A ureterectomy is the surgical excision of all or part of a ureter — the paired muscular tubes (~25-30 cm in length) that carry urine from the renal pelvis]] of each kidney to the urinary bladder through a peristaltic, valveless flow mechanism. The procedure may be total (removal of the entire ureter from the ureteropelvic junction (UPJ) to the ureterovesical junction (UVJ) with or without a bladder cuff) or partial/segmental (excision of only a diseased or injured segment, followed by reconstruction via ureteroureteralanastomosis, ureteroneocystostomy, Boari flap, ileal ureter interposition, or transureteroureterostomy depending on segment length). The most common and oncologically critical indication is urothelial carcinoma of the ureter (C66.1/C66.2), where complete ureterectomy — always including a circumferential bladder cuff excision — is a non-negotiable oncologic requirement to prevent ureteral stump recurrence, given the field cancerization susceptibility of the entire urothelial lining. When ureterectomy is performed together with ipsilateral nephrectomy for upper tract urothelial carcinoma (UTUC), the combined procedure is a nephroureterectomy (CPT 50234, 50236, or 50548) — and in that context the ureterectomy component is already included in the nephroureterectomy CPT and must NOT be separately billed. Standalone ureterectomy — without concurrent nephrectomy — is indicated for: isolated distal ureteral tumors where the kidney is preserved; ectopic ureter (CPT 50660); ureteral stump syndrome after prior nephrectomy; or non-oncologic severeureteral stricture/injury where the ureter cannot be repaired. For AAPC-certified profee coders, the most common ureterectomy coding error is double-billing CPT 50650 alongside CPT 50948 (laparoscopic ureteroneocystostomy) — per AAPC coding alerts, 50948 already includes the distal ureterectomy component and 50650 cannot be separately reported in that scenario.
Greek οὐρητήρ (ourētḗr) — “the channel that carries urine”; from ourein — “to urinate”; from ouron — “urine”
The ureteral tube was described in ancient Alexandrian anatomy (Herophilus, ~300 BCE) but consistently confused with the urethra until Andreas Vesalius definitively distinguished the two structures in De humani corporis fabrica (1543); the Greek term ourētḗr specifically denotes the upward-carrying urinary channel, distinguishing it from ourēthra (the terminal discharge tube); gives combining forms ureter-, uretero-, and root ur- across all urinary terminology
Greek οὖρον (ouron) — “urine”; PIE root *wers- — “to flow, to rain”
The primordial root of all urinary terminology in Western medicine; present in urine, urology, ureter, urethra, uremia, urinalysis, hematuria, pyuria, glucosuria, dysuria; one of the most productive medical roots, appearing in over 200 clinical terms
The standard surgical suffix denoting complete excision/removal; distinguished from -tomy (incision into) and -stomy (creation of a permanent opening); the -ec- (from ek-, out) specifically implies total removal, as opposed to -otomy (just cutting); same root in appendectomy, tonsillectomy, mastectomy, hysterectomy, cholecystectomy
The word ureterectomy follows the standard Greek compound construction used throughout 19th-century surgical nomenclature, combining ourētḗr (ureter) with ektomē (excision) along the same pattern as nephrectomy (1869, Gustav Simon) and cystectomy. The earliest documented use of the term ureterectomy in English appears in the British Medical Journal in April 1893, reporting a case by French surgeon Reynier, who removed the entire ureter from a patient — making it one of the earliest published total ureterectomies in the literature. The procedure remained rare and technically challenging throughout the early 20th century due to the difficulty of the deep pelvic dissection required to excise the intramural ureter and bladder cuff. The oncologic rationale for total ureterectomy with bladder cuff as the mandatory standard for ureteral urothelial carcinoma was firmly established in the mid-20th century, paralleling the recognition that urothelial carcinoma is a pan-urothelial disease susceptible to multifocal recurrence anywhere along the urinary collecting system. The rise of laparoscopic ureterectomy in the 1990s and the robotic distal ureterectomy in the 2000s transformed what had been a morbid open procedure into a reproducible minimally invasive operation — though the CPT coding infrastructure has not kept pace, leaving laparoscopic ureterectomy to this day reported under the unlisted code 50949, benchmarked to the open 50650.
🔀 ALIASES / ALTERNATE TERMS
Term
Relationship
Total ureterectomy
Entire ureter removed from UPJ to UVJ; always requires bladder cuff excision for oncologic cases; CPT 50650 (open with bladder cuff) — the standard oncologic procedure
Partial / segmental ureterectomy
Only a diseased or injured segment removed; reconstruction required; not a separate CPT — included within the reconstructive procedure code that follows (e.g., 50740 ureteropyelostomy, 50948ureteroneocystostomy)
Distal ureterectomy
Excision of the distal ureter ± bladder cuff; most common segment for isolated ureteral TCC; enables kidney-sparing surgery when tumor is confined to lower third of ureter; CPT 50650 if bladder cuff included
Ureterectomy with bladder cuff
Synonymous with oncologically complete ureterectomy; mandates circumferential excision of the bladder wall around the ureteral orifice; the standard CPT 50650 descriptor language
Completion ureterectomy
Removal of ureteral remnant/stump after prior nephrectomy that left the ureter in situ; indication = ureteral stump syndrome or stump carcinoma; CPT 50650 (open) or 50949 (laparoscopic, unlisted)
Ureteral stump excision
Synonymous with completion ureterectomy; the remaining ureter after prior nephrectomy; coded 50650 when bladder cuff included; important surveillance consideration post-nephroureterectomy if original surgery left a stump
Ectopic ureter excision
CPT 50660 — total ureterectomy, ectopicureter, via combination abdominal/vaginal/perineal approach; an entirely different CPT than 50650; ectopic ureter inserts outside the trigone (bladder neck, urethra, vagina, vestibule, rectum); coded with congenital malformation ICD-10 Q62.61/Q62.62
Laparoscopic ureterectomy
No specific CPT exists; reported with 50949 (unlisted laparoscopy procedure, ureter); benchmarked to open 50650; submit with operative report and cover letter; includes robotic-assisted laparoscopic ureterectomy
Ureterectomy + ipsilateral nephrectomy performed as a single combined operation; CPT 50234 (open, same incision), 50236 (open, separate incisions), 50548 (laparoscopic); ureterectomy is INCLUDED in these codes — do NOT separately bill 50650
⚠️ NOT ureterectomy — ureterolysis is surgical freeing/decompression of the ureter from surrounding adhesions or fibrosis, WITHOUT excision; CPT 50715 (open) / 50949 (laparoscopic unlisted); do not confuse with ureterectomy
🔗 RELATED TERMS
Ureter — the paired muscular tubes carrying urine from renal pelvis to bladder; ~25-30 cm long; three natural areas of anatomical narrowing (UPJ, pelvic brim crossing iliac vessels, UVJ) that are sites of stone impaction, stricture, and tumor; divided into upper, middle, and lower thirds for surgical and oncologic staging purposes
Upper tract urothelial carcinoma (UTUC) — urothelial carcinoma of the renal pelvis and/or ureter; the primary oncologic indication for complete ureterectomy (with or without nephrectomy); coded C65.1/C65.2 (renal pelvis) and C66.1/C66.2 (ureter); when both sites involved, code both
Bladder cuff — the circumferential segment of bladder wall surrounding the intramural ureter and ureteral orifice; must be excised en bloc with ureterectomy in all oncologic cases; leaving the bladder cuff results in 30-75% ureteral stump recurrence rate; its excision is the distinguishing feature of CPT 50650 vs. incomplete ureterectomy
Ureteral stump syndrome — symptoms arising from a retained ureteral remnant after prior nephrectomy; may include recurrent infection, pain, or carcinoma developing in the ureteral stump; indication for completion ureterectomy (CPT 50650/50949); coded based on symptoms or findings (stump carcinoma = C66.1/C66.2; stump infection = N28.89; stump hydronephrosis = N13.30-N13.39)
Vesicoureteral reflux (VUR) — retrograde urine flow from bladder to ureter/renal pelvis; graded I-V; severe grades with non-functioning kidney may require nephroureterectomy; coded N13.70-N13.739 (with/without reflux nephropathy and hydroureter)
Ectopic ureter — ureter inserting outside the normal trigone position; insertion sites include bladder neck, urethra, vagina, vestibule; causes incontinence, infection, and/or hydronephrosis; indication for CPT 50660 (ectopic ureterureterectomy via combined abdominal/vaginal/perineal approach); congenital malformation codes Q62.61 (right) / Q62.62 (left)
Ureteral stricture — narrowing of the ureteral lumen causing upstream obstruction; with hydronephrosis coded N13.1; without hydronephrosis N13.5; caused by prior surgery, radiation, infection (TB, schistosomiasis), ischemia, or external compression; may require segmental ureterectomy with reconstruction or complete ureterectomy depending on extent
Hydroureter — dilation of the ureter from obstruction (stricture, calculus, tumor, or external compression); coded N13.4; often concurrent with hydronephrosis when obstruction is proximal; may be the presenting finding leading to diagnosis of ureteral carcinoma
Ureteroneocystostomy — surgical reimplantation of the ureter into the bladder after distal ureteral resection; the reconstructive procedure following distal ureterectomy; laparoscopic = CPT 50948 (without cystoscopy/stent) or 50947 (with cystoscopy/stent); open = CPT 50780-50785; 50948 INCLUDES the distal ureterectomy component — do NOT add 50650 to 50948
Psoas hitch — surgical technique anchoring the bladder to the psoas muscle tendon to bridge a ureteral gap after distal ureterectomy; reduces tension on ureteroneocystostomy anastomosis; included within the ureteroneocystostomy CPT (50780/50948) — not separately billable
Boari flap — bladder flap reconstruction used to bridge a longer ureteral gap after mid-to-distal ureterectomy; bladder wall is tubularized to replace the missing ureteral segment; includes ureteroneocystostomy; coded CPT 50830 (urinary undiversion) or open ureteroneocystostomy codes depending on context
Ileal ureter — interposition of an ileal segment to replace an entire or near-total ureter destroyed by stricture, injury, or radical pelvic surgery; CPT 50840 (replacement of all or part of ureter by ileal segment); indication = long-segment stricture or ureteral loss not amenable to primary reanastomosis
Transureteroureterostomy (TUU) — anastomosis of one ureter to the contralateral ureter; used when the ipsilateral bladder or lower ureter cannot be used for reimplantation; open CPT 50770
Ureteral carcinoma in situ (CIS) — high-grade flat urothelial carcinoma of the ureteral lining without invasion; coded D09.10 (carcinoma in situ of unspecified urinary organ) or D09.19 (other urinary organs); high risk of progression; may prompt ureterectomy in context of prior bladder urothelial CIS with ureteral extension
CODING CORNER
📋 ICD-10-CM — Ureterectomy Indications
⚠️ C66.1 and C66.2 are the billable laterality codes for ureteral carcinoma — parent code C66 is NOT billable. Always confirm laterality from the operative report and pathology. When both renal pelvis (C65.x) AND ureter (C66.x) are involved by tumor on the same side, code BOTH. Ureteral CIS (D09.19) is separately coded from invasive carcinoma (C66.x) — they are not mutually exclusive and both may be listed when documented. N13.5 (stricture without hydronephrosis) and N13.1 (stricture with hydronephrosis) are DISTINCT codes — hydronephrosis status must be confirmed from imaging before coding.
Malignant neoplasm of right ureter (urothelial/transitional cell carcinoma of right ureter — primary indication for right distal/total ureterectomy or right nephroureterectomy; Excludes1: malignant neoplasm of ureteric orifice of bladder [C67.6])
Carcinoma in situ of other urinary organs (ureteral CIS — flat high-grade urothelial carcinoma in situ of ureter; may indicate ureterectomy when extensive or multifocal)
Hydronephrosis with ureteral stricture, not elsewhere classified (ureteral stricture WITH hydronephrosis — when long-segment stricture not amenable to repair and ureterectomy with reconstruction indicated)
Crossing vessel and stricture of ureter without hydronephrosis (ureteral stricture WITHOUT hydronephrosis — early or compensated; may still indicate ureterectomy when endoscopic management fails)
Anomalous implantation of right ureter (ectopic right ureter — primary indication for CPT 50660 [ectopic ureter ureterectomy]; insertion outside trigone causing incontinence, infection, or hydronephrosis)
Congenital ureteropelvic junction obstruction (congenital UPJ obstruction — typically treated by pyeloplasty CPT 50544/50400; ureterectomy considered if UPJ is non-functional or renal salvage not possible)
Other postprocedural complications and disorders of genitourinary system (iatrogenic ureteral injury post-surgery — when repair not possible; ureterectomy with reconstruction)
Other injury of ureter, initial encounter (traumatic ureteral laceration/disruption — initial encounter; may require ureterectomy when devascularized segment not salvageable)
Personal history of malignant neoplasm of other urinary organs (post-ureterectomy surveillance — history of ureteral carcinoma; use when no current evidence of disease)
Encounter for follow-up examination after completed treatment for malignant neoplasm (post-ureterectomy oncologic surveillance visit principal code)
🔧 CPT Codes — Ureterectomy Procedures
⚠️ THE TWO MOST CRITICAL URETERECTOMY CODING RULES: (1) CPT 50650 is designated a “SEPARATE PROCEDURE” — this means it bundles into more comprehensive ureteral and nephrectomy CPT codes when performed at the same session, including 50948 (laparoscopic ureteroneocystostomy), 50234, 50236, and 50548 (nephroureterectomy). Do NOT bill 50650 alongside these codes. (2) There is NO specific CPT for laparoscopic ureterectomy — laparoscopic ureterectomy must be reported with unlisted code 50949, benchmarked to open 50650, with a cover letter and operative report. Billing a laparoscopic ureterectomy under 50650 without noting the approach is incorrect CPT application — 50650 describes an open procedure.
Ureterectomy, with bladder cuff (separate procedure) (open excision of ureter with circumferential bladder cuff — the primary standalone open ureterectomy code; used for: isolated distal ureteral TCC with kidney preservation; completion ureterectomy/ureteral stump excision; partial/total ureterectomy when bladder cuff included; “separate procedure” designation means it bundles when performed as part of a more comprehensive procedure at the same session)
Ureterectomy, total, ectopic ureter, combination abdominal, vaginal and/or perineal approach (total ureterectomy specifically for ectopic ureter inserting outside the trigone; uses combined surgical approaches appropriate to the ectopic insertion site; DISTINCT from 50650 — do not use 50660 for non-ectopic ureteral pathology)
Unlisted laparoscopy procedure, ureter (laparoscopic ureterectomy — no specific CPT exists; report 50949 for any laparoscopic ureteral procedure without a designated code, including laparoscopic/robotic ureterectomy, laparoscopic completion ureterectomy, laparoscopic ureterolysis; benchmark to open equivalent 50650; submit with cover letter and operative report; Medicare performs manual review — no automated fee schedule)
Nephroureterectomy — Ureterectomy INCLUDED (Do NOT Add 50650)
Laparoscopy, surgical; ureteroneocystostomy without cystoscopy and ureteral stent placement (laparoscopic ureteroneocystostomy including psoas hitch and distal ureterectomy; 50948 INCLUDES the distal ureterectomy — 50650 is NOT separately billable per AAPC coding alerts)
Ureteroneocystostomy; anastomosis of single ureter to bladder (open ureteral reimplantation after distal ureterectomy — includes psoas hitch when performed)
Urinary undiversion (e.g., from temporary urinary diversion or permanent urinary undiversion) (complex ureteral reconstruction — includes ureterectomy of dysfunctional segment when applicable)
Replacement of all or part of ureter by ileal segment (ileal ureter — for long-segment ureteral loss or stricture not amenable to primary repair; includes excision of diseased ureteral segment)
Transureteroureterostomy, anastomosis of ureter to contralateral ureter (when ipsilateral bladder/lower ureter unavailable for reimplantation; open approach)
Cystoureteroscopy with ureteroscopy and/or pyeloscopy; diagnostic (pre-ureterectomy staging ureteroscopy and biopsy of ureteral mass; also post-ureterectomy surveillance of contralateral system)
Right side — required for all unilateral ureterectomy CPT codes; 50650, 50660, 50947, 50948, 50780 all require laterality modifier; right ureteral malignancy (C66.1) = right-side modifier
Multiple procedures — secondary procedures at same session; e.g., open ureterectomy (50650) and concurrent cystoscopy (52000) for bladder inspection; reduce payment on secondary code; do NOT apply -51 to add-on codes
Reduced services — planned total ureterectomy but only partial segment removed due to intraoperative findings (unexpected pathology, patient instability); document extent of ureter removed in operative report
Distinct procedural service — required when 50650 is billed alongside a procedure it would normally bundle with, but documented as a truly distinct and separately indicated service (e.g., completion ureterectomy for stump carcinoma performed at same session as contralateral procedure) — use only with strong documentation; do NOT use to unbundle 50650 from 50948
Staged procedure — planned second-stage ureterectomy within 90-day global period of a prior related procedure; e.g., staged completion ureterectomy after prior nephrectomy when both procedures planned at the time of initial surgery
Unrelated procedure during global period — contralateral ureterectomy or unrelated procedure during global period of prior ureterectomy on opposite side; different structure = unrelated
⚠️ Coding Notes & Payer Guidance
CPT 50650 “separate procedure” designation — the most common ureterectomy overbilling trap: CPT 50650 carries the parenthetical “(separate procedure)” in its descriptor — this is CPT’s signal that the code describes a component that is normally bundled into larger, more comprehensive procedures. When a distal ureterectomy is performed as part of laparoscopic ureteroneocystostomy (50948/50947), the ureterectomy is INCLUDED in those codes and 50650 cannot be separately billed. Per AAPC coding alerts published both in 2015 and 2020, reporting 50650 alongside 50948 is specifically identified as incorrect unbundling — submitting 50948 alone covers all services provided. The only scenario where 50650 is correctly billed separately is when it is performed as a truly standalone procedure with no concurrent more-comprehensive ureteral CPT at the same session.
Laparoscopic ureterectomy = 50949 unlisted — not 50650: CPT 50650 describes an openureterectomy. When the procedure is performed laparoscopically or robotically, the correct code is unlisted CPT 50949 (Unlisted laparoscopy procedure, ureter), benchmarked to open 50650 for fee-setting purposes. Billing a laparoscopic ureterectomy under 50650 without noting the laparoscopic approach could be considered incorrect CPT application. Per AAPC coding alerts, submit 50949 with the operative report, a cover letter explaining the procedure performed, and a benchmarking statement comparing it to open 50650 and its current Medicare fee schedule value. Medicare performs manual review on all unlisted codes — expect delayed payment and potential additional documentation requests.
50234/50236/50548 (nephroureterectomy) already include total ureterectomy — never add 50650 or 50949: When ureterectomy is performed as the distal component of a nephroureterectomy, the CPT codes 50234, 50236, and 50548 already describe a procedure that includes total ureterectomy with bladder cuff as an inherent component of the operation. Adding 50650 (open) or 50949 (laparoscopic unlisted) to a nephroureterectomy claim is a clear NCCI bundle violation. The ureterectomy component is only separately reportable if it is performed at a different surgical session or on the contralateral side.
Hybrid approach — laparoscopic nephrectomy (50548) + open bladder cuff (50650) — the one exception: As noted in nephroureterectomy coding, when the upper ureteral/nephrectomy component is performed laparoscopically (50548) and the distal ureterectomy/bladder cuff is performed through a separate open incision at the same session, both 50548 and 50650 may be billed together with modifier -59 (or -XS on Medicare) on 50650 to break the NCCI bundle — this is the documented hybrid approach exception per AAPC guidance. This is the single scenario where 50650 and a nephroureterectomy CPT can coexist on the same claim.
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