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Biopsy of urethra

CPT4 code

Name of the Procedure:

Biopsy of the Urethra

Summary

A biopsy of the urethra involves removing a small tissue sample from the urethra (the tube that carries urine out of the body) for examination under a microscope. This helps diagnose or rule out various medical conditions.

Purpose

A urethral biopsy is performed to:

  • Diagnose inflammatory conditions, infections, or cancers of the urethra.
  • Investigate abnormal growths or lesions.
  • Determine the cause of urethral strictures (narrowing) or other abnormalities.

The goal is to identify the underlying issue so appropriate treatment can be started.

Indications

  • Persistent urethral pain or discomfort.
  • Unexplained bleeding from the urethra.
  • Abnormal findings from imaging tests.
  • Presence of lumps, bumps, or ulcerations in the urethra.
  • Diagnostic requirement for conditions such as urethral cancer.

Preparation

  • Patients may be asked to fast for several hours before the procedure.
  • Certain medications may need to be adjusted or stopped, such as blood thinners.
  • A urine sample may be required, and a full medical history will be reviewed.
  • Pre-procedure tests, such as urinalysis or imaging, might be conducted.

Procedure Description

  1. The patient is positioned appropriately, usually in a lithotomy position.
  2. Local anesthesia or sedation may be administered to minimize discomfort.
  3. The urethral opening is cleaned, and a sterile drape is placed.
  4. A cystoscope (a thin tube with a camera) may be used to visualize the urethra.
  5. Biopsy forceps or a small cutting instrument is used to remove a tissue sample.
  6. The tissue sample is sent to a laboratory for analysis.

Duration

The procedure typically takes 15-30 minutes.

Setting

Performed in outpatient clinics, hospital's procedure rooms, or surgical centers.

Personnel

  • Urologist or surgeon
  • Medical assistant
  • Nurse
  • Anesthesiologist, if sedation is used

Risks and Complications

  • Bleeding at the biopsy site
  • Infection
  • Pain or discomfort post-procedure
  • Urethral stricture development
  • Adverse reactions to anesthesia, if used

Benefits

  • Accurate diagnosis of underlying urethral conditions.
  • Informative biopsy results typically available within a few days.
  • Enables targeted treatment planning for better outcomes.

Recovery

  • Mild discomfort or spotting may occur for a few days.
  • Patients are usually advised to avoid strenuous activity for about 24-48 hours.
  • Follow-up appointments to discuss biopsy results and next steps.
  • Patients may be instructed on detailed hygiene and care practices to avoid infection.

Alternatives

  • Watchful waiting with regular monitoring might be an option in some cases.
  • Imaging tests (like MRI or CT scans) instead of direct biopsy.
  • Non-invasive urine tests for certain conditions.
  • The choice of an alternative depends on the individual's condition and expected outcomes.

Patient Experience

  • Some discomfort or pressure during the procedure.
  • Mild, manageable pain post-procedure with over-the-counter pain relief.
  • Detailed post-procedure and pain management instructions provided for a better recovery experience.

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