Microbot Medical Inc. (MBOT) Earnings Call Transcript & Summary

Good morning, good afternoon, good evening for everybody who's joining us today. I think it's a perfect time to wish everybody happy holiday season. Happy Hanukkah. Happy New Year. Today is our second Access-Ability For All by Microbot. When we introduced Access-Ability For All, it wasn't just the Access-Ability for patients, for physicians, for healthcare providers, it was also Access-Ability for all other stakeholders, including physicians, investors, anybody else who has interest in how robotics will influence the healthcare in general and endovascular specifically. You are part of gaining this access. With your support, we can actually change how patients are being treated, no matter where they are around the world. In our last meeting, we had Professor Flacke from Beth Israel Lahey talking about his experience in the endovascular space and talking about how we saw the space evolving over the last decade or so. Today, I'm very excited to have our Chief Medical Officer, Dr. Eyal Morag, hosting Dr. Ripal Gandhi from Miami Baptist Health and talk about his experience not only in the endovascular space but also his personal experience using robotics in the endovascular space. Dr. Gandhi, Dr. Morag, the floor is yours.

Good evening, and hello to everybody. Thanks for attending. It gives me really great pleasure to introduce a dear colleague and a pioneer in the endovascular robotics. Dr. Gandhi is an international -- Interventional Radiologist and a senior member of the Miami Cardiac & Vascular Institute in Miami Cancer Center. He specializes in minimally invasive treatments for peripheral vascular disease, cancer and other nonvascular diseases. He has a long history as an innovator in the endovascular robotics field. He is an associate clinical professor at the University of South Florida, School of Medicine and Professor at FIU of Herbert Wertheim College of Medicine. Dr. Gandhi is deeply involved with the IR fellowship, regularly trains and teaches position in various endovascular and other interventional oncology techniques. He served as a research fellow at the NIH and has published his findings in several important scientific journals. He's also the author of several textbooks, textbook chapters and presented his research at national and international meetings. He is a Course Director for the International Symposium on Endovascular Therapy and Symposium on Clinical Interventional Oncology. Dr. Gandhi, welcome, and thank you for being with us.

Thank you for the introduction, the very nice introduction, and it's a pleasure to be here.

Yes. I think I would like to spend the first few minutes in this discussion kind of discussing your current practice, and I would love for you to share with us some of the most common procedures that you perform today.

Sure. We have a very unique practice. I think it's really a privilege to be where I practice in Miami. We have a unique group, we have a combination of interventional radiologists, vascular surgeons as well as diagnostic radiologists. It's a multi-specialty group. And we really do the full range of what I would consider minimally invasive vascular and endovascular procedures. A large part of my practice is dedicated to interventional oncology, treating a lot of patients with cancer [ with ] a dedicated cancer center. I also do a large volume of patients with peripheral vascular disease. We are a center of excellence for vascular disease, and we've done a lot of clinical trials in this space. Another big area of personal interest and something that we've been really growing is specifically the treatment of thromboembolic disease, DVT and especially pulmonary embolism. And that's an area that we're doing a lot of clinical trials on as well. And then, of course, we do the other full range of procedures, including dialysis and other general interventional radiology-type procedures.

Yes. I've been to your institution, and Miami Vascular is definitely a unique place. But still, if you can describe to us some of the challenges that you face today, I mean what are some of the main bottlenecks and obstacles in your -- in the current clinical practice, Miami Vascular?

Well, I think any institution has its own challenges and issues. I think, honestly, some of the major issues that I deal with today -- in today's day and age is really dealing with insurance companies, which really is not necessarily directly medically related or related to the procedure. But some of the procedures that we do, we get insurance denials. I'm seeing more and more denials for some of the procedures as we're trying to innovate and come up with new applications and new procedures. There are definitely more and more challenges there. So I'd say, that's probably my #1 challenge and probably the thing that I'd like to deal with least.

As far as other improvements or things that you think you might want to improve today other than the whole issue with insurance, I mean I'm talking about is it different equipment, manpower issues. I know some other practices are suffering from that workflow issues, any of that -- any of these factors?

Yes. No, I think in terms of those things, I think I'm very fortunate. We have really state-of-the-art equipment. We happen to have -- now our fluoroscopy equipment happens to be Philips, and we really have a state-of-the-art equipment there. So I'm very happy about that. I think similar to many practices or like most practices in the United States, given some of the issues related to COVID, we certainly had some manpower issues in terms of having adequate nurses and technologists, but we're really pretty much getting back to our baseline. So I think we're happy from that perspective. In terms of workflow, I mean probably like any place, we'd like to do procedures more rapidly, have more rapid turnover and get more done during the day and have more rooms. I'd love to have more partners. I would love to have more PAs. Probably like any other major practice, we can always do better. And if I had a wish list, those are all the things that I would really want.

I think you do have the unique combination of being exposed to the medical device industry and development of new products, but -- as well as the advancement in clinical approaches. So it's a really unique combination. Can you share with us some of the most exciting new technologies or products that you have experienced over the last few years?

I mean, there's -- I mean, it's a very broad question. I could definitely maybe touch on a few of them. I'm sure I'm going to be missing out on many as I think there are so many exciting areas, and we're definitely doing research in some of them, and I'm definitely seeing research out of other institutions for some of them. But some of the big ones, I think, if I were to group it by disease process, for aortic aneurysm therapy, certainly you're doing a more [ finished ] branch graft devices. I think that allows us to treat more patients than we have had been able to in the past, and there are newer and newer grafts. There is recently approval of [ utilization ] for a subclavian branch device in the U.S., and I think we're going to be expanding beyond that. In the dialysis space. We've had percutaneous AV fistula creation, which has developed over the last few years, and there's 2 major devices available in the market. And things which were traditionally done entirely surgically, we're able to do it percutaneously. So that really gives patients another option. I think that's exciting. Also along kind of the percutaneous bypass option for peripheral [ curl ] disease, there is a [ comp ] device called a PQ Bypass System where we're able to achieve essentially the same outcome or similar to outcome to a surgical bypass, utilizing entirely endovascular technology. So that's certainly promising. Mechanical thrombectomy for various different disease processes, including arterial thrombectomy, DVT. And pulmonary embolism is specifically an interest of mine. There have been many new technologies that they are introduced for mechanical thrombectomy as well as advanced thrombolysis with newer devices. So that is definitely very promising, and we're continuing to innovate in that area. And probably the last thing I would -- or last couple of things I would mention now is deep venous arterialization, is a unique procedure to treat patients who have no option, critical [ limb ischemia ]. We're exploring that. And there's various new treatments for cancer. And certainly, we are innovating and getting better at treating patients with, especially, liver cancer. We're looking at combining some of our immunotherapies with local regional therapies and looking at innovating in areas such as treating pancreatic cancer as well. I think some of these we'll learn more about in the coming years as some of these trials are currently underway.

Yes. So I mean, I think since we started our training right in the last 10 -- at least 10 years, it seems like we have really an amazing range of tools and technologies, which enable us to really perform procedures in a wild range of disease processes. I'm curious if you -- if there is an Achilles' heel in endovascular procedures today. What would that be for you?

That's also a very big broad-based question. I think if I were to talk about it. I think I'd have to talk about [indiscernible] disease process, for example. So when we're treating peripheral arterial disease or AV fistula or any AV graft for that reason, for that matter, restenosis is issue. If we could figure out -- and for coronary disease for that matter. If we could figure out a way to decrease or eliminate internal hyperplasia and restenosis, and we could -- we completely change the management of these patients. Imagine if we would never have to do a repeat intervention on a patient. So I mean, that's definitely a big issue of the peripheral arterial disease. If we're talking about aortic disease, I think, in the past, one of the things was dealing with short [ proximal ] aortic connects, where now we have [indiscernible], I think the new front here is going to be dealing with aortic arch disease and maybe with a complete endovascular treatment of the entire aorta. And I think the technology is getting better and better, and we'll ultimately get there. In terms of others, specifically cancer therapy, Achilles' heels is again trying to figure out what we would -- this thing known as an abscopal effect, meaning that you treat one area or treat one tumor and to have a response in other parts of the body, maybe in a patient with metastatic disease and our ability to combine immunotherapy with local regional therapies and actually induce an abscopal response. I think that is something that we got to learn more about. As well as treating other areas that we haven't been able to treat in the past, such as the brain -- with brain cancer. For example, we could treat patients with stroke, we could treat patients with intracranial AVMs, we could treat patients with intracranial aneurysms, but what about treating brain cancer? [ We've done ] some work in [ endovascular ] therapies. And I think these will be areas that we'll be exploring in the future for sure.

Yes, interesting. As far as guidewires and catheters, and I don't know what your experience is like, but I feel like we're reaching some sort of a plateau in development. I would like to kind of migrate to your robotic experience. And you have -- you are one of the very few IR physicians that have used endovascular robotics and performed, I believe, over 100 procedures. What was your experience like with endovascular robots?

Well, I have to say, it's definitely very exciting. Everything that we did was kind of first in the world. So every time we did a procedure, it will be first in the world of this type of procedure or that type of procedure. And we were constantly learning as we were doing every procedure, really didn't have any guidance from anybody else, but it was definitely an exciting time. I mean a few of the things that we kind of learned as we were doing this is one of the things that I really had a concern about was that I would lose my manual feedback or haptic feedback when doing procedures with the robotic system. And I think there is an element of that, but I realize that a lot of the -- what I imagine would be losing the haptic feedback, it tends to be a little bit more visual than you would actually realize. So that's definitely something that I learned. But basically, every procedure we did was new. It was fun, exciting. And we realized that clearly there's a first-generation robot that we were utilizing. But that -- that's just the beginning. And with further innovation, we can really, really get much further than we were with the first robotic system.

So what is the real attractiveness of using an endovascular robot? I mean you're really one of the few, starting this fall, using this technology. What attracted you to a robot? Why?

Yes. No, I think it's a great question. I think, I mean, if you look at other areas, we have robotics in a lot of different areas. When you look at automation, you look at -- you go to a medical device company and you ever see some of these medical devices, some of their stuff is done manually, but a lot of it is done with the robots. So you look at car -- building of cars, a lot of that stuff is almost entirely done robotically. In medicine, we're looking at laparoscopic and robotic surgery. And I thought this is a huge area. We're doing millions and millions of procedures, and we barely touched the surface. So why robotics? I mean, for me, I mean, look, I'm still -- I would consider myself kind of mid-career, but I see my older colleagues as well as even younger colleagues, I'm wearing this [ LED ] every day, it definitely takes its toll. I try to exercise and try to stay in shape. But there are times that my back hurts. And I mean anybody I know in this field, nobody is -- there's never -- there's not a single person I haven't met who hasn't had some type of orthopedic fatigue. There's certainly some ergonomics with -- when you're doing some of these procedures that no matter what you do, you're going to have some kind of strength. So that was number one. Number two, decreasing or ultimately eliminating radiation exposure, I think, is very important. We know that there are definitely deleterious effects of radiation. Cataracts, for sure, has been shown to be related to a specific dose of radiation. We do get concerned about long-term potential risk of cancer. There is -- I know there was one study, I think [ INJECT ], which showed increased risk of atherosclerosis in patients with significant radiation exposure. So to be able to decrease or eliminate that just for -- not just for myself but also for the patient, I think it was promising. Go ahead.

No, I'm saying, which robotic systems were you evaluating at that time?

Yes. At the time, we were utilizing the Magellan Robotic System. It was created -- build or created by a company known as Hansen Medical, which was current -- I think they were ultimately sold to another company. And they ultimately ended up taking it off the market. I think they're utilizing the resources for other systems or...

Yes. So there were significant barriers of adoption. I mean, this was not a widespread use?

Yes, there were. And I could tell you, I mean, I think there's a few issues in terms of adopting that robotic system. I mean, number one, it's a pretty large device. And I could actually show you a device at some point. I might have a couple of images in my computer, but it's a very large device. And that takes up significant space in the room. You have to have the special -- I mean the thing is heavy. You need special brackets and so forth to utilize it. And you couldn't -- you [ could ] pretty much just use that in one room. It was hard to move it from one room to another. So you kind of have to plan accordingly. Number two, I mean there's a significant expense. I mean, at that time, the device cost about $1 million, which we were able to get through some donation, but it wasn't something that could be widely adopted in the community. And then there is a cost to each disposable, which, again, at the time -- I don't remember the exact pricing. I want to say, it's about $4,000 to $5,000. I mean this is a significant cost for something where you're not really going to get reimbursed to that much. So you have the capital expense as well as the expense. And then finally, they -- you have to train people, you have to train the staff and setting this thing up, which honestly was no -- I mean it was a challenge. We have a lot of people. We have people -- we have a big lab, and training everybody or even training some of the people was a challenge.

So that the learning curve of the supporting staff as well as the physicians was an issue. You're not using currently a robot. Are you?

We currently aren't. I mean I was disappointed that the system was taken off the market. I think, with further iterations of that, we could get to the next level. But no, we did explore utilizing Corindus as a robotic system, but I think it was -- I think it's much better suited for coronary interventions. I didn't think it was ideal for some of the [ aforementioned ] ventures that we're doing.

And so given your experience with the Magellan Robotic System, what kind of prompted you to look for other technologies and kind of draw your attention to the LIBERTY Robotic System?

Look, I still believe in robotics. And I think what we need is a better robotic system. The potential benefits of robotics, in addition to the things that I mentioned, specifically, less operator fatigue and decrease radiation exposure, other potential benefits are decreasing procedural time, allowing for improved precision and catheter manipulation and guidewire manipulation, potentially reducing vascular trauma or eliminating or reducing catheter exchanges actually during some of these procedures. I think it also facilitates more complex procedures for operators with less foundations, such as fellows. We train residents and fellows at our institution, and I see this as a means of potentially training these physicians with less training and less experience and potentially getting them to that level much faster. And in exploring that, we came across the Microbot robotic system. And I think this is, I think, probably pretty well suited for the type of procedures or a lot of the procedures that I do. And I think it has certain benefits over the Magellan System for sure.

Yes. Can you kind of elaborate on that a little bit as far as the differences and why you think that, that is a better solution display?

Sure. I mean, again, I mean, they're very different robotic systems, and I don't think either one can replace it. But some of the issues that I discussed with the Magellan System, the Microbot system gets around those or overcomes them. So for example, and I can show you a picture here in a second, but this Magellan System was very large, very heavy, you couldn't move it around. And the Microbot system is very small. It's less than a kilogram. It doesn't take -- it has a very small footprint, it doesn't take up any space in the room, and there's no requirement for any capital purchase, which is very nice. This is a completely disposable robotic system. Number two, the console, the way we operated the Magellan Robotic System, it has a large screen, this large system. And it was nice. I mean it was -- you could sit there and utilize it. However, it's not -- again, you have to have a dedicated space where you kept this, and that was it and to have this almost like Xbox type of control system that anybody in my generation, especially people younger than me, have all been kind of brought on this. It's very easy to kind of adapt to that. And I thought that was very nice. I think the -- I mean, it was definitely a big process in setting up the Magellan System, whereas the Microbot system is very intuitive. And I like the fact that it doesn't require any special catheters. You can utilize off-the-shelf, we know whatever catheter and guidewire that you want to utilize, which really makes it very easy. You don't have to purchase any specific catheters in order to utilize it. In terms of training staff and having a dedicated room, that's not really an issue because I think, number one, the setup process is very easy, and you don't need a dedicated room. You can utilize this in any room that you want because you won't have a big, bulky device. So I think all of those things were very beneficial. And if I can, can I share my screen and...

Sure. Absolutely.

Just -- I think sometimes an image can be very beneficial. Are you able to see my screen?

Right now, it's...

Let me try it again. Sorry. Are you able to see that? It's not a full screen, but I think it does justice anyway. So anyway, here we have -- this is the Magellan Robotic System, which you can see it's a very large system. It's very heavy. This is actually the robotic catheter here that goes into the patient. And you can see it takes up pretty much the entire or almost half of the patient's bed here. Very large. And just to kind of compare and contrast that to, here's LIBERTY System by Microbot. And this is the little system, which actually controls the catheter and the guidewire, and this is the Xbox-like control system. So very easy. And just one final slide here, just showing you -- this is me utilizing the Magellan System, which had this giant hand -- this guide basically to guide the catheter and this dedicated screen. And here is the very different system. You're utilizing this tiny little hand control, and you could utilize any monitor inside the room or outside the room. So you can clearly see the major differences here and how this could really overcome some of the limitations that we have with the Magellan System for sure.

Yes. No, that's -- thanks for the illustrations. That makes a lot of sense. We don't have -- I could continue this discussion for a long time, but for the limitation of time, I -- if I -- if somebody could fulfill your wireless fantasies as far as the ideal robot and robotic procedure, talking about what the next 5 to 10 years would actually look like, how would you view that with your experience?

Yes. I mean, look, I think with any robotic system, it's going to -- like you're going to have a first generation or second generation, third generation -- like anything else. But if I had a wish list, I mean what do I want? I would want a device which would allow for, number one, better precision, better degrees of freedom and likelihood to decrease injury to the blood vessels, ability to get to vessels or -- much easier and to potentially democratize care. And what I mean by that is -- for example, let's talk about stroke intervention. There are many centers who don't have stroke intervention. And unfortunately, I mean, a few years ago, my grandmother passed away from stroke. And it was at a hospital where we had to give her tPA, and there was nobody on staff who could do a stroke intervention. I mean imagine if you could actually do this procedure from afar. And that's what I mean by democratizing care. I mean that's where I want to see this go. And that's where I could see that 10 years ago and -- 10 years from now. And there might be people who say, "Oh, that's a pipe dream." But I don't think it is. In fact, there was -- with the Corindus Robotic System, there were 5 cases which were published in the Lancet, which were done in India, where my parents are from, from Gujarat. And there were 5 patients that were treated [indiscernible] remotely, there were no complications. And that just showed us just proof of concept that this can be done. So that will be number one thing that I'd love to see. In terms of the robotic system itself, I wanted to basically allow for better precision. If there was a way to incorporate haptic feedback, that would be beneficial as well. I want to have it basically removed manual assistance from certain parts of the procedure. And right now, with any robotic system, it requires that. But maybe we can get to a point where you could eliminate that and you could deliver whatever type of therapy, whatever type -- its a stent or a balloon or an embolic therapy or whatever it may be completely remotely, which can be extremely beneficial, I think, for a lot of different things. And finally, I think there are times when we don't want to be in the room. I mean, the biggest example I could give you is COVID. I can tell you, at the beginning of COVID, we were all scared. Nobody wanted to do a procedure, nobody wanted to be in the -- and that -- I mean who knows in the future, maybe we're going to have some other type of pandemic, where imagine if we could do the procedures completely remotely and eliminate or reduce exposure to healthcare personnel. I can see that to be extremely attractive.

Yes. I know there were some descriptions of procedures performed remotely. And during COVID, for that reason, the staff was just not available. So guidance was given remotely. They talked about image analyzed -- convergence of technologies with AI and image analysis and 3D navigation. And some people talk about VR and AR kind of using a vascular GPS system. So I guess we can fantasize about these things. And I hope that we're actually going to be involved in developing them. That's great. I would love to continue this fascinating discussion, but time is kind of up. So I really want to thank you for joining us and for your great input. And I open this for questions. Or Harel, you can take over.

Thank you very much, and thank you for the invitation. It's been a pleasure being here.

Yes, it was great. Thank you.

Thank you, Dr. Gandhi and Dr. Morag. This was fascinating, really. Thank you. And we have two questions that just came in. The first question is for you, Dr. Gandhi. And it says, how do you see the endovascular space in general? And do you believe it's growing and why?

Yes, that's a great question. I mean, I think there is data on this, and I don't happen to have that data in front of me. But just looking at my own experience and seeing what we're doing and just speaking to colleagues across the country, it seems like it is definitely growing. And I think that's probably secondary to various reasons. Number one, we're constantly innovating, and there are newer and more procedures that we can do endovascularly that we couldn't do in the past. Just some examples, some applications for cancer therapy, some of the newer therapies in embolization such as prostate artery embolization patients who are -- that was an option that we didn't have 5 years ago, 5 to 10 years ago or things that we're now looking at doing embolization for patients with arthritis. Maybe the next frontier might be treating patients with obesity, with the left gastric embolization. More research phase right now. But my point here is that we're developing newer and newer applications that -- for procedures that we can do endovascularly. In addition, the aging population in the U.S. and the baby boomer population, I'm just speaking in the U.S., but internationally, I think overall, these procedures will continue to grow as we develop new applications and newer techniques.

That's wonderful. And we are almost out of time. So I'd like to ask you one final question before Harel closes the session for us. How do you think LIBERTY Robotic System compares to other devices you have used in the past? And I know you touched on that.

Yes. So I mean I think there are some of the things that I mentioned before. But I think, again, having a system which I think any lab in the country, not just very dedicated or university-based programs or programs that have a lot of money you can purchase, but something that any lab can actually obtain, which is very user friendly. And honestly, with the younger physicians, I mean I think you can train probably residents and fellows to do these procedures very quickly with these because they're used to doing these things. And interestingly, there was actually -- when we're looking at the Magellan System, there was actually an old study, which looked at data with an older Sensei robotic system, which is where they looked at a fellow utilizing the robotic system, and they compared it to an attending utilizing a manual technique. And actually, the robotics -- the fellows utilizing robotic technique function as well as an attending utilizing a manual technique. Now, some of us who are a little more arrogant will say, I don't know who the attendings were, were they really -- but I think the point here is I think there is a lot of promise here, and there is definitely the ability with this LIBERTY system to allow for, I think, easier training for residents and fellows to get to a certain level of expertise much faster. And I think anybody in the world should be able to utilize the system. And you don't need dedicated staff, you don't need a dedicated room. We don't have this large device with the capital purchase. I think it really has a lot of tremendous benefits over prior systems, which we've utilized.

Thank you, Dr. Gandhi, and thank you Dr. Morag for this very enlightening discussion. For everybody on this call that listened to you, I want to remind you that we will be at JPMorgan the week of January 12 in San Francisco. And anybody who wants to see a live demo, is welcome to join us to reach out to the company and try to schedule a live demo. We will be there for the entire week of JPMorgan. During JPMorgan, we will also have another session of Access-Ability Life by Microbot, where this time we will talk to some industry experts after we heard from 2 leading physicians. We're going to hear from an -- from a couple of industry experts about how do they see, from corporate America to the early-stage companies, the endovascular space and the role robotics and the ecosystem around robotics. With this, I would like to wish everybody again happy holiday season. Happy New Year, and thank you for joining us.

Thank you, all. Thank you, Dr. Gandhi.

Thank you very much. Bye-bye.