Ureteral Reimplantation (Ureteroneocystostomy)

CPT 50780 · 19.45 wRVU · 90-day global

CPT50780

wRVU19.45

Global90-day

ApproachOpen

ComplexityComplex

Add-on / Variant CPTs

50785 wRVU: 21.67 — Ureteroneocystostomy with vesico-psoas hitch or bladder flap (21.67 wRVU, 90-day global); use for psoas hitch or Boari flap technique
50783 wRVU: 20.18 — Ureteroneocystostomy with extensive ureteral tailoring/tapering (20.18 wRVU, 90-day global); use for megaureter requiring excisional or plication tapering — NOT for 'extensive dissection'
50782 wRVU: 19.17 — Ureteroneocystostomy, anastomosis of duplicated ureter to bladder (19.17 wRVU, 90-day global); use for duplex collecting system/ureteral duplication — NOT for Boari flap
50947 wRVU: 25.14 — Laparoscopic/robotic ureteroneocystostomy with cystoscopy and ureteral stent placement (25.14 wRVU, 90-day global); DJ stent bundled — do not add 52332
50948 wRVU: 23.22 — Laparoscopic/robotic ureteroneocystostomy without cystoscopy/stent (23.22 wRVU, 90-day global)

Preoperative Diagnosis:

Right [left] distal ureteral [stricture / injury / iatrogenic division / vesicoureteral reflux grade III-V], requiring ureteral reimplantation

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] ureteroneocystostomy [with psoas hitch / Boari flap / direct reimplant], [open / laparoscopic / robotic], [Lich-Gregoir extravesical / Cohen cross-trigonal intravesical / Politano-Leadbetter intravesical] anti-reflux technique

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal

Indications:

[ADULT / INJURY / STRICTURE:]
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 is [X] cm in length. Direct repair was not feasible given [defect length / distal ureteral quality]. Ureteral reimplantation [with psoas hitch] planned.

[PEDIATRIC VUR:]
The patient is a [age]-year-old [male/female] with [right / left / bilateral] vesicoureteral reflux, Grade [III / IV / V], confirmed on voiding cystourethrogram. [Breakthrough febrile UTI on continuous antibiotic prophylaxis (CAP). / Renal cortical scarring on DMSA scan. / Grade V VUR — surgical threshold per AUA guideline.] [Failure of antibiotic prophylaxis after adequate trial.] Risks including ureteral obstruction, persistent reflux, need for reoperation, and anesthetic risks discussed. Consent obtained.

Findings:

The right [left] ureter was identified and traced to the level of the injury/stricture at [X] cm from the bladder. The ureteral defect was [X] cm. The proximal ureteral end was healthy with adequate caliber and visible peristalsis. The bladder [was mobile and could reach the ureter with psoas hitch / required Boari flap given [X]-cm defect that exceeded psoas hitch reach]. Anti-reflux tunnel of [X] cm constructed (5:1 tunnel-to-ureter diameter ratio per Paquin's rule).

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, preserving the periureteral tissue to protect the ureteral blood supply.

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. Ureteral caliber and patency confirmed with a [5 Fr] feeding tube.

[PSOAS HITCH:]
The bladder was mobilized by dividing the contralateral superior vesical pedicle. The bladder was brought toward the ureter. [The psoas minor tendon was identified — present / absent.] The bladder was secured to [the psoas minor tendon (when present) / the psoas major muscle — longitudinal sutures parallel to the muscle fibers, avoiding deep or lateral bites to protect the genitofemoral nerve on the anterior surface of the psoas and the femoral nerve within the psoas muscle] with [2] non-absorbable [2-0 Prolene] sutures, bringing the bladder [4-6] cm toward the ureter.

[LICH-GREGOIR EXTRAVESICAL TECHNIQUE:]
The bladder was not opened. The detrusor muscle was incised longitudinally for [3-4] cm on the posterolateral bladder wall to create a detrusor trough, leaving the bladder mucosa intact (mucosa not entered / a small mucosal opening was made at the distal end only). The ureter was laid in the trough. The detrusor was closed over the ureter with [2-0 Vicryl], creating a submucosal tunnel of [X] cm (5:1 ratio to ureteral diameter of [X] mm — anti-reflux mechanism). The ureterovesical anastomosis was completed at the distal end.

[COHEN CROSS-TRIGONAL INTRAVESICAL TECHNIQUE (pediatric VUR):]
A [3-4]-cm cystotomy was made. The intravesical ureter was dissected free of the trigone for [X] cm. A submucosal tunnel was created across the trigone toward the contralateral side. The ureter was pulled through the tunnel submucosally, with tunnel length [X] cm (5:1 tunnel-to-ureter diameter ratio per Paquin's rule). The ureterovesical anastomosis was constructed with [5-0 Vicryl] interrupted sutures.

[POLITANO-LEADBETTER INTRAVESICAL TECHNIQUE:]
Cystotomy made. A new hiatus was created superolateral to the original orifice. The ureter was rerouted through the new hiatus and a submucosal tunnel of [X] cm was created (5:1 ratio). Anastomosis completed with [5-0 Vicryl].

A [6 Fr × 22-26 cm] DJ stent was placed [antegrade / retrograde]. [For pediatric patients: [4.7 Fr × 12-16 cm] DJ stent.]

[Cystotomy 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 [Fr × cm], [19 Fr] pelvic drain, [16 Fr] urethral catheter

Disposition:

The patient was taken to the PACU in stable condition. Drain removed when output less than 50 mL/day with drain creatinine confirming non-urinary fluid. Urethral catheter removed at [5-7 days]. DJ stent removed cystoscopically at [6 weeks].

Epic SmartPhrase Version

PREOPERATIVE DIAGNOSIS: Right/Left ureteral ***, requiring reimplantation
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left ureteroneocystostomy [with psoas hitch / Boari flap / direct] — [extravesical Lich-Gregoir / intravesical Cohen / Politano-Leadbetter]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General

INDICATIONS: .PTAGE-year-old .PTSEX with right/left ureteral *** (stricture/injury/VUR grade ***). Defect *** cm. [Breakthrough febrile UTIs on CAP / renal scarring on DMSA.] Consent obtained.

FINDINGS: Ureter transected *** cm above injury. Proximal end viable, adequate caliber. Bladder mobile/***. Anti-reflux tunnel *** cm (5:1 ratio to ureteral diameter *** mm).

PROCEDURE:
Supine. *** incision. Retroperitoneum entered. Ureter dissected to injury, periureteral tissue preserved. Transected *** cm above normal tissue. Spatulated *** cm. [Psoas hitch: contralateral superior vesical pedicle divided; psoas [tendon/major muscle] secured with 2 x 2-0 Prolene; genitofemoral nerve avoided.] [Lich-Gregoir: detrusor trough *** cm; mucosa intact; ureter laid in trough; detrusor closed over ureter; tunnel *** cm (5:1).] [Cohen: cystotomy; submucosal tunnel across trigone *** cm (5:1); ureter pulled through; anastomosis 5-0 Vicryl.] DJ stent *** Fr x *** cm 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 (CPT 50785)

For defects of 10-15 cm that cannot be bridged by psoas hitch alone. A bladder flap is outlined anteriorly based on a posterior pedicle with superior vesical artery supply. Critical: flap length-to-width ratio must not exceed 3:1 to prevent ischemic necrosis of the flap tip. The flap is tubularized over a stent with running [3-0 Vicryl] to form a neo-ureter. The proximal end is anastomosed end-to-end to the native ureter with [5-0 Vicryl]. Boari flaps can bridge defects up to 15 cm; for defects >15 cm, consider ileal ureter interposition or renal autotransplantation. CPT 50785 (21.67 wRVU).

Robotic/laparoscopic ureteroneocystostomy (CPT 50947/50948)

CPT 50947 (25.14 wRVU, 90-day global) when DJ stent placed via cystoscopy at the same session. CPT 50948 (23.22 wRVU) when stent placed antegrade or not placed. Both codes apply regardless of patient age or robotic vs. standard laparoscopic approach. Open codes (50780-50785) should not be applied to laparoscopic/robotic cases. Document port configuration, extravesical vs. intravesical technique, anti-reflux tunnel length, and stent placement.

Pediatric VUR — Cohen cross-trigonal (intravesical, open)

Most common open pediatric intravesical technique for bilateral VUR. Both ureters can be reimplanted through a single cystotomy by crossing each ureter across the trigone to the contralateral side. Published success rates approximately 98%. Ideal for bilateral VUR or when extravesical approach risks ureteral devascularization. Limitations: requires intravesical dissection (post-op hematuria, spasm), and retrograde catheterization may be difficult post-op (crossed ureters). Document bilateral tunnel length and 5:1 ratio on each side.

Megaureter tapering (CPT 50783)

For primary obstructive or refluxing megaureter where the dilated ureter is too large for an effective anti-reflux tunnel (typically >1 cm diameter). Two techniques: excisional tailoring (Hendren) — longitudinal strip of ureter excised and closed over a stent; or imbrication/plication (Starr) — excess wall folded inward and plicated. Taper to approximately 10-12 Fr for adequate 5:1 tunnel ratio. CPT 50783 (extensive ureteral tailoring, 20.18 wRVU). Document pre-taper ureteral diameter, technique used, and post-taper caliber.

Charting Tips

Document anti-reflux tunnel length and ratio. Paquin's 5:1 rule (tunnel length to ureteral diameter) is the established teaching standard. Measure tunnel length and ureteral diameter; document: 'submucosal tunnel of [X] cm created; ureteral diameter [X] mm; 5:1 tunnel-to-ureter ratio achieved.' Recent evidence suggests 3-4:1 may be adequate but 5:1 remains the board and teaching standard.
Document psoas hitch suture placement with nerve anatomy note. The psoas minor tendon is absent unilaterally in approximately 65% of patients. Document: 'psoas minor tendon [present and used / absent]; sutures placed [in psoas minor tendon / longitudinally through psoas major muscle parallel to fibers, avoiding deep/lateral bites to protect the genitofemoral nerve on the anterior surface and femoral nerve within the psoas].'
Document preservation of periureteral tissue and ureteral blood supply. The ureter derives its blood supply from segmental branches running in the periureteral adventitia — stripping this tissue causes ischemia and stricture. Document: 'ureter dissected with periureteral tissue preserved to maintain blood supply.'
Document drain creatinine before removal. Elevated drain creatinine (>2x serum creatinine) indicates anastomotic leak/urinoma. Document: 'drain output [X] mL, creatinine [X] — consistent with serosanguinous (non-urinary) fluid; drain removed.'
For pediatric VUR: document VUR grade (per VCUG), laterality, prior CAP trial and duration, breakthrough febrile UTI history, and DMSA findings (renal scarring). These establish surgical indication for insurers and are required for medical necessity documentation.

Billing Tips

50780 (ureteroneocystostomy, anastomosis of single ureter to bladder, 19.45 wRVU, 90-day global) is the primary code for standard ureteral reimplantation of a single non-duplicated ureter. Select the code tier based on anatomic complexity: 50780 (single ureter, standard reimplant), 50782 (anastomosis of duplicated ureter to bladder — for duplex collecting systems/ureteral duplication anomalies, 19.17 wRVU), 50783 (with extensive ureteral tailoring/tapering — for megaureter requiring excisional or plication tapering, 20.18 wRVU), 50785 (with vesico-psoas hitch or bladder flap, 21.67 wRVU — use when psoas hitch or Boari flap is required to bridge a ureteral defect).
50782 is for duplicated (duplex) ureter anastomosis — it is NOT the code for Boari flap. 50783 is for extensive ureteral tailoring/tapering (remodeling of a dilated megaureter) — it is NOT for 'extensive dissection.' 50785 is the correct code for psoas hitch and Boari flap. Selecting 50782 or 50783 for wrong indications is a billing error.
Laparoscopic/robotic ureteroneocystostomy: 50947 (laparoscopy, surgical ureteroneocystostomy with cystoscopy and ureteral stent placement, 25.14 wRVU, 90-day global) when a DJ stent is placed via cystoscopy at the same session. 50948 (without cystoscopy and stent placement, 23.22 wRVU) when the stent is placed antegrade or not placed. Per CPT, 52332 (ureteral stent placement) is included in 50947 and cannot be separately billed. Use the open codes (50780-50785) for open surgery only — laparoscopic/robotic cases use 50947 or 50948 regardless of patient age.
Bilateral reimplantation at the same session: bill each side separately with modifier -RT and -LT on two separate claim lines. The higher-valued side is paid at 100%; the lower-valued side is subject to the multiple-procedure reduction (typically 50% by Medicare). Do not mix modifier -50 (bilateral) with -RT/-LT billing; choose one convention per payer requirements.
Ureteral stent placement (52332, 2.75 wRVU) is NCCI-bundled with the open ureteroneocystostomy codes (50780-50785) when performed at the same session through the same approach. Document stent size, type, and that it was placed — but do not submit 52332 as a separate code with the open codes unless it was performed at a distinct separate cystoscopy.
Global period is 90 days. Post-op stent removal at cystoscopy, urogram, and routine follow-up are bundled. The stent removal cystoscopy after 90 days is separately billable.

General coding reference. Verify with your institution’s billing department before submitting claims.

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