Ronney Abaza: Let's talk about ASC Robotics. I think this is really exciting. We're right on the edge of it. It's really on the verge. These are my disclosures. And I would start by saying that if you want to start an ASC Robotic program, think back to when your hospital first started their robotic program and all the challenges that you had at that time. You're going to have all of those challenges and more in the ASC. One of the major issues, probably the first issue that you're going to come across is contracting. That's going to be the make or break. As of January 1st CMS in their infinite wisdom or lack thereof, decided to no longer pay for our robotic codes in the ASC. So they'll still pay for gallbladder and hysterectomy, but not for prostatectomy, partial nephrectomy, et cetera. So you can't do your Medicare patients, at least as of now.

Hopefully that's going to change. So insurance contracting is really critical. And then you need to figure out how much volume you're going to have, of course. So look at your hospital volume, figure out what patients would be eligible to be done in the ASC, talk to the surgeons and figure out what your monthly volume is going to be. Because obviously you're going to have this large fixed cost that you need to overcome before you start making profit. So there's a certain amount of volume that you're going to need and a certain amount that you get paid per case that's going to allow you to do it. What we found is that because the contracting that our group was able to do was so favorable, the monthly volume of cases that we need to do is relatively low. And once we exceed that, of course it's all gravy.

And then there's some physical limitations that you need to consider, which is you've got to have space for the robot. And what we discovered was that in our ASC, it's very small, there's only two ORs for general anesthesia. And we discovered that our OR is literally the smallest that you can possibly have a robot in because the intuitive folks came in, measured the room and said, "You just barely made it." So you've got to have enough room. And one thing that you have to think about, you probably don't think about is how tall is the ceiling and how much overhead clearance you have because the robot's quite tall. In the hospitals, you don't really have to think about that. But in ASCs, particularly in ours, we had to make some adjustments. And then do you have CO2 gas running through the wall or are you going to use tanks?

Tanks are tough. At one of the three hospitals that I operate at still uses tanks for CO2. It's very painful. The staff is constantly running to change the tanks typically two or three times a day, so it's very painful. But if you can run CO2 in, that's a cost that you have to obviously keep in mind. And then there's also special sterilization equipment that you need for the robotic instruments that I'm sure you don't have now. It's not like you just put them in the stairs with your cystoscopes. No, the robotic instruments have their own sterilization devices and you've got to have enough room for it. So we had to overcome that because we didn't have the space. So we actually contracted with STERIS in Pittsburgh and we run the instruments back and forth to Pittsburgh to be sterilized. So there are workarounds is what I'm saying. But you have to think about all these things that we really didn't think about until we got started with the idea of the program. And it took us about six months to figure out all the kinks.

And then some ASCs have overnight capabilities, some don't. Our ASC does not have overnight capability. We don't have overnight beds. So you either have to send everybody home the same day or you have to have a backup plan. I mean, you have to have a backup plan either way if you're planning to send everybody home. And we do. We have a relationship with a nursing facility, a skilled nursing facility that's about a mile and a half down the road from our ASC. We've not had to use it yet, thank God, but we have it there as a backup. But otherwise we send everybody home the same day. For those surgeons who do robotic surgery and that makes them nervous, the idea of sending home patients the same day, obviously you wouldn't want to start your experience in the ASC where you have to. So as you're doing cases in the hospital, start getting used to sending patients home the same day.

Start with the easy ones, the healthier first case of the day, et cetera. And that way once you start your ASC program, you'll have a much easier time knowing what needs to happen for them to be able to go home the same day. And then also other logistics include your OR time and scheduling. If your ASCs are running at capacity right now and your ASC ORs are full, well you've got to remember that this robotic volume is going to be all new volume. Not like the hospital where they were converting lap cases and open cases to robotic. If you're not doing robotic cases now I'm sure you're not doing lap nephrectomies in your ASC, most likely not. You're not doing open nephrectomies. So the robotic volume's going to be all new volume and you've got to make sure that you've got time and you can work out the block times and whatnot.

But the good news is that the opportunity cost versus the other procedures that you would've been doing, like ureteroscopies and other cases that are probably the bread and butter for your ASC, the robotic cases have a lot more meat on the bone. So whatever cases you end up sacrificing to start doing the robotic cases, financially at least I don't think you'll regret it. So for us, again, as I mentioned, we don't have overnight capabilities. And even if you do have overnight capabilities, obviously there's a limit to how many patients you can keep overnight and you don't want to stretch those resources thin. So again, you've got to get used to being able to send most of these patients home. So years ago I started asking myself the question, what's so different about the case that I do and a lap chole when all the lap chole go home the same day?

And so back in 2016, I started offering same day surgery for the prostates because that's the most common case we do. And as you can see there year after year it got more and more and now it's almost all patients. And I started a couple years after that with partial nephrectomy, same thing. And now the vast majority of those go home the same day. And people typically ask me, "Well you're cherry picking, right?" It's like the little two centimeter tumor. We don't do a lot of partial nephrectomies for two centimeter tumors. We do surveillance for those. So this is an example of a patient, an 80 year old guy, 4.1 centimeter hilar mass, had a partial nephrectomy, he was the third case of the day. So it's not just the first case of the day, he's the third case of the day and he went home the same day.

So really age, complexity of case time of day, those are not necessarily limiting factors as long as you have a strong track record and know that your surgeries are going to be relatively predictable in terms of outcomes. And COVID really helped this a lot. So we published this paper after the initial COVID crisis in the Gold Journal. And COVID made it a lot easier to send patients home the same day because all of a sudden nobody wanted to be in the hospital anymore. So it became very easy. And then in terms of the how to, that would be a whole lecture in and of itself. How do you get patients home the same day after robotic surgery? I would point you to a couple publications. In 2019, we published our initial series with prostatectomy and there's some tips in there for how we do it, but actually the more useful paper from just a practical point of view is this paper that we published in Urologists in Cancer Care, which is a companion journal for Urology Times.

And it's free online if you want some tips on how to go about getting patients home the same day and how we do it, the tips are in there. So take advantage of that if you are thinking of adopting that. And then just to share my experience, I've been part of LUGPA, very proud to be part of LUGPA now for about a year and a half. And so this is my experience so far with robotic cases. We didn't start our robotic program until October of last year. So we've only had a robotic program for a year. So as you can see, I did about twice as many cases so far in the hospital. But right now it's about 50/50 because again, it's all insurance based. So if the insurance lets us do it at the ASC, I do it at the ASC. So about half of my cases are at the ASC, half at the hospital. But as you can see, there are the hospital cases I did, 99% went home the same day, 1.5% readmission rate.

And the ASC patients, again, all of them have gone home the same day, less than 2% readmission rate. And these are the cases that we've done at our ASC so far. The majority of them are prostatectomy just because that's the most common robotic case we do. But not because we're shy of doing the other cases. And then because robotics, robotic urology in ASCs is so new and there's so few places doing it, we are collecting this data and measuring it with the utmost care to make sure that we can do it safe, make it reproducible, and then share this information with others. So I can't go through all of this data with you, I won't bore you with it. I'll just point out at the very end that the time the patient spends in recovery room before they go home and the total length of stays very important to us.

Because again, we don't have overnight capability and we have to keep our throughput going in the ASC. It's all about efficiency. There's only so much space and you can't have a patient sitting there for eight hours in the recovery room. You got to use that for the ureteroscopy and the other case that's coming. So our recovery room time on average, as you can see there is less than two hours. So they finish their robotic surgery, they're home within two hours, just like a lap chole. And that's what I tell everybody involved in their care. The anesthesiologist, pre-op nurse, post-op nurse, treat them like a lap chole. They know exactly what I mean. So the total length of stay of our patients is somewhere around five to six hours from when they hit the door to when they're getting in their car to go home, it's roughly five to six hours. Whether it's a prostate, partial nephrectomy, nephrectomy, whatever it is.

So in conclusion, there's definitely challenges to starting an ASC robotic program, but it's very doable. And you can do it even with limited resources and really the same rationale for why you do anything at your ASC. Obviously preserving physician independence, having control. And that's something that I think the patients really benefit from because you can tailor it to the robotic surgery patient. And so far we have a survey that we ask the patients the next day and one of the questions we ask them is whether they were satisfied with having their robotic surgery at the ASC rather than having had at a hospital. And so far, a hundred percent of them have said yes that they were satisfied. A couple resources I'll mention before I finish. One is that we have an observation program where you can come in, spend a day with us, observe cases, meet with our ASC folks and learn how we do things. So if you're thinking of starting a robotic program, I think it could be very valuable to you. So reach out to me.

I have my email there. Don't abuse it, please. But reach out to me if you're interested in coming to visit us for a day. We would love to have you and share our experience with you so far because we again, want to make this reproducible. We want this to be a mechanism by which physician practices can remain independent. And this is a way that we can do that by helping you start up these programs. And I would mention that our group in Columbus is part of US Urology Partners, that's our PE parent organization. And I have to say that they were really instrumental in making it possible because of the capital outlay that was necessary. They were really instrumental in making it possible for us to do this program. So again, we're happy to export this knowledge that we've gained from starting our program. And then the last thing I'll mention is that NARUS and LUGPA have a relationship, a collaboration.

This is the second year that we'll be doing it where we will have a LUGPA speaker at the NARUS meeting. It's February 2-4 in Las Vegas as you can see. I really still to this day believe that NARUS is the best robotic meeting out there anywhere, so join us. There's live surgeries, again, there'll be a LUGPA lecturer. Mike was our lecturer last year, so thanks for that. And we look forward to seeing you there. There's a lot of good information. It's a practical meeting. Unlike a lot of these meetings that you go to, which is very data driven and research and stuff that you're never going to do, this is meant for us guys in the trenches who are doing the cases so it's very practical. So thank you for your time and happy to answer questions during the Q&A.