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BETA v.3.0

2025 CPT code 53445

Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff.

Medical necessity for this procedure is established by documenting the patient's significant impairment in daily activities due to urinary incontinence, failure of conservative treatments, and the expectation of substantial functional improvement following sphincter implantation.

The surgeon performs the procedure, including placement of all components, ensures proper device activation (sometimes delayed after prostate surgery), and educates the patient on device usage. The surgeon also measures the urethra to correctly size the cuff and addresses post-op care like incision closure and bleeding control.

In simple words: A surgery to implant an artificial device to control urine leakage. The device has a cuff around the urethra that stays inflated to hold urine, a balloon to regulate pressure, and a pump to deflate the cuff when you need to urinate.The doctor places the cuff, balloon and pump under the skin through small cuts and they are connected by small tubes.

This procedure involves the insertion of an artificial urinary sphincter to treat urinary incontinence, often caused by a weakened urinary sphincter or complications from prostate surgery. The device consists of three main components: a cuff placed around the urethra, a pressure-regulating balloon implanted in the abdomen or pelvic region, and a pump placed in the scrotum or labia. The cuff remains inflated to prevent leakage, and the patient can manually deflate it via the pump to urinate.

Example 1: A male patient experiencing stress urinary incontinence after a radical prostatectomy undergoes insertion of an artificial urinary sphincter to regain urinary control., A female patient with intrinsic sphincter deficiency causing severe stress incontinence undergoes the procedure to improve quality of life., A patient with a neurogenic bladder causing incontinence undergoes artificial sphincter insertion to manage bladder control issues.

Documentation should include the reason for incontinence (e.g., post-prostatectomy, intrinsic sphincter deficiency), type of incontinence (stress, urge, mixed), severity of incontinence, prior treatments, pre-operative evaluation including urodynamic studies, operative report detailing the procedure, device specifics, and post-operative instructions given to the patient.

** The pump location varies by sex – scrotum for males, labia for females. Activation of the device may be delayed following prostate surgery to allow for healing.

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