Preoperative split renal function study (nuclear medicine GFR) results should be referenced. For a solitary kidney or bilateral disease, document the preoperative GFR and the decision-making process.
- For flank approach with rib resection, document whether the rib was resected or preserved. Rib resection provides better exposure but adds morbidity (intercostal neuralgia); document the reason for your choice and the rib level.
Billing Tips
- Open simple nephrectomy: 50220 (18.21 wRVU, 90-day global). Use for benign or non-oncologic indications (non-functioning kidney, renovascular hypertension, donor nephrectomy) where the dissection is perinephric and the adrenal is spared.
- Open complex nephrectomy: 50225 (21.33 wRVU). Use when prior ipsilateral renal surgery, prior retroperitoneal surgery, dense adhesions, or a large inflammatory mass significantly increases operative difficulty. Document the specific complicating factors; modifier -22 alone is insufficient without a separate procedure code.
- Open radical nephrectomy with regional lymphadenectomy: 50230 (23.21 wRVU). Use when a lymph node dissection is performed as part of an oncologic resection. Document the template of dissection and the stations included.
- Adrenalectomy performed en bloc is separately billable (60540 open adrenalectomy, 13.89 wRVU) with modifier -51. Document that ipsilateral adrenalectomy was performed and the indication (adjacent tumor, direct invasion, or adrenal mass).
- Nephroureterectomy for upper tract urothelial carcinoma uses distinct codes: 50220 is not appropriate. Use 50548 (laparoscopic nephroureterectomy) or 50236 (open) when the ureter and bladder cuff are removed. Document extent of ureteral excision.