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Sherita King: So here are my disclosures. I am a consultant for Coloplast. I also have another disclosure that I actually do not do IPPs at my ASC, because my institution found that it was not financially feasible for me. So it's important that you look at the financials with your individual institution. So I'm going to go through the things that I did to try to prepare to go to the ASC, even though I had a roadblock. So I'll go through pre-op, intra-op, and post-op. So pre-op, first thing you got to do is find these patients. So we're talking about post-prostatectomy patients. And the best way that I have found that I've been able to do this is to partner with my GU onc surgeons in my area. We have a cancer survivorship program and I knew going into sexual medicine that I'll have to be a therapist, but I didn't realize it will be with my colleagues.

So I had to teach them that it's not you, it's the cancer. I know that we're all type A, we think we leave beautiful veils of Aphrodite. We don't cut the nerves. We nerve spared. But even with taking out the prostate, you're going to put a little traction on those nerves and they're going to have neuropraxia. So it's important that you just partner with your GU oncs. The other thing is if you are the prostatectomist, then everybody is a potential ED patient. And even outside of that, anybody that comes into my office with a penis, I ask them about their erection. So I just feed myself. The other thing is once you find these patients, you want to do an expedited treatment pathway. The AUA guidelines now say that you can do whatever you want on the menu. So I give them the whole menu, but I still go step-wise through it.

That way, I don't have to run into problems with insurance saying, oh, well you didn't try injections or pills first. The other important thing to do is manage expectations leading up to surgery and also educating your patients on their disease process and the surgery, so to prevent them from having cold feet later. So another thing that I look at is patient selection. So if you're going to be going to the ASC, you want to make sure that you have minimal comorbidities just as you would with any other surgery. I would be careful with patients who had past surgical history that's going to alter your placement, especially the reservoir placement. So if they had anal or hernia repairs or cystectomies, I would be aware of putting those patients out there at first, because if you have a complication that's going to slow down your process, you want to do a lower BMI, we call it biscuit poisoning in Augusta, just to make sure that you're not having patients that you're going to be struggling with.

And the other thing is at first, be careful with doing concomitant procedures. I do a lot of Peyronie's disease, but if I was first starting out in ASC, I probably would hold off on that and cherry-pick at first. So this is an important aspect that you can get from both implant companies. So benefit verification and cancellation prevention. So we know with elective surgeries that you're going to have some cancellations going in there. 60 to 80% is because of hospital, they say OR time and PACU availability. I'd like to add in there that getting approved for insurance is a big problem at my hospital. The other problem is patient related, so there's 20 to 40%. So that's pre-op assessment patients just not showing up, financial constraints, or other medical reasons. So with Boston Scientific, they have a pre-authorization portal that you can use.

You can use it for prosthetic urology but also for Rezum and SpaceOAR, so keep that in mind. If you use this portal, you can get benefits verification within two days. And they also help with employer exclusion, which is huge, because that can be up to 75% of non-coverage issues. So if you want to know more about this, then you should contact your Boston Scientific territory manager. The other thing is Boston Scientific has an amazing health economics program going right now, and they are really trying to blow open the market, just because there's more men out there that have ED that are just not being treated. So they're trying to liken the IPP to a total knee. So it's very fascinating stuff. I think they're really going to change the game and I would encourage you to partner with them if you're having issues with financial feasibility at your institution.

The other company, Coloplast, they kind of went about it a different route. They also have benefit verification. It's through a third-party vendor called Argenta. And then they started this program that I piloted with them. At first, it was called Cares. They're now calling it Informed Patient Program. And what it does is they try to figure out what is the most common reason that you have last minute cancellations. So you have your patient in the room, you're setting them up for surgery, you sign them up for the program. They have a little QR code that you can show the patient. I just don't give them the sheet and tell them to sign up at home. I watch them do it, because if I lay eyes on them, then I know it's done. And then once they do that, they start receiving notifications about either with the pre-surgery checklist, patient education about this surgery, again, insurance information. They also go through medical clearance and what to expect after surgery.

So intra-op, things that you can do is keep it simple, okay? So you want to streamline your preference card. My preference card at my institution, I tried to put a picture up here, but it was just a lot. It's very busy. So on our last page, you can write notes. So I just put exactly what I want, so hopefully, it kind of stops all the madness of everything being opened. The other thing you can do is peel pack essential disposable items. This is from Paul Perito in Miami, Florida. And basically, what it does, it just prevents your techs and your circulators from running around. So it is going to be patients getting in the room faster and turnovers to be a lot quicker. The other thing is you want to have consistent OR staff and circulator and tech. However, if you can't get that, I have this picture on my phone so if there's ever somebody new, I can shoot it to them and they know exactly what I need.

These are all the tools that I use for the whole implant, and that's it. The other thing is you can also have them refer to the Video Journal of Prosthetic Urology. There's a video by Ashley Tapscott on there, where she goes through operative setup, which is really good. So another thing that I started doing once I got into practice was doing pudendal blocks. So this is an article that we actually published recently, and it showed that doing pudendal blocks decrease intraoperative narcotic requirements. I found this out because one of the CRNAs at the VA that I practiced at came up to me and was like, why isn't everybody doing this? Your patients are not requiring so much pain medicine. So I decided to try to look at this and it did show a statistically significant decrease in the amount of narcotics given intra-op. So just last week at SMS, the group at Albert Einstein College of Medicine took this a step further.

So if you're decreasing narcotic requirements intra-op, what is that going to do immediately after surgery? And they found that it actually decreased their time in the PACU. So it's going to keep that flow of patients going through. Because remember, time is money, right? So next is what I've been doing post-op. So I had the vision of moving this to outpatient care. When I was coming through at MCG, everybody got admitted at least one to two nights. So I partnered with home health and then what they were doing was D/Cing the Foley on post-op day one and it will come back in D/C a JP on post-op day three. This was accelerated by Covid, but then it got hindered by nursing shortages. So I decided that I was going to empower and educate my patients to take part in their post-op care, so I have them D/C their Foley on post-op day one. And depending on the patient, if I trust them or not, I'll let them remove their JP or they'll come to a nursing clinic visit.

And then now my sweet spot is I float between home health and empowering the patient, just depending on the availability of home health and their insurance. So in summary, time is money. You just got to keep patients coming in, moving through, and then not having to be admitted afterwards. So you want to find the patients and get them into the OR. You want to set yourself up for success with your patient selection. You want to make sure your cases don't get canceled with benefit verification and using the tools from the companies to reduce cancellations.

Intra-op, I try to simplify my surgery as much as possible and do a pudendal block. And then post-op, I don't admit anybody and I try to partner with home health or teach patients of their aftercare. I also wrote up a four-page post-op care sheet that I give to my patients, however, most of them don't read it, but it's there if they ever want to review it. And then another thing that I didn't really talk about is patient educators. So I have patient educators from both companies. So these are patients that I operated on and had a good outcome and I use them to enable to talk to patients, and it kind of slows down the calls that I get. So I've done everything that I could and hopefully one day they'll just put me in and let me do surgeries.

Thank you.