Q.1: PROSTATE

For Cases Diagnosed prior to January 1, 2003

C61.9
SURGICAL APPROACH

 

Code

Description

0

None; no cancer-directed surgery of primary site

1

Endoscopy, NOS (transurethral)

2

Laparoscopic, NOS

3

Open, NOS

4

 

Suprapubic

5

 

Perineal

7

 

Trans-sacral

8

 

Retropubic

Note: Code the approach for radical prostatectomy as retropubic unless otherwise specified.

9

Unknown; not stated; death certificate only

 

SURGERY OF PRIMARY SITE

 

Code

Description

00

None; no cancer-directed surgery of primary site

10

Local tumor destruction or excision, NOS

11

 

Transurethral resection (TURP), NOS

12

 

 

TURP cancer is incidental finding during surgery for benign disease

13

 

 

TURP patient has suspected/known cancer

14

 

Cryoprostatectomy

15

 

Laser

16

 

Hyperthermia

17

 

Other method of local resection or destruction

30

Subtotal or simple prostatectomy, NOS

Note: A segmental resection or enucleation leaving the capsule intact.

40

Less than total prostatectomy, NOS

Note: An enucleation using an instrument such as a Vapotrode which may leave all or part of the capsule intact.

50

Radical prostatectomy, NOS; total prostatectomy, NOS

Note: Excised prostate, prostatic capsule, ejaculatory ducts, seminal vesicle(s) and may include a narrow cuff of bladder neck.

70

Prostatectomy with en bloc resection of other organs; pelvic exenteration

Note: Surgeries coded 70 are any prostatectomy with an en bloc resection of any other organs. The other organs may be partially or totally removed. En bloc resection is the removal of organs in one piece at one time. Procedures that may involve an en bloc resection include, but are not limited to: cystoprostatectomy, radical cystectomy and prostatectomy.

80

Prostatectomy, NOS

90

Surgery, NOS

99

Unknown if cancer-directed surgery performed; death certificate only

 

SURGICAL MARGINS

The codes are hierarchical, if more than one code is applicable, use the numerically higher code.  For example, if multiple margins are microscopically and macroscopically involved, code the macroscopic involvement (5).

Multiple margins are two separate margins, both of which are microscopically involved with tumor.  DO NOT CODE multiple margins (4) if one margin has multiple foci of tumor.

Code

Description

0

All margins grossly and microscopically negative

1

Margin(s) involved, NOS

2

 

Microscopic involvement

3

 

 

Single margin

4

 

 

Multiple margins

5

  

Macroscopic involvement, NOS

7

Margins not documented (TURP)

8

No cancer-directed surgery of primary site

9

Unknown whether margins were involved or negative; death certificate only

 

SCOPE OF REGIONAL LYMPH NODE SURGERY

The regional lymph nodes are:

 

Code

Description

0

No regional lymph nodes removed

1

Regional lymph nodes removed, NOS

9

Unknown; not stated; death certificate only

 

NUMBER OF REGIONAL LYMPH NODES EXAMINED

 

Code

Description

00

No regional lymph nodes removed

01

One regional lymph node removed

02

Two regional lymph nodes removed

..

 

90

Ninety or more regional lymph nodes removed

95

No regional lymph nodes removed but aspiration of regional lymph nodes was performed

96

Regional lymph node removal documented as a sampling and number of lymph nodes unknown/not stated

97

Regional lymph node removal documented as dissection and number of lymph nodes unknown/not stated

98

Regional lymph nodes surgically removed but number of lymph nodes unknown/not stated and not documented as sampling or dissection

99

Unknown; not stated; death certificate only

 

SURGERY OF OTHER REGIONAL SITE(S), DISTANT SITE(S) OR DISTANT LYMPH NODE(S)

Do not code orchiectomy. For prostate primaries, code orchiectomies under Hormone Therapy.

The most commonly removed distant lymph nodes are: aortic (para-aortic, peri-aortic, lumbar), common iliac, inguinal, superficial inguinal (femoral), supraclavicular, cervical, and scalene.

 

Code

Description

0

None; no surgery to other regional or distant sites

1

Surgery to other sites or nodes, NOS; unknown if regional or distant

2

 

Other regional sites

3

 

Distant lymph nodes

4

 

Distant sites

5

  

Combination of 4 with 2 or 3

9

Unknown; not stated; death certificate only

 

RECONSTRUCTION/RESTORATION - FIRST COURSE

 

Code

Description

0

No reconstruction/restoration

1

Reconstruction/restoration, NOS

2

 

Collagen injection for incontinence

3

 

Penile prosthesis

4

 

Artificial urinary sphincter

5

 

Combinations of 4 with 2 or 3

9

Unknown; not stated; death certificate only

 

 

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