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MP 7.01.31 Continent Ileostomy and Urostomy

 

Medical Policy    
Section
Surgery
Original Policy Date
3/31/96
Last Review Status/Date
Reviewed by consensus/3:2003
Issue
3:2003
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.

 


 

Description

The continent urostomy and continent ileostomy are surgical procedures that use a section of ileum to create an internal reservoir to hold urine or feces following cystectomy or colectomy. These procedures are sometimes referred to as the Kock continent urostomy and Kock continent ileostomy or Kock pouch. The internal reservoir allows a patient to void without wearing an external collecting bag. The patient intermittently drains the pouch by self-catheterization via a small stoma created in the abdominal wall.

A variant of the Kock ileostomy is the Barnett continent reservoir, which was designed to decrease the incidence of valve leakage. The main innovation is to configure the portion of ileum that serves as a valve in an isoperistaltic position, thus peristalsis moves toward the pouch, increasing its stability.

 


 

Policy

The Kock continent urostomy may be considered medically necessary following cystectomy.

The Kock continent ileostomy may be considered medically necessary in patients who have undergone coloproctectomy.

The Barnett continent reservoir may be considered medically necessary in patients who have undergone coloproctectomy.

 


 

Policy Guidelines

The most common candidates for the Kock continent ileostomy and Barnett continent reservoir are those who have undergone a coloproctectomy for ulcerative colitis or familial polyposis.

 


 

Benefit Application

No applicable information

 


 

Rationale

The Barnett continent reservoir is a relatively new alternative to the Kock continent ileostomy. In a multicenter, uncontrolled case series, Mullen reported the results of 510 patients who underwent the procedure. (1) Of the 510 patients operated on, 470 (92.2%) had fully functioning pouches at least 1 year after initial surgery and, of these, 372 (79.1%) required no further pouch-related operations. Sixty patients (12.8%) required major subsequent surgical procedures. Complications included pouch failure, value slippage, and fistula formation. Centers participating in the uncontrolled case series include Century City Hospital in Los Angeles, Lutheran Medical Center in St. Louis, Palms of Pasadena Hospital in St. Petersburg, RHD Memorial Medical Center in Dallas, and West Boca Medical Center in Boca Raton, Florida.

1. Mullen P, Behrens D, Chalmers T et al. Barnett continent intestinal reservoir. Multicenter experience with an alternative to the Brooke ileostomy. Dis Colon Rectum 1995;38(6):573-82.

A search of literature was completed through the MEDLINE database for the period of January 1995 through December 1998. The search strategy focused on references containing the following words:

– Continent
 
– Ileostomy
 
– Urostomy

See also:

Technology Evaluation and Coverage 1988: p. 27

 

Codes

Number

Description

CPT  44151  Colectomy, total abdominal, without proctectomy with continent ileostomy 
  44316  Continent ileostomy (Kock procedure) 
  50825  Continent diversion, including intestine anastomosis using any segment of small and/or large bowel (Kock pouch or Camey enterocystoplasty) 
  51596  Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder 
ICD-9 Procedure  45.8  Total intra-abdominal colectomy 
  46.22  Continent ileostomy 
  56.51  Formation of cutaneous ureter-ileostomy 
  57.71  Radical cyctectomy 
  57.79  Other total cystectomy 
ICD-9 Diagnosis  No code 
HCPCS  A5081  Continent device; plug for continent stoma 
  A5082  Continent device; catheter for continent stoma 
Type of Service  Surgery 
Place of Service  Inpatient 

 


 

Index

Barnett continent reservoir
Continent urostomy and ileostomy
Ileostomy, kock continent
Kock continent urostomy and ileostomy
Urostomy, kock continent

 


 

Policy History

Date Action Reason
03/31/96 Add to Surgery section New policy
03/15/99 Replace policy Policy revised to include Barnett Continent Reservoir
04/15/02 Replace policy Policy reviewed without literature review; new review date only
10/9/03 Replace policy Policy reviewed by consensus without literature review; no changes in policy; no further review scheduled