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Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach

CPT4 code

Name of the Procedure:

Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach

Summary

The procedure involves the drainage of one or more cysts on the ovaries through a vaginal approach. This minimally invasive technique is performed to relieve symptoms caused by ovarian cysts.

Purpose

This procedure addresses the presence of symptomatic ovarian cysts, which can cause pain, bloating, and menstrual irregularities. The primary goal is to remove the cystic fluid, alleviate symptoms, and prevent potential complications.

Indications

  • Severe pelvic pain or discomfort
  • Persistent or enlarging ovarian cysts
  • Cysts causing menstrual irregularities
  • Suspicion of cyst rupture or torsion
  • Infertility due to cysts

Preparation

  • Patients may need to fast for several hours before the procedure.
  • Pre-procedure imaging such as ultrasound or MRI may be required.
  • Adjustments to certain medications (e.g., blood thinners) might be necessary.
  • A complete medical history and physical examination will be conducted.

Procedure Description

  1. The patient is positioned in a lithotomy position.
  2. General or regional anesthesia is administered.
  3. The surgeon uses a speculum to access the vagina and then identifies the location of the cyst using ultrasound guidance.
  4. A small incision is made in the vaginal wall.
  5. A needle or catheter is inserted into the cyst to aspirate its contents.
  6. The cyst fluid is drained, and the needle or catheter is removed.
  7. The incision is closed, if necessary.

Tools and equipment include a speculum, ultrasound machine, needle or catheter for aspiration, and surgical instruments for incision and closure.

Duration

The procedure typically takes 30-60 minutes.

Setting

This is usually performed in a hospital or outpatient surgical center.

Personnel

  • Gynecologist or surgeon
  • Anesthesiologist
  • Surgical nurse
  • Sonographer (for ultrasound guidance)

Risks and Complications

  • Infection at the incision site
  • Bleeding
  • Injury to surrounding organs
  • Recurrence of cysts
  • Allergic reaction to anesthesia

Benefits

  • Relief from pelvic pain and discomfort
  • Regulation of menstrual cycles
  • Reduction of cyst-related complications
  • Quick recovery time due to the minimally invasive nature of the procedure

Recovery

  • Patients may experience some mild discomfort or spotting.
  • Pain can be managed with over-the-counter painkillers.
  • Most patients can resume normal activities within a few days.
  • Follow-up appointments are necessary to monitor for recurrence.

Alternatives

  • Watchful waiting and regular monitoring with ultrasound
  • Oral contraceptives to reduce cyst formation
  • Surgical removal of the cysts via laparoscopy or laparotomy

Patient Experience

Patients may experience mild pressure or discomfort during the procedure due to the position and speculum insertion but should not feel pain due to anesthesia. Post-procedure, mild cramping and spotting are common, which can be managed with prescribed pain medication and rest. Regular follow-up appointments will help ensure a smooth recovery and monitor for any recurrence of cysts.

Medical Policies and Guidelines for Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach

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