Is minimally invasive PCNL suitable for outpatient settings? In this master class, Dr. Julio Davalos of Chesapeake Urology gives practical tips and considerations for transitioning MIP cases from the hospital to the ASC.
So I'm gonna be chatting about transitioning from impatient or hospitalized hospitals setting for P C N L to outpatient so outpatient can encompass. Uh, you know, two different areas we can talk about outpatient in the hospital where a patient comes in, has a procedure. You have the option, thio. Observe them overnight, or you can send them out the same day. Once you get comfortable with that, then you can start to consider again. I think Onley with move over this on Lee with a very skilled team and season team, could you then consider, um perhaps shifting your peace and I'll practice to a true outpatient setting in an inventory setting. So, you know the first PC nl? Certainly. This is not a new procedure. Um, you know, the procedure was performed 1976. I think when we talk about standard PC NL, we kind of look at what was done in the 19 eighties as the standardized approach which is ir changed. The access things were done in the hospital setting. We use the ferocity tubes in many cases, very large tubes aan den. I think generally that that is probably the step that led to hospitalization. Generally, of course, there are other considerations in terms of, um, you know, the risk associate with the procedure. But I think that when we talk about P. C N l, we have to kind of understand that there's historically maybe the 19 eighties PC NL's and to what we can do today. And I think this talk in particular this topic about the mid system and the many p c n l. Which is the myth M system really lends itself to, uh, considering outpatient surgery. Hi there. So the first publication for an outpatient PCL actually came from Darren Beko back in 09 And then he published a series in 2010. Um, I was had just kind of started into my higher volume peace and all practice around that time and I, you know, seen these publications kind of piqued my interest into the possibility of Transitioning PCL to an outpatient setting. Dr. Abbott and I reported our first case report back in 17 but we started doing outpatient cases really back in 11 4012 in our first A C cases in 2015. So we're about five years under our belt on then? Of course, The doctor, sir, And said Dr Beaches have published their stories a couple years ago. Next, Right, So I have some recommendations, a little bit of transition planning and then specifically talking about you know, how Mitt will sort of really fits nicely into into this kind of thinking. So again, my recommendations are you do wanna have high case volumes before you consider, at least in ambulatory setting. Um, even an outpatient setting, I think, in the hospital is something that you would wanna have, you know, a fair amount of experience under your belt before you. Really? You try this. Uh, in some cases, I've talked to groups where there's multiple physicians performing piece. You know, I agree that, you know, we wanna make this an inclusive thing where many could do this. But I think early on, you wanna have high volume centers and high volume teams. Most of my O R. Team has performed over 1000 piece NL's with me. Some of them were 1500. Now on we use the same anesthesiologists. We use the same scene arm text, so it really makes for a very ah like a well oiled machine, if you will. And that's really the kind of set up you want before you start to consider moving thing and moving anything like this to an outpatient or certainly an inventory setting next line. But when you look a transition planning, there's clinical, operational and financial, and I think that's true of almost any program you know you can't really have. If one of these fails, then you're not gonna be able to move a program forward. Um, clinically, Um next, Like Jamie clinically, we look at my ex wife. Thanks. So this gets asked a lot. You know who are patients that can be done in outpatient setting, in which patients are ones that cannot be. Five years ago, I would have had this list would've looked a little bit different. In other words, I would have had, I think, a lot more defined characteristics as to what can or can't be done an outpatient setting today. What I would say is that really, with the more experience that you gain, the thing that really keeps you from doing this as an outpatient is gonna be the medical stuff, So it's not really gonna be stone burden. It's not gonna necessarily be stone location or density or Perry real anatomy, these air things you have to consider. But once you gain enough experience with this, you know we've taken care of staghorn stones in the A S C. We've taken care of multiple diverticular stones in the A S C. We've done multiple tracks. We've done, you know, super sub costal access. So you know. But in the beginning, you, of course, want to take on. I think again this the nips system. The MIDEM system fits nicely here because in that 10 to 20 millimeter stone size, that tends to be more straightforward. Many P c N l. I think that one is a great one to choose for an outpatient or a SC setting. But today, the things that limit us our major cardiac and pulmonary issues B. M I is about 40 can be tough about 50 or basically an absolutely no. Then I would caution you about the other three on the list. The patient has chronic pain. You really want to be, you know, thinking about the fact that you may not want to do them in an ambulatory center. And if they have a straightforward case in your mind, otherwise, infection risk. You know, if you really suspected the patient may need i v antibiotics beyond just, ah, single dose that you're able to give it an ambulatory setting or a couple doses that somebody may want to take to the hospital And then, of course, bleeding risk. So if anybody has a bleeding risk, Um, clearly, those were cases you would not want to be. Uh, you know, out on the limb they're trying to take care of of an issue like that in the in the place, that would be difficult to do. So next slide. So clinically, I think the main thing is that I sort of drive home or you want urologists obtained renal access. I'm a big proponent of that. Roger. You have a great talk on using ultrasound. I think whatever technique you use if you get good at it and you get efficient at it, the thing I tell everybody is make sure you have great access. I think we can all agree that if you have great access, you're gonna have a great case again. Uh, experience if you wanna think about an ambulatory setting, particularly true A S C. That's free standing 100%. You need to do a lot of outpatient cases in the hospital setting. First, I would say between 50 and 100. And what I would recommend is that you actually try to predict before you do the case, who who's gonna go home and who's not? And then you track your results. Because once you get to an inventory setting in A S C, um, if you're wrong, that means you're gonna be transferring patients. Be annoyed, ambulance most of the time. And that's something you want to try to minimize. And then again, pain management. We we now start with pain management on nausea management even before they hit the door. Almost because that's going to be the things that would really tie up again to ambulatory setting, where you may not have as much ability to tow, watch patients or keep patients or a large number of patients for extended stays. Overnight states next slide close. Procedurally, I think you know you want to get patients as much information as you can set expectations. What I found that was kind of incredible was that once the patient knew they were doing this isn't as an outpatient or in an ambulatory setting. It's like the whole mindset changes much like I think the surgeons mindset may change. So it sort of come in with the expectation that they're gonna, you know, have a procedure. Yes, it's gonna be uncomfortable and painful as many you know, a Xeni. Oh, our case. Maybe any surgical procedure, I joke with my patients. I have yet to figure out how to do painless p c N L. But I'm working on it on dso if you can set those expectations A zoo. We talked about the Seth mentioned this. The MIPS system really lends itself to being to bliss, as three mentioned. Totally toothless is even better. The less drains patients have post op, the less pain they're gonna have. Post op. Of course, you have to be selective about how you do that and how you approach it. But I think that minimizing drainage tubes, eyes something that this nip system really lends itself to. And I'm a big advocate of that on then. You know, I have a cocktail of medications and instructions that get patients. I think it's also important to have all that set up a next side. So operationally, I think you need to think about the infrastructure, particularly you're gonna be building an A S C or moving into an A S C. There's certainly equipment and technology. Euro are set up what disposals you may need. But then the thing I really highlight is workflow. If you if you don't, if you have a good work flow down, then you're gonna be able to transition through your day much, much better. We could do about four of these in a day and be done by 4 p.m. So four by four is our goal for peace emails by 4 p.m. I'm not saying we pull it off every single time, but we pull it off with pretty consistent results. And that has a lot to do with your workflow, both from the pre op and clearance and patient selection all the way through how you register the patient, how they come through the pre op area, how your o. R. Team kind of functions. Number of scope sets. You have many, many things to consider to get that workflow optimized next slide. So your infrastructure, you know, I personally think having a nice sizable room is helpful. I've done these in what I call a closet. Oh, ours before means, you know, you can do these anywhere. But I think if you have a good sized room, it does sort of allow for, ah, greater efficiency of equipment, kind of moving out of the way, but not necessarily out of the room. And then patients in and out of the room a little bit quicker. A zai mentioned before You wanna have a good pre op area, good, adequate pack you beds and you want to really consider again in the true A S C. Are you gonna be keeping patients overnight or not? In our practice, we opted to We actually weren't allowed to keep patients overnight. Even though the federal law allowed it. The Maryland State law didn't. So in some ways, I think the SCP CNL program took off because of the fact that I wasn't able to keep him overnight. I think if I was given that option five years ago, if state the state of Maryland had said you can keep your patients overnight, I would have done it, but because they said you couldn't and we wanted to sort of move in this direction. We kind of slowly tiptoed in that direction, and it worked out our average pack. You Time is just a little bit over 90 minutes now, so it's incredible how you can watch these patients. And I think, and you know, we're not discharging them inappropriately. We they meet all parameters for discharge, generally within 80 to 100 minutes in some patients can meet the discharge criteria even faster. Next slide. Let's just keep going. So there's a lot of equipment and technology. Want to keep my eye on time here, So let's just keep moving forward. Eso You know you've seen I think at least one other picture of a no are set up. You know, I had to use this panoramic to get the whole or in equipment in there, and that's just the kind of the point of this I'm happy to share are set up with anybody who wants it. But the bottom line is that you've just got a lot of equipment, a lot of stuff, and I think the more that you can manage a system that works for you away. You could get a patient in and out without having to really kind of, you know, redo the room every times I think helpful next slide. And this is really what I alluded to earlier. So the workflow, you know, it starts with preoperative. It starts with patient selection and knowing what things to look for, um, asking the right questions. You know, I've asked patients before if they have any harder, long issues, even though their history says it's negative and they'll say, Oh, you know, somebody told me I had sleep apnea once and I never got it looked into. And that's something that, on the day of the procedure, if that comes up, that may be something the anesthesiologist doesn't want to move forward. And especially in a SC setting, you're checking process again, as already mentioned, the or set up instrumentation. So again, one nice thing about the MIPS system and the M, as as I think is a sweet spot, is that you know, you've got reusable, uh, equipment. You've got low cost of ah, capital cost Onda again. You wanna have multiple sets. If you're looking to create an efficient system, backup equipment and we have at least two lasers again, that can get expensive. But you don't really want to be caught without a backup and then developing good discharge criteria. Just having experienced even the pack you team not just necessarily experienced over our team or surgeon. But even in the pack, you wanna have good nurses that really have dealt with a little bit more higher acuity patients so that they could really manage your patients appropriate next line. So I just talk a little bit about financial. Um, I think it's safe to say that in most payer mix is, um, Medicare comprises about 25%. Again, this is just a general average. This is not a specific. That means the commercial takes up about 25%. So one thing about kidney stones is that they don't affect patients over age 65. Like many of the BP, many of the urology conditions like BPH might or O A. B s. Oh, you've got kind of a full spectrum of patients. That means you've got a good number of patients that are in their thirties and forties and fifties who, you know, may have better commercial insurance. And this could be to your benefit, especially if you're looking at are the program where your financial on the hook for this next slide eso you wanted, You know, with any with any financial plan you want to determine your fixed costs, you want to track variable costs, and that's gonna give you a pretty simple equation to determine profitability. The next slide. So again, back to the MIPS system, the nice thing about Mitt is that it is a p c N l. So it isn't. It is not a different CPT. Co. We're not re inventing the wheel here. You can use the very same codes that are used in the hospital in your surgery center setting. It depends on the stone burden under over 20 millimeters. While it's true that the MIPS system they lend itself to the 10 to 20 millimeter stone size, we have used it on stones up to 30 35 millimeters very effectively. I mean, I would say that a good number of our many perks and r m p C N L r. Five years or 81 cases um, at least where I am again. None of this is. You know, all these comments about coding and financial is gonna be very different from state to state and region to region and certainly different countries that this may not apply it all. But, you know, at least even though the 81 and 80 code may reimbursed differently from a professional fee, we find that we get the same commercial. I'm sorry we get the same facility fees for both. So that's actually very nice, because if you've got a system like Mitt M where you can reuse much of the much of the equipment, you're still going to get paid the same whether you're doing ah, smaller stone or a larger stone, but the other the other take home messages. You gotta negotiate your rates on. Do you know if you're in a large enough group or if your group has enough of a presence, then you know you are able to kind of go to the commercial cares and say, Look, you know, we do it for about 30% less than the hospital on DSO. That's made it attractive for all the commercial carriers toe. Want us to do these in the surgery center last week, I had to get on to. This is a negative word of caution. You know, last week I had to get on to calls to sort of tell these insurance companies why I can't do it in the surgery center. So once you start doing this in the surgery center, they're gonna want everybody done there, even the sicker patients. But you just have to take the time to tell them. Look, we can't do everybody there. There are certain cardiac pulmonary issues. B m I issues where you know that's not gonna be You're not gonna able to do this in our patients Next slide on that zall I got. I tried toe kind of get speed through that to get us caught up a little bit and then we're over time. But, you know, I think turn it back over the Roger RMC Thank you. Great. Thank you. Leo Sri and Seth. Julio, I I got a question for you. Could you just recap if someone wanted to start doing outpatient PC NL's? What would be a good starter patient or what is the Can you summarize the criteria. Yeah, so at great question. Roger. So, you know, backing up to 2015 The very first patient I operated on was a patient on whom I had done a contra lateral procedure at the hospital. And he had done great on DSO before. And so he was an ideal patient that take into an ambulatory setting because I was doing the opposite side of the news outcomes. That's what makes, uh, say as a preface. So you wanna pick a patient that you know, passes the eyeball test so you're not too worried about them having pain issues, You know, they're not too skinny, not too fat. I think all of us know that patients that are very, very thin can sometimes be a challenge as well for p c N l. Because of the access on the hyper Mobil kidney. So you know, patients whose are kind of medium sized, no harder long issues eso medically a good candidate. And then I would, you know, obviously like if you can pick up 15 millimeter renal pelvis stone. You know, I think that's that's a great case to start with, um, again, you know, start out simple and then increased complexity. I will say this and you know, three talked about it. You know, when you're looking at these cases that are between 10 and 20 millimeters, you can do them. You read risk optically. But what I find that what we're sort of trying to show with some of the data that we're collecting is that we just get better outcomes with the mini with the mini p c N l With the myth M, we're able to make them stone free, were able to still send them home the same day. Um, you know, you can again consider no tubes at all or just a stent, which is the same is that you re Doris Copy. We could take stents out within 48 hours. Eso there. I think there are many advantages, but you have to have that level of comfort with doing P c N l. In general and then doing transitioning to a mini, and I think it really lends itself to this outpatient setting. But, you know, keep it simple. Avoid large VM. I's avoid complex patients, medically or surgically in the beginning. Once you've got 10 or 15 patients under your belt. Then you can kind of start. You know, Thio, expand your criteria. You know, if you look back at the 1st 25 I did, I'm sure that they were all, you know, just the most ideal cannons. And it took me a year to do 25 cases. You know, we do 25 a month now, but in the beginning, there was a year to do 25 a C cases.
