58210

Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s)

CPT code 58210 represents a highly complex and extensive oncologic surgical procedure known as a radical abdominal hysterectomy, classically referred to as the Wertheim procedure. This comprehensive intervention is indicated primarily for the surgical management of invasive gynecologic malignancies, most notably early-stage cervical cancer (such as Stages IA2, IB, and IIA) and select cases of endometrial carcinoma with cervical stromal involvement. Unlike a standard total abdominal hysterectomy (which removes only the uterus and cervix), a radical hysterectomy encompasses the en bloc resection of the uterus, the cervix, the upper third to upper half of the vagina, and the extensive supporting structures known as the parametrium and paracolpos. Furthermore, CPT 58210 inherently includes bilateral total pelvic lymphadenectomy, requiring the meticulous dissection and excision of the lymphatic tissue from the external iliac, internal iliac, and obturator fossa regions bilaterally. It also mandates para-aortic lymph node sampling or biopsy to accurately stage the extent of disease spread and guide postoperative adjuvant therapies. The procedure may or may not include a unilateral or bilateral salpingo-oophorectomy (removal of the fallopian tubes and ovaries), depending on the patient's age, menopausal status, and specific tumor pathology; whether or not these adnexal structures are removed, the code 58210 remains the single appropriate reporting code and should not be unbundled. The surgery is performed via a large open abdominal incision, typically a vertical midline incision or a transverse Maylard incision, under general anesthesia. Given the extensive anatomical dissection involved—particularly the unroofing and mobilization of the ureters down to their insertion at the bladder to allow for wide parametrial resection—the procedure carries significant risks of urinary tract injury, hemorrhage, and post-operative voiding dysfunction. Surgeons must carefully navigate the complex pelvic vasculature and neural networks. This code accurately reflects the high degree of surgical skill, advanced anatomical knowledge, and extensive intraoperative time required by gynecologic oncologists to achieve negative surgical margins, perform thorough oncologic staging, and ultimately optimize the patient's long-term survival.

Clinical Indications

  • Invasive cervical cancer, clinical stages IA2, IB1, IB2, and select cases of IIA.
  • Endometrial carcinoma with clinical or pathological evidence of cervical stromal invasion (Stage II).
  • Select cases of upper vaginal carcinoma requiring extensive upper pelvic resection.
  • Recurrent localized pelvic malignancies that have not previously been treated with maximum radiation or radical surgery.
  • Microinvasive cervical cancer where fertility preservation is no longer desired and lymph node status must be established.

Procedure Steps

  1. The patient is placed under general anesthesia in the supine or modified lithotomy position.
  2. A vertical midline or appropriate transverse (e.g., Maylard) abdominal incision is made to enter the peritoneal cavity.
  3. Thorough exploration of the abdominal and pelvic cavities is performed, including inspection of peritoneal surfaces, liver, and diaphragm, with peritoneal washings collected if indicated.
  4. The retroperitoneum is opened bilaterally to expose the iliac vessels and the ureters are identified, mobilized, and unroofed down to the ureterovesical junction.
  5. The paravesical and pararectal spaces are developed to isolate the parametrial and paravaginal tissues.
  6. The uterine arteries are identified, ligated, and divided at their origin from the internal iliac arteries to ensure en bloc resection of the parametrium.
  7. The uterosacral and cardinal ligaments are widely resected near their pelvic sidewall attachments.
  8. The upper third to upper half of the vagina is mobilized, transected, and closed to remove the uterus, cervix, upper vagina, and parametrium as a single radical specimen.
  9. Bilateral total pelvic lymphadenectomy is performed, clearing lymphatic tissue from the external iliac, internal iliac, and obturator fossa regions.
  10. The para-aortic region is dissected, and lymph nodes are sampled (biopsied) for pathologic staging.
  11. If indicated by the patient's age or disease status, a unilateral or bilateral salpingo-oophorectomy is performed concurrently.
  12. Hemostasis is meticulously secured, drains may be placed in the retroperitoneal spaces or pelvis, and the abdomen is closed in anatomical layers.

Coding Guidelines

  • Do not report 58210 in conjunction with separate codes for pelvic lymphadenectomy (e.g., 38570, 38571, 38572) or para-aortic lymph node sampling, as these are inherently included in 58210.
  • Do not append separate codes for salpingo-oophorectomy (e.g., 58720) or salpingectomy (e.g., 58700), as the descriptor explicitly states 'with or without removal of tube(s), with or without removal of ovary(s)'.
  • Code 58210 describes an open abdominal approach. Do not use this code for laparoscopically or robotically assisted radical hysterectomy (refer to CPT 58548).
  • Append modifier 22 if the procedure required significantly greater effort or time than typically required (e.g., severe endometriosis, extreme obesity, or extensive adhesions), supported by thorough operative note documentation.
  • Differentiate from CPT 58200, which is a total abdominal hysterectomy (not radical) with pelvic and para-aortic lymph node sampling; 58210 involves radical resection of the parametrium and upper vagina.
  • If extensive bowel resection or complex urologic reconstruction is performed concurrently by the same or a different surgeon, those procedures should be coded separately, potentially requiring a modifier (e.g., modifier 62 for co-surgeons or modifier 51 for multiple procedures).

Associated ICD-10 Codes