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Transplantation Kidney, Right to Syngeneic with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | T Urinary System |
| Operation | Y Transplantation |
| Body Part | 0 Kidney, Right |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | 1 Syngeneic |
Operation Definition
Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part
Procedure Overview
Transplantation in the urinary system refers to kidney transplantation, in which a kidney from a living or deceased donor is surgically placed into a recipient to take over the function of failing native kidneys. This procedure is performed for patients with end-stage kidney disease who can no longer sustain adequate function through their own kidneys and who are not being managed solely with dialysis.
The donated kidney is connected to the recipient's blood vessels and urinary tract so that it can filter blood and produce urine much as a native kidney would. This is typically the preferred long-term treatment for suitable candidates with kidney failure, since a functioning transplant generally offers better quality of life and survival outcomes compared with lifelong dialysis.
Anatomy & Axis Detail
Kidney, Right
Transplantation of the right kidney involves grafting a donor organ into the recipient, most commonly placed in the ipsilateral or contralateral iliac fossa with vascular anastomoses to the iliac vessels and ureteral implantation into the bladder, rather than into the native renal fossa. This procedure is performed for end-stage renal disease when a matched donor kidney, living or deceased, is available, and documentation should specify that the graft is the right kidney being transplanted, since laterality here refers to the donor organ rather than necessarily its final anatomic position in the recipient. The native kidneys are typically left in place unless a separate indication for their removal exists, meaning transplantation is coded independently from any concurrent native nephrectomy. Operative records should confirm donor source and surgical approach, as these details support accurate procedural and outcome documentation.
Approach: Open
Open approach means the surgeon cuts through skin, mucous membrane, or other tissue layers to physically expose the target site to view before performing the procedure. It gives direct visualization and hands-on access, distinguishing it from Percutaneous approaches where instruments pass through a small puncture without exposing the site. Open is typical for procedures needing wide access, such as most laparotomies.
Qualifier: Syngeneic
This qualifier denotes a syngeneic tissue substitute, sourced from a donor who is genetically identical to the recipient, such as an identical twin. It is a narrower category than the allogeneic qualifier, which covers any same-species donor regardless of genetic match, and is distinguished from zooplastic tissue, which comes from another species.
Coding & Documentation
Coders must confirm that the documentation identifies the transplanted organ as coming from another individual, whether a living donor or a deceased donor, and should note the qualifier distinguishing autologous from allogeneic or syngeneic sources. Operative and donor records should clearly describe the vascular and urinary tract connections made during the procedure. A common assignment error is confusing kidney transplantation with a simple graft or Supplement procedure, when in fact an entire donor organ is being placed to take over function, which is unique to the Transplantation root operation.
Accurate coding also depends on properly documenting any concurrent procedures, such as removal of a failed native kidney, which are captured separately from the transplantation itself.