Urinary Incontinence Treatment After Prostate Surgery (CPT)

an image of prostate cancer
Prostate cancer

When a male patient is diagnosed with prostate cancer and undergoes a radical prostatectomy, he may develop urinary incontinence. This can be a devastating and emotional experience for the patient. The incontinence is caused by the treatment of the prostate and is predictable and possibly preventable. Generally, the incontinence improves within 12 months following surgery. However, if it persists past that timeframe, treatment may be necessary to help correct or reduce the loss of involuntary urine.

Fast Facts About Prostate Cancer

  • Prostate cancer is the most common type of cancer in men, with around 60% of diagnosed cases in men being 65 or older. 
  • The most common treatment for prostate cancer confined to the prostate is a radical prostatectomy. This procedure involves the removal of the prostate and seminal vesicles. 
  • Urinary incontinence is one of the major complications of radical prostatectomy, with about 10-15% of men reporting frequent leakage or no control six months after treatment.   
  • Long-lasting incontinence occurs in about 6 to 8% of men who have had their prostate removed.  

How a Prostatectomy Affects Urination

Typically, urine is emptied into the bladder from the kidneys. Two valves called sphincters keep the urine inside the body by remaining closed until the body sends a signal to open them.

When a patient has his prostate completely removed, the surgeon has to remove the prostate gland and one of the sphincters outside the prostate. Having only one sphincter is not usually a problem. Other times, it can affect the nerves and muscles from the surgery and result in urine leakage.      

Risk Factors For Urinary Incontinence

Factors that put a person at risk of incontinence after prostate treatment include advanced patient age, larger prostate size, and a shorter membranous urethral length based on an MRI.  

Evaluation of Incontinence

After prostate treatment, the physician should evaluate the patient with incontinence. A history, physical exam, and diagnostic tests are performed to determine the type and severity of incontinence, its progression or resolution, and the degree to which it bothers the patient. 

The physician should question the patient as to which activities cause the incontinence. This helps determine if it is stress urinary incontinence due to intrinsic sphincter deficiency (ISD), urge incontinence due to bladder dysfunction, or both. Intrinsic sphincter deficiency (ISD) is the most common cause of incontinence after prostate treatment and is likely a direct result of the surgery.  

Before surgical intervention, a physician may perform a urodynamic study to assess the urinary tract function and a 24-hour pad test to determine how many pads are used and the amount of urine leaked. In addition, the physician may perform a cystourethroscopy to assess the patient’s urethra and bladder.   

Types of Urinary Incontinence After Prostate Treatment

The four main types of urinary incontinence after prostate treatment (IPT) include stress, urge, mixed, and overflow: 

  • After prostate surgery, stress urinary incontinence (SUI) is the most common type and involves urine leakage when coughing, laughing, sneezing, or exercising. It is not related to mental stress. The cause is usually a problem with the valve that keeps urine in the bladder sphincter. 
  • Urge urinary incontinence (UUI) is a sudden need to urinate. 
  • Mixed urinary incontinence is a combination of SUI and UUI.
  • Overflow urinary incontinence occurs when there is a problem emptying the bladder.

Treatment of Urinary Incontinence

Before and immediately following a radical prostatectomy, physicians recommend behavioral modification, a practitioner-guided pelvic floor muscle training program or home exercise program, and pads/diapers/penile clamps/condom catheters to enhance continence recovery. A pelvic floor muscle training program or exercises can also be effective at any point postoperatively. 

If urinary incontinence is bothersome after prostate treatment and conservative therapy is not successful, surgery may be considered as early as six months later. 

Surgical Options and CPT Coding

The surgical options for incontinence after prostate treatment (IPT) include an artificial urinary sphincter (AUS) device, male sling, and periurethral balloon. A urologist or urologic oncologist usually performs these procedures. They are done on an outpatient basis or with an overnight hospital stay.

Artificial Urinary Sphincter (AUS) Device

This three-part implanted device consists of an inflatable cuff/ring around the urethra, a saline-filled balloon next to the bladder, and a scrotal pump. The procedure is typically performed under general anesthesia, and a catheter is inserted to make sure the bladder remains empty during surgery. A perineal incision is made to place the cuff. An inguinal incision is then made to place the balloon and the scrotal pump. When the scrotal pump is manually compressed, the cuff opens and automatically closes after two to three minutes. The device works much like the patient’s own sphincter.

The single cuff perineal approach is the preferred method. There is also a dual/tandem cuff placement using a transverse scrotal incision, but it increases the risk of complications.

The AUS system is the most reliable and predictable treatment for SUI after prostate treatment. It can successfully treat all degrees of urine leakage and lasts for about seven years. 

CPT Codes for AUS Device

Insertion, removal and/or replacement, and repair of an artificial urinary sphincter system are reported with CPT codes 53444-53449.  

  • 53444, Insertion of tandem cuff (dual cuff)
  • 53445, Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff
  • 53446, Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff 
  • 53447, Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session
  • 53448, Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session, including irrigation and debridement of infected tissue
  • 53449, Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff

CPT code 53445 (Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff) is reported most often.

When a previously inserted AUS system fails, a tandem cuff may need to be inserted to replace the original cuff. When this occurs, 53444 [(Insertion of tandem cuff (dual cuff)] should be assigned. 

AUS Coding Example

A 65-year-old male presents with an AUS device for urinary incontinence after a previous radical prostatectomy. The device is 15 years old and is no longer working correctly. The device is removed and replaced with a new system. Assign for CPT.

53447, Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session

Male Sling

The surgeon uses a synthetic mesh-like tape as a supportive sling. An incision is made through the perineal tissue (area between scrotum and anus) to expose the urethra. The sling is then wrapped around part of the urethral bulb that covers the upper part of the urethra near where it enters the area of the urethral sphincter. The purpose of wrapping the sling around the urethral bulb is to relocate the urethra and increase resistance in this area gently. Once the sling is in place, the perineum is closed with absorbable sutures. 

There are three types of male slings available: 

  • A Transobturator sling is a noncompressive sling that relocates the proximal urethra closer to the sphincter complex. It also lengthens the membranous urethra. 
  • Quadratic sling relocates the proximal urethra and compresses the ventral urethra. 
  • Adjustable sling is not currently used in the U.S. However, it can be altered to optimize continence or prevent the retention of urine. 

Another type of sling, the bone-anchored sling, has fallen out of favor due to the risk of osteomyelitis.  

The male sling has been successful in mild to moderate stress urinary incontinence cases after radical prostatectomy. It is not recommended for individuals who have undergone radiation as part of their prostate treatment. 

Since it is not major surgery, the recovery time is short. Complications of the sling procedure are rare. However, the sling may need to be removed or revised when the inability to urinate or another complication develops.  

CPT Codes for Sling Procedure

Placement and removal or revision of a sling for male urinary incontinence are reported with CPT codes 53440 and 53442.  

  • 53440, Sling operation for correction of male urinary incontinence (e.g., fascia or synthetic) 
  • 53442, Removal or revision of sling for male urinary incontinence (e.g., fascia or synthetic)

Do not confuse these codes with the sling procedure codes for female urinary incontinence (57287, 57288, 51992, and 53500). 

Sling Coding Example

A male patient presents to the urologist’s office with complaints of stress urinary incontinence. Three years ago, the patient was diagnosed with prostate cancer and had a radical prostatectomy. The physician performs a sling operation using synthetic materials to support the urinary sphincter and to allow it to function properly. Assign for CPT.

53440, Sling operation for correction of male urinary incontinence (e.g., fascia or synthetic) 

Adjustable Balloon Device

Periurethral adjustable balloon placement is a minimally invasive procedure performed in patients with stress urinary incontinence. Two silicone balloons are placed near the bladder neck to compress the prostate externally. First, the bladder is filled with contrast to give the bladder and bladder neck an opaque appearance. The balloons are positioned distal to the bladder neck and passed percutaneously through the perineum. This procedure is performed under fluoroscopic guidance or transrectal ultrasound guidance. Ports connected to the balloons are buried superficially. This allows for balloon volume adjustment as needed.

This procedure is performed to treat male intrinsic sphincter deficiency after a radical prostatectomy and may be recommended in cases of mild stress urinary incontinence. There have also been reports to indicate that this procedure is effective in moderate to severe cases of stress urinary incontinence after a radical prostatectomy. Individuals who have undergone radiation are not good candidates for the balloon procedure due to an increased risk of balloon migration and fibrosis.   

CPT Codes for Adjustable Balloon Device

Insertion (unilateral and bilateral), removal, and adjustment of periurethral transperineal adjustable balloon continence device (ProACT) is reported with CPT codes 53451-53454. These codes replaced the four Category III codes 0548T, 0549T, 0550T, and O551T on January 1. 

  • 53451, Periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance [ProACT System]
  • 53452, Periurethral transperineal adjustable balloon continence device; unilateral insertion, including cystourethroscopy and imaging guidance [ProACT System]
  • 53453, Periurethral transperineal adjustable balloon continence device; removal, each balloon [ProACT System]
  • 53454, Periurethral transperineal adjustable balloon continence device; percutaneous adjustment of balloon(s) fluid volume [ProACT System]

Adjustable Balloon Device Coding Example

A patient with intrinsic sphincter deficiency and stress incontinence previously had a unilateral ProACT continence device inserted. Today the device is removed due to a mechanical breakdown of the implant. Assign for CPT.

53453, Periurethral transperineal adjustable balloon continence device; removal, each balloon [ProACT System]

As always, be sure to assign the appropriate ICD-10-CM codes to justify the services provided as medically necessary. 


I wrote the above article for BC Advantage (billing-coding.com) under the title “Staying Dry After Prostate Surgery.” It was recently published in their magazine and is being reprinted here with their permission. 

References

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