52353

Cystourethroscopy with lithotripsy (ureteral or renal)

Cystourethroscopy with lithotripsy (CPT 52353) is a sophisticated endoscopic procedure performed by urologists to treat stones located within the ureter or the kidney (renal pelvis and calyces). The procedure is characterized by the use of high-definition endoscopy to navigate the complex anatomy of the lower and upper urinary tract without the need for external incisions. After the patient is appropriately anesthetized and positioned in the lithotomy position, the surgeon introduces a cystoscope through the urethra to inspect the bladder. A guidewire is then navigated through the ureteral orifice on the affected side under fluoroscopic guidance. Depending on the stone's location and the surgeon's preference, a semi-rigid ureteroscope may be used for distal ureteral stones, while a flexible ureteroscope is typically employed for proximal ureteral or intrarenal stones (pyeloscopy). The cornerstone of this procedure is lithotripsy, which involves the application of physical energy to break the calculus into smaller, passable fragments or fine dust. The Holmium:YAG laser is the current clinical gold standard for this task due to its ability to fragment stones of all chemical compositions and its relative safety regarding surrounding soft tissues. Other modalities include electrohydraulic, pneumatic, or ultrasonic lithotripsy. Throughout the procedure, continuous irrigation is maintained to ensure a clear operative field and to cool the laser fiber. Once the stone is sufficiently fragmented, the surgeon may use a nitinol stone basket to extract pieces for chemical analysis or to ensure immediate decompression of the system. The procedure concludes with a visual survey of the ureter to check for mucosal injury and to verify the clearance of obstructing fragments. This code includes any ureteral catheterization required for the procedure, such as for the injection of contrast or the placement of safety guidewires.

Clinical Indications

  • Symptomatic ureteral calculus causing renal colic
  • Renal pelvis or calyceal calculus (nephrolithiasis) not amenable to lithotripsy (ESWL)
  • Obstructive uropathy due to urolithiasis
  • Calculus associated with recurrent urinary tract infections
  • Failure of conservative medical expulsive therapy (MET)
  • Calculus in a solitary kidney requiring intervention
  • Stones larger than 10mm in the proximal ureter

Procedure Steps

  1. Place the patient in the dorsal lithotomy position under general or spinal anesthesia.
  2. Perform a diagnostic cystourethroscopy to inspect the urethra and bladder.
  3. Cannulate the affected ureteral orifice with a guidewire under fluoroscopic visualization.
  4. Advance the ureteroscope (semi-rigid or flexible) over the guidewire into the ureter or renal pelvis.
  5. Identify the calculus and assess its size and mobility.
  6. Introduce the lithotripsy probe (e.g., laser fiber) through the working channel of the ureteroscope.
  7. Activate the lithotriptor to fragment the stone into smaller pieces or 'dust'.
  8. Irrigate the area to maintain visibility and clear small debris.
  9. Utilize a stone basket or grasper to remove larger fragments if necessary.
  10. Withdraw the scope and perform a final check of the ureteral lumen for patency or injury.

Coding Guidelines

  • CPT 52353 includes diagnostic cystourethroscopy, ureteroscopy, and/or pyeloscopy; do not report 52351 separately.
  • Ureteral catheterization (52005) is bundled into 52353 and should not be reported separately.
  • If an indwelling ureteral stent (e.g., double-J stent) is placed at the conclusion of the procedure, report 52332 as a separate line item.
  • For bilateral lithotripsy procedures, append modifier 50 to the code.
  • If lithotripsy is performed in both the ureter and the kidney on the same side, 52353 is only reported once.
  • Do not report 52353 in conjunction with 52352 (stone extraction) unless they are performed on completely different stones/locations and meet specific bundling requirements.

Associated ICD-10 Codes