直覺手術 (ISRG) 2018 Q4 法說會逐字稿

Ladies and gentlemen, thank you for standing by. Welcome to the Intuitive Surgical Q4 2018 Earnings Release call. (Operator Instructions) As a reminder, today's call is being recorded.

女士們、先生們，感謝你們的耐心等待。歡迎參加直覺外科公司2018年第四季財報發布電話會議。（操作員說明）提醒您，今天的通話將會被錄音。

I will now turn the call over to Senior Director of Finance, Investor Relations, Calvin Darling. Please go ahead, sir.

現在我將把電話轉交給財務高級總監兼投資者關係主管卡爾文·達林。請繼續，先生。

Thank you. Good afternoon, and welcome to Intuitive Surgical's Fourth Quarter Earnings Conference Call. With me today, we have Gary Guthart, our President and CEO; and Marshall Mohr, our Chief Financial Officer.

謝謝。下午好，歡迎參加直覺外科公司第四季財報電話會議。今天和我在一起的還有我們的總裁兼執行長 Gary Guthart；以及我們的財務長 Marshall Mohr。

Before we begin, I would like to inform you that comments mentioned on today's call may be deemed to contain forward-looking statements. Actual results may differ materially from those expressed or implied as a result of certain risks and uncertainties. These risks and uncertainties are described in detail in the company's Securities and Exchange Commission filings, including our most recent Form 10-K filed on February 2, 2018, and 10-Q filed on October 22, 2018. Our SEC filings can be found through our website or at the SEC's website. Investors are cautioned not to place undue reliance on such forward-looking statements.

在開始之前，我想告知各位，今天電話會議中提到的評論可能被視為包含前瞻性陳述。由於存在某些風險和不確定性，實際結果可能與明示或暗示的結果有重大差異。這些風險和不確定性在公司向美國證券交易委員會提交的文件中均有詳細描述，包括我們最近於 2018 年 2 月 2 日提交的 10-K 表格和於 2018 年 10 月 22 日提交的 10-Q 表格。您可以透過我們的網站或美國證券交易委員會的網站找到我們向該委員會提交的文件。投資者應注意，不要過度依賴此類前瞻性陳述。

Please note that this conference call will be available for audio replay on our website at intuitive.com on the Latest Events section, under our Investor Relations page. In addition, today's press release and supplementary financial data tables have been posted to our website.

請注意，本次電話會議的音訊回放可在我們網站intuitive.com的「最新動態」欄位下的「投資者關係」頁面中找到。此外，今天的新聞稿和補充財務數據表已發佈在我們的網站上。

Today's format will consist of providing you with highlights of our fourth quarter results as described in our press release announced earlier today, followed by a question-and-answer session.

今天的會議形式將包括：首先向您介紹我們今天早些時候發布的新聞稿中所述的第四季度業績亮點，然後進行問答環節。

Gary will present the quarter's business and operational highlights. Marshall will provide a review of our fourth quarter financial results, then I will discuss procedures and clinical highlights and provide our updated financial outlook for 2019. And finally, we will host a question-and-answer session.

Gary 將介紹本季的業務和營運亮點。馬歇爾將回顧我們第四季的財務業績，然後我將討論流程和臨床亮點，並提供我們更新的 2019 年財務展望。最後，我們將舉行問答環節。

With that, I will turn it over to Gary.

接下來，我將把麥克風交給蓋瑞。

Thank you, Calvin. Entering 2019, our business is showing strength. In 2018, over 1 million surgeries were performed using da Vinci systems, accompanied by approximately 1,500 peer-reviewed clinical journal articles. The total number of procedures performed since first launch exceeded 6 million and the total peer reviewed clinical database contains over 16,000 articles.

謝謝你，卡爾文。進入2019年，我們的業務展現出強勁勢頭。2018 年，使用達文西系統進行了超過 100 萬例手術，並發表了約 1500 篇同行評審的臨床期刊文章。自首次推出以來，已完成的手術總數超過 600 萬例，同行評審的臨床資料庫共收錄了超過 16,000 篇文章。

While these milestones represent a step forward, I believe that outstanding product design, robotics, advanced imaging and informatics are just starting to take their place in surgery and in acute interventions more broadly. Surgery and acute interventions are sophisticated interactions among highly trained professionals. They have a common goal of delivering outstanding care to a patient in need. Starting with a careful understanding of operating and interventional environments, engineers and interaction designers collaborate closely with physicians to develop smart, connected devices with the goal of the quadruple aim. First, decreasing complications; second, increasing patient satisfaction; third, increasing care team satisfaction; and fourth, to improve the efficiency and lowering of the total cost to treat.

雖然這些里程碑代表著向前邁出了一步，但我相信，傑出的產品設計、機器人技術、先進的成像技術和資訊學才剛開始在外科手術和更廣泛的急性幹預中佔據一席之地。外科手術和急診介入是訓練有素的專業人員之間的複雜互動。他們擁有一個共同的目標，那就是為有需要的患者提供卓越的醫療服務。工程師和互動設計師從對手術和介入環境的深入了解出發，與醫生緊密合作，開發智慧互聯設備，以實現四重目標。首先，減少併發症；其次，提高病人滿意度；第三，提高護理團隊滿意度；第四，提高效率並降低治療總成本。

Considering our current da Vinci systems and the procedures and countries that are our focus today, we believe applicable procedures exceed 5 million annually. As we consider our new concepts coming to market, including but not limited to: our da Vinci single port system; our advanced imaging technologies; and our Ion flexible catheter system, the long term total opportunity for our products to make a positive difference in physicians and their patients' lives is greater still.

考慮到我們目前的達文西系統以及我們目前關注的手術流程和國家，我們認為適用的手術流程每年超過 500 萬例。隨著我們考慮將包括但不限於以下產品推向市場的新概念：達文西單端口系統；先進的成像技術；以及 Ion 柔性導管系統，我們的產品在長期內為醫生及其患者的生活帶來更大的積極改變。

Given the positive response of our customers and in pursuit of the substantial opportunity to improve surgery and intervention that lies ahead, we plan to accelerate some investments over the next several quarters. We'll review our guidance on spend later in the call.

鑑於客戶的正面回饋，以及未來在改善手術和介入治療方面存在的巨大機遇，我們計劃在未來幾季加快一些投資。我們將在稍後的電話會議中回顧我們的支出指導。

Given our prerelease this month, I'll be brief in summarizing our 2018 highlights.

鑑於我們本月即將發布新品，我將簡要總結我們 2018 年的亮點。

Global procedure growth was strong, with approximately 19% growth in the fourth quarter and 18% for the full year. Growth in procedures was largely consistent through the year, with United States showing particular strength in hernia repair, colorectal procedures and practice-related general surgery procedures, including cholecystectomy. Mature procedure growth in the United States, including prostatectomy and hysterectomy, was solid again in 2018, though we expect slowing in these mature procedures going forward in some countries.

全球手術量成長強勁，第四季成長約 19%，全年成長約 18%。全年手術量成長基本上保持穩定，其中美國在疝氣修補術、結直腸手術和與實踐相關的普通外科手術（包括膽囊切除術）方面表現尤為強勁。2018 年，美國成熟的手術計畫（包括前列腺切除術和子宮切除術）的成長依然穩健，但我們預計未來一些國家的成熟手術計畫成長速度將會放緩。

In Japan, procedures grew over 40% in the second half of 2018, in response to additional reimbursements granted in Q2. Aggregate European procedure performance was generally in line with our expectations again this quarter, with particular strength in the U.K. and France. Calvin will review procedure trends in greater detail later in the call.

在日本，由於第二季額外給予的報銷，2018 年下半年手術量增加超過 40%。本季歐洲整體手術量表現總體上再次符合我們的預期，其中英國和法國表現尤為強勁。卡爾文將在稍後的通話中更詳細地回顧手術流程的發展趨勢。

Our capital placement performance in 2018 was also strong, with growth in total placements rising 35% from 684 in 2017 to 926 in 2018. Net of trade-ins and retirements, our da Vinci installed base grew 13% over 2017. The mix of system placements between our flagship Xi System and our value X System generally aligned with our strategy regionally.

我們在 2018 年的資本配置績效也十分強勁，總配置量從 2017 年的 684 項成長到 2018 年的 926 項，成長 35%。扣除以舊換新和退役設備後，我們的達文西手術系統安裝基礎比 2017 年增加了 13%。我們的旗艦產品 Xi 系統和經濟型 X 系統之間的系統部署組合，總體上與我們的區域策略一致。

As we discussed on our last earnings call, customers are interested in leasing and alternative capital placement models. The proportion of the systems placed under lease increased again in the quarter, from 25% in Q3 of 2018 to 29% in Q4.

正如我們在上次財報電話會議上討論的那樣，客戶對租賃和替代資本配置模式很感興趣。本季租賃系統的比例再次上升，從 2018 年第三季的 25% 上升到第四季的 29%。

Financial highlights of our fourth quarter results are as follows: revenue for the quarter was over $1 billion, up 17%; pro forma gross profit margin was 71.8% compared to 72.4% in the fourth quarter last year; instrument and accessory revenue increased to $539 million, up 18%; total recurring revenue in the quarter was $722 million, representing 69% of total revenue. We generated a pro forma operating profit of $412 million in the quarter, up 7% from the fourth quarter of last year; and pro forma net income was $353 million, up 16%.

我們第四季業績的財務亮點如下：本季營收超過 10 億美元，成長 17%；以備考計算的毛利率為 71.8%，而去年第四季為 72.4%；儀器和配件收入成長至 5.39 億美元，成長 18%；本季經常性收入總額為 7.22 億美元，佔總收入的 69%。本季我們實現了 4.12 億美元的備考營業利潤，比去年第四季成長了 7%；備考淨利潤為 3.53 億美元，成長了 16%。

We launched the Intuitive Foundation with an initial contribution of $25 million in the quarter. The Intuitive Foundation's mission is to support clinical and technology research in acute interventions as well as philanthropy in the communities which we serve and in which we live.

本季我們啟動了直覺基金會，初始捐款額為 2,500 萬美元。直覺基金會的使命是支持急性介入的臨床和技術研究，以及在我們服務和居住的社區進行慈善活動。

Financial highlights for the full year 2018 results are as follows: revenue for the year was $3.7 billion, up 19%; pro forma gross profit margin was 71.5% for the full year compared to 71.9% for 2017; instrument and accessory revenue increased to $2 billion, up 20%; total recurring revenue in the year was $2.6 billion, representing 71% of total revenue. We generated a pro forma operating profit of $1.5 billion in the year, up 17% from 2017 and pro forma net income was $1.3 billion, up 23%, with the difference in growth rate between operating profit and net income largely driven by the 2017 Tax Act and interest income earned.

2018 年全年財務亮點如下：全年營收為 37 億美元，成長 19%；全年毛利率為 71.5%，而 2017 年為 71.9%；儀器和配件收入增至 20 億美元，成長 20%；全年經常性收入總額為 26 億美元，佔總收入的 71%。本年度，我們實現了 15 億美元的備考營業利潤，比 2017 年成長了 17%；備考淨利潤為 13 億美元，成長了 23%。營業利潤和淨利潤成長率之間的差異主要受 2017 年稅法和利息收入的影響。

Looking ahead, a review of clinical outcomes for complex surgery and acute interventions across large populations still highlights a substantial need for improvement. We measure our efforts by their ability to positively impact the quadruple aim. Real progress requires more than minimally invasive tools and more than digital technologies. These technologies are necessary but not sufficient.

展望未來，對大量人群複雜手術和急性介入的臨床結果進行回顧，仍凸顯出亟需改善。我們衡量自身努力的標準是：這些努力能否對四重目標產生正面影響。真正的進步需要的不僅僅是微創工具和數位技術。這些技術是必要的，但還不夠。

We believe intelligent surgery takes the integration of 3 elements: first, a deep understanding of human interactions that inform holistic system design; second, the development of high-quality smart and cloud connected robotic imaging and instrument systems; and lastly, informatics and AI to deliver relevant validated insights.

我們認為智慧手術需要整合三個要素：首先，深入了解人類互動，從而指導整體系統設計；其次，開發高品質的智慧雲端連接機器人成像和儀器系統；最後，利用資訊學和人工智慧提供相關的、經過驗證的見解。

While we've made significant progress over our history, we believe continuous improvement is required and we've deployed our investments toward these aims.

雖然我們在過去的發展歷程中取得了顯著進步，但我們相信需要不斷改進，並且我們已經將投資用於實現這些目標。

We're bringing together several efforts in pursuit of our mission. We are early in our Phase I launch of da Vinci SP. We've installed 15 systems in 2018 and a few hundred procedures have been performed to date. Surgeon and patient feedback have been positive for usability and patient experience in these early days of launch.

我們正在整合多項資源，以實現我們的使命。我們目前正處於達文西SP第一階段推廣的早期階段。2018 年我們安裝了 15 套系統，迄今已執行了數百項操作。在產品推出初期，外科醫師和病患的回饋都對產品的易用性和病患體驗給予了正面評價。

We submitted our 510(k) for our second indication, transoral robotic surgery in Q4 of 2018 and are responding to FDA questions on this second indication. We are also working through supply chain optimization, as we begin to ramp production for SP, in addition -- in anticipation of additional clearances in broader launch.

我們在 2018 年第四季提交了第二個適應症——經口機器人手術的 510(k) 申請，目前正在回應 FDA 關於該第二個適應症的問題。隨著 SP 產量的逐步提高，我們也在努力優化供應鏈，同時預計在更廣泛的上市中獲得更多許可。

Our first step into flexible diagnostics, Ion, is nearing Phase I launch. We submitted our 510(k) in 2018 and have responded to FDA questions this month. We anticipate a Phase I limited launch of Ion in 2019, focused on the need for definitive early diagnosis of suspicious lesions for lung cancer.

我們邁向靈活診斷領域的第一步—Ion，即將進入第一階段發布。我們於 2018 年提交了 510(k) 申請，並在本月回覆了 FDA 的問題。我們預計 Ion 將於 2019 年進行 I 期有限上市，重點是早期明確診斷肺癌可疑病變。

In instruments and accessories, we plan to broaden the launch of our SureForm 60-millimeter stapler for da Vinci in the first half of 2019. The 60-millimeter stapler is used primarily in abdominal surgeries, including bariatric surgery. Surgeon response has been encouraging and our team has performed well in establishing its supply chain.

在儀器和配件方面，我們計劃在 2019 年上半年擴大 SureForm 60 毫米達文西縫合器的上市範圍。60毫米吻合器主要用於腹部手術，包括減重手術。外科醫生的回饋令人鼓舞，我們的團隊在建立供應鏈方面表現出色。

Over the past several years, we have been increasing our cloud computing and informatics capabilities. Today, we routinely deliver programmatic insights to customers using our systems, which have been smart and connected for the past decade. We believe there are opportunities to further enhance these capabilities. Our advanced imaging programs and augmented reality programs are making progress. We anticipate first clinical use of our augmented reality program in 2019.

過去幾年，我們一直在提升雲端運算和資訊技術能力。如今，我們利用過去十年來一直智慧互聯的系統，定期向客戶提供程序化洞察。我們相信這些能力還有進一步提升的空間。我們的先進成像程序和擴增實境程序正在取得進展。我們預計擴增實境程序將於 2019 年首次應用於臨床。

As described in our pre-release, we've also been increasing investments in building our business operations in countries important to our future. Our efforts in China will accelerate in 2019, with the da Vinci distribution arm of Fosun Pharma, Chindex, joining our joint venture this quarter. Combined with the release of the next system quota and the clearance of da Vinci Xi in China, we will be accelerating investments to establish our base to serve China over the long term.

正如我們在預發布版本中所述，我們也一直在增加對對我們未來至關重要的國家的業務運營建設投資。2019年，我們在中國的努力將加速推進，復星醫藥旗下達文西機器人分銷公司Chindex將於本季加入我們的合資企業。隨著下一批系統配額的發放以及達文西Xi在中國獲得批准，我們將加快投資，建立基地，並長期服務中國市場。

In 2018, we also acquired our da Vinci business in India and Taiwan and anticipate strengthening our investments and presence over the next several quarters. We described the multiyear nature of these investments in our JPMorgan talk, using Intuitive Japan as an example.

2018 年，我們還收購了我們在印度和台灣的達文西業務，並預計在接下來的幾個季度中加強我們的投資和業務佈局。我們在摩根大通的演講中描述了這些投資的多年性質，並以 Intuitive Japan 為例進行了說明。

Market development in country is an arduous, multiyear process. It involves building a strong management team and company culture, establishing strong working relationships with surgical societies, policymakers, regulators and key customers as well as building training and proctoring capability, along with a local clinical evidence base. As we bring these efforts together, we plan to accelerate our spend rate above our historical norms for the next several quarters. As described above, the increase in spend is driven primarily by funding in growth of our joint venture in China, the ramp of our informatics efforts, infrastructure to support our procedure growth, including manufacturing lines and facilities, and the launch of our new platforms.

一個國家的市場開發是一個艱辛的、需要多年的過程。這包括建立強大的管理團隊和公司文化，與外科協會、政策制定者、監管機構和主要客戶建立牢固的工作關係，以及建立培訓和指導能力，並建立當地臨床證據基礎。隨著我們各項工作的推進，我們計劃在接下來的幾季中加快支出速度，使其高於以往的平均水準。如上所述，支出增加主要是由於為我們在中國的合資企業的成長提供資金、加大資訊化投入、為支持我們流程成長的基礎設施（包括生產線和設施）以及推出我們的新平台而推動的。

We pace the rate of investment not just by the opportunity for growth, which we believe is substantial, but by our ability to integrate talented staff and execute against our objectives.

我們控制投資速度，不僅取決於我們認為的巨大成長機會，還取決於我們整合優秀人才和實現目標的能力。

In closing, as we start 2019, our focus will be on, first, supporting adoption of da Vinci in general surgery and in key procedures in global markets. Second, launching our SP and Ion platforms. Third, driving intelligent surgery innovation. And finally, supporting additional clinical and economic validation in our focus procedures and countries.

最後，在 2019 年伊始，我們的重點將首先放在支持達文西手術系統在全球市場的普通外科手術和關鍵手術中的應用。其次，推出我們的 SP 和 Ion 平台。第三，推動智慧手術創新。最後，支持在我們重點關注的程序和國家進行額外的臨床和經濟驗證。

I'll now turn the call over to Marshall to review financial highlights.

現在我將把電話交給馬歇爾，讓他回顧一下財務要點。

Good afternoon. I'll describe the highlights of our performance on a non-GAAP or pro forma basis. I will also summarize our GAAP performance later in my script. A reconciliation between our pro forma and GAAP results was posted on our website.

午安.我將以非GAAP或備考財務報表為基礎，介紹我們業績的亮點。我稍後會在演講中總結我們的 GAAP 業績。我們已在網站上公佈了模擬財務報表與GAAP財務報表之間的調節表。

Consistent with our preliminary press release on January 9, fourth quarter 2018 revenue was $1,047,000,000, an increase of 17% compared with $892 million for the fourth quarter of 2017 and an increase of 14% compared with third quarter revenue of $921 million.

與 1 月 9 日的初步新聞稿一致，2018 年第四季營收為 10.47 億美元，比 2017 年第四季的 8.92 億美元成長了 17%，比第三季的 9.21 億美元成長了 14%。

Fourth quarter 2018 procedures increased approximately 19% compared with the fourth quarter 2017, and increased approximately 11% compared with last quarter. Procedure growth continues to be driven by general surgery in the U.S. and urology worldwide. Calvin will review details of procedure growth later in this call.

2018 年第四季手術量比 2017 年第四季成長約 19%，比上一季成長約 11%。手術量的成長主要由美國的普通外科手術和全球的泌尿外科手術所推動。Calvin將在本次通話中稍後詳細介紹手術進展。

Instrument and accessory revenue of $539 million increased 18% with last year, which is lower than procedure growth, reflecting approximately $6 million of I&A repurchased from distributors in China and Taiwan in conjunction with transactions to go direct in both geographies and customer buying patterns, partially offset by increased usage of our advanced instruments.

儀器及配件收入為 5.39 億美元，比去年增長 18%，低於手術量增長，這反映出我們從中國大陸和台灣的分銷商處回購了約 600 萬美元的儀器及配件，同時在這兩個地區和客戶購買模式方面也進行了直接銷售的交易，但部分被我們先進儀器的使用量增加所抵消。

Instrument and accessory revenue realized per procedure was approximately $1,890, a decrease of 1% compared with the fourth quarter of 2017 and relatively unchanged compared with last quarter. Excluding the buyback of inventory from China and Taiwan, instrument and accessory revenue per procedure was similar to last year.

每台手術的器械和配件收入約為 1,890 美元，與 2017 年第四季相比下降了 1%，與上一季相比基本持平。不計從中國大陸和台灣地區回購庫存，每台手術的器械和配件收入與去年相似。

Systems revenue of $341 million increased 20% compared with the fourth quarter of 2017, primarily reflecting higher placements and higher lease related revenue. We placed 290 systems in the fourth quarter of 2018 compared with 216 systems in the fourth quarter of 2017 and 231 systems last quarter. 84 operating lease transactions representing 29% of total placements were completed in the current quarter, compared with 40 or 19% of total placements in the fourth quarter of 2017 and 58 or 25% of total placements last quarter. Operating leases include some usage-based financing that we provide certain large hospitals. We believe that these usage-based financing alternatives align with customer objectives, enabling faster market expansion.

系統營收為 3.41 億美元，比 2017 年第四季成長了 20%，主要反映了更高的安裝量和更高的租賃相關收入。2018 年第四季我們安裝了 290 套系統，而 2017 年第四季安裝了 216 套系統，上一季安裝了 231 套系統。本季完成了 84 筆經營租賃交易，佔總交易量的 29%，而 2017 年第四季完成了 40 筆，佔總交易量的 19%，上一季完成了 58 筆，佔總交易量的 25%。經營租賃包括我們向某些大型醫院提供的一些基於使用量的融資。我們相信，這些基於使用量的融資方案符合客戶的目標，能夠更快地擴大市場。

As of December 31, we have 350 operating leases outstanding and we realized approximately $16 million of revenue related to these arrangements in the quarter. The proportion of these types of arrangements could increase in the long term and will be lumpy quarter-to-quarter. 28% of the current quarter system placements involve trade-ins, reflecting customer desire to access or standardize on our fourth-generation technology. This is approximately the same proportion as last quarter and last year. Trade-in activity could be lumpy and difficult to predict. 73% of the systems placed in the quarter were da Vinci Xis and 18% were da Vinci X systems, compared with 68% da Vinci Xis and 28% da Vinci Xs last quarter. 12 of the systems placed were SP systems.

截至 12 月 31 日，我們有 350 份未結清的經營租賃合同，本季度我們與這些安排相關的收入約為 1600 萬美元。從長遠來看，這類安排的比例可能會增加，並且每季的比例都會出現波動。本季系統安裝中有 28% 涉及以舊換新，反映出客戶希望獲得或採用我們的第四代技術。這與上季和去年同期的比例大致相同。以舊換新活動可能波動較大，難以預測。本季安裝的系統中，73% 為達文西 Xi 系統，18% 為達文西 X 系統；而上一季度，達文西 Xi 系統佔 68%，達文西 X 系統佔 28%。其中12套系統為SP系統。

Our installed base for the da Vinci systems increased 13% year-over-year and our average system utilization grew in the mid-single-digit range.

我們的達文西手術系統安裝量年增 13%，平均係統利用率也實現了中等個位數的成長。

Globally, our average selling price, which excludes the impact of operating leases, lease buyouts and revenue deferrals was approximately $1.46 million, compared with $1.47 million last year and $1.45 million last quarter. The changes compared with prior periods primarily reflect the mix of systems.

在全球範圍內，我們的平均售價（不包括營業租賃、租賃買斷和收入遞延的影響）約為 146 萬美元，而去年同期為 147 萬美元，上一季為 145 萬美元。與以往時期相比，這些變化主要反映了系統組合的變化。

Outside of the U.S., results were as follows: fourth quarter revenue outside of the U.S. of $307 million, increased 24% compared with the fourth quarter of 2017 and increased 25% compared with last quarter; OUS procedures grew approximately 24% compared with the fourth quarter of 2017 and increased 10% compared with the third quarter. Outside the U.S., we placed 115 systems in the fourth quarter compared with 86 in the fourth quarter of 2017 and 75 systems last quarter. Current quarter system placements included 55 into Europe, 31 into Japan and 9 into Brazil. 35 of the 115 systems placed in the fourth quarter were X systems and 15 were operating leases.

在美國以外，業績如下：第四季美國以外地區的營收為 3.07 億美元，比 2017 年第四季成長 24%，比上一季成長 25%；美國以外地區的手術量比 2017 年第四季成長約 24%，比第三季成長 10%。在美國以外，我們在第四季安裝了 115 套系統，而 2017 年第四季為 86 套，上一季為 75 套。在當前季度製度下的就業分配包括：55人進入歐洲，31人進入日本，9人進入巴西。在第四季安裝的 115 套系統中，有 35 套是 X 系統，15 套是經營租賃系統。

Placements outside of the U.S. will continue to be lumpy, as some of the OUS markets are in early stages of adoption. Some markets are highly seasonal, reflecting budget cycles or vacation patterns, and sales into some markets are constrained by government regulations.

美國以外地區的市場佈局仍將不穩定，因為一些美國以外市場的採用尚處於早期階段。有些市場具有強烈的季節性，反映了預算週期或度假模式，而對某些市場的銷售則受到政府法規的限制。

Moving on to gross margin and operating expenses. The pro forma gross margin for the fourth quarter of 2018 was 71.8% compared with 72.4% for the fourth quarter of 2017 and 71.5% last quarter. The decrease compared with fourth quarter of 2017 primarily reflects product mix and costs associated with the new products. Future margins will fluctuate based on the mix of our newer products; the mix of systems and instrument and accessory revenue; system ASPs and our ability to further reduce costs and improve manufacturing efficiency.

接下來分析毛利率和營運費用。2018 年第四季的備考毛利率為 71.8%，而 2017 年第四季為 72.4%，上一季為 71.5%。與 2017 年第四季相比，下降主要反映了產品組合和新產品相關的成本。未來的利潤率將根據我們新產品的組合、系統、儀器和配件收入的組合、系統平均售價以及我們進一步降低成本和提高生產效率的能力而波動。

Pro forma operating expenses increased 31% compared with the fourth quarter of 2017 and increased 27% compared with last quarter. Fourth quarter 2018 operating expenses included a $25 million contribution to the newly formed Intuitive Foundation. The foundation is a charitable organization aimed at improving patient outcomes. It will donate to qualified nonprofit academic organizations, directed at surgeon training and education, including fellowships, advanced clinical research and advanced robotics research. The $25 million will enable the foundation to make meaningful contributions over the next several years.

與 2017 年第四季相比，以備考計算的營運費用成長了 31%，與上一季相比成長了 27%。2018 年第四季營運支出包括向新成立的直覺基金會捐贈 2,500 萬美元。該基金會是一個旨在改善患者治療效果的慈善組織。它將向符合條件的非營利學術組織捐款，用於外科醫生培訓和教育，包括獎學金、高級臨床研究和高級機器人研究。這2500萬美元將使基金會在未來幾年內做出有意義的貢獻。

Our pattern of future contributions will vary based on various factors, including the financial performance of the company and opportunities for the foundation to make meaningful contributions within its mission.

我們未來的捐款模式將根據各種因素而有所不同，包括公司的財務表現以及基金會在其使命範圍內做出有意義貢獻的機會。

Excluding the contribution to the foundation, pro forma operating expenses increased 21% compared with the fourth quarter of 2017. The increase in fourth quarter expenses reflect: one, increased costs that fluctuate directly with revenue, including sales and corporate incentive compensation; two, costs we elected to accelerate, including spend on infrastructure in order to scale the business; and three, investments that drive our future opportunity, including costs associated with going direct in China, Taiwan, India and cost of prototypes.

不計入對基金會的捐款，以備考計算的營運費用比 2017 年第四季成長了 21%。第四季支出增加反映了以下幾點：一、與收入直接相關的成本增加，包括銷售和企業激勵薪酬；二、我們選擇加速實施的成本，包括為擴大業務規模而進行的基礎設施支出；三、推動我們未來發展機遇的投資，包括在中國大陸、台灣、印度直接開展業務的相關成本以及原型成本。

We believe that we are early in our journey to expand minimally invasive surgery and feel the fundamentals in the business are strong. So we are accelerating our investment in selected areas, while continuing to invest in key product areas, including SP, Ion, vision, and advanced instruments. We will accelerate spending on our informatics capabilities, expansion of our OUS markets including China, India and Taiwan, and investments that enable us to scale the business, including expansion of and automation of manufacturing.

我們相信，我們正處於拓展微創手術的早期階段，並且感覺該業務的基本面很強勁。因此，我們正在加快對特定領域的投資，同時繼續投資關鍵產品領域，包括 SP、離子、視覺和先進儀器。我們將加快資訊科技能力、包括中國、印度和台灣在內的海外市場以及能夠擴大業務規模的投資，包括擴大和自動化製造業。

We believe these are important investments. That said, we intend to control spending and headcount growth to that which we could manage well. This leads us to a broad estimate of operating expense increase of 20% to 28% in 2019. Some spending naturally fluctuates with revenue and procedures like sales, production expenses and corporate incentive compensation. Other spending is longer-term in nature and positions us for future growth. For example, SP, Ion and imaging. We would target to spend the lower end of the 20% to 28% range at the bottom end of procedure growth guidance. We are investing with an eye towards long term for the company and the market, and as such, don't intend to modulate long-term investments in response to transient conditions.

我們認為這些都是重要的投資。也就是說，我們打算將支出和人員成長控制在我們能夠很好地管理的範圍內。由此我們大致估計，2019 年營運費用將成長 20% 至 28%。有些支出會隨著收入和流程而自然波動，例如銷售額、生產費用和公司激勵性薪酬。其他支出具有長期性，旨在為我們未來的成長奠定基礎。例如，SP、離子和成像。我們的目標是將支出控制在 20% 到 28% 範圍的下限，即手術增長指導的下限。我們著眼於公司和市場的長期發展進行投資，因此，我們不打算根據暫時的市場情況調整長期投資。

Our pro forma effective tax rate for the fourth quarter was 20%, compared with our expectations of 19% to 20%. Our tax rates will fluctuate with changes in the mix of U.S. and OUS income, changes in taxation made by local authorities and with the impact of onetime items.

我們第四季的預期實際稅率為 20%，而我們先前的預期為 19% 至 20%。我們的稅率會隨著美國境內外收入組成的變化、地方政府稅收政策的變化以及一次性項目的影響而波動。

Our fourth quarter 2018 pro forma net income was $353 million or $2.96 per share, compared with $305 million or $2.67 -- $2.60 per share for the fourth quarter of 2017 and $337 million or $2.83 per share for the third quarter of 2018. Excluding the Intuitive Foundation contribution, pro forma net income was $373 million or $3.13 per share.

2018 年第四季，我們的備考淨收入為 3.53 億美元，即每股 2.96 美元；而 2017 年第四季為 3.05 億美元，即每股 2.67 美元至 2.60 美元；2018 年第三季為 3.37 億美元，即每股 2.83 美元。不計入直覺基金會的捐款，備考淨收入為 3.73 億美元，即每股 3.13 美元。

I will now summarize our GAAP results. GAAP net income was $293 million or $2.45 per share for the fourth quarter of 2018, compared with GAAP net loss of $32 million or $0.28 per share for the fourth quarter of 2017 and GAAP net income of $293 million or $2.45 per share for the third quarter of 2018.

現在我將總結一下我們的GAAP業績。2018 年第四季 GAAP 淨利為 2.93 億美元，即每股 2.45 美元；而 2017 年第四季 GAAP 淨虧損為 3,200 萬美元，即每股 0.28 美元；2018 年第三季 GAAP 淨利潤為 2.93 億美元，即每股 2.45 美元。

The GAAP net loss for the fourth quarter of 2017 reflects the impact of the Tax Act, while the fourth quarter of 2018 includes the $25 million contribution to the Intuitive Foundation. The adjustments between pro forma and GAAP net income are outlined and quantified on our website and include excess tax benefits associated with employee stock awards, employee equity and IP charges and legal settlements.

2017 年第四季的 GAAP 淨虧損反映了稅法的影響，而 2018 年第四季則包括向 Intuitive 基金會捐贈的 2,500 萬美元。我們的網站上列出了備考淨收入與 GAAP 淨收入之間的調整，並進行了量化，其中包括與員工股票獎勵、員工股權和知識產權費用以及法律和解相關的超額稅收優惠。

We ended the quarter with cash and investments of $4.8 billion compared with $4.6 billion at September 30, 2018. The increase generally reflects cash generated from operations, partially offset by investments in working capital and infrastructure. In the quarter, we grew inventory by approximately $40 million to $409 million, representing approximately 4 months of inventory. We continue to build inventory to address the growth in the business as well as mitigate risks of disruption that could arise from trade, supplier and other matters.

截至本季末，我們的現金和投資為 48 億美元，而 2018 年 9 月 30 日為 46 億美元。該增長總體上反映了經營活動產生的現金流，但部分被營運資金和基礎設施投資所抵消。本季度，我們的庫存增加了約 4,000 萬美元，達到 4.09 億美元，相當於約 4 個月的庫存。我們持續增加庫存，以因應業務成長，並降低因貿易、供應商和其他事項可能造成的中斷風險​​。

With the growth in the business and our focus on efficiency and scale, we expect our capital expenditures will increase to over $250 million in 2019. We did not repurchase any shares in the quarter and have approximately $718 million remaining under the board buyback authorization.

隨著業務的成長以及我們對效率和規模的重視，我們預計 2019 年的資本支出將增加到 2.5 億美元以上。本季我們沒有回購任何股票，根據董事會授權的回購計劃，我們還有大約 7.18 億美元的資金。

And with that, I'd like to turn it over to Calvin who will go over procedure performance and our outlook for 2019.

接下來，我將把發言權交給 Calvin，他將介紹手術流程的執行情況以及我們對 2019 年的展望。

Thank you, Marshall. Our overall fourth quarter procedure growth was 19% compared to 17% during the fourth quarter of 2017 and 20% last quarter. Our Q4 procedure growth was driven by 18% growth in U.S. procedures and 24% growth in OUS markets. Overall procedure growth for the full year 2018 was approximately 18% compared to 16% in 2017, comprised of 17% growth in the U.S. and 22% growth in OUS markets.

謝謝你，馬歇爾。我們第四季的整體手術量成長了 19%，而 2017 年第四季為 17%，上一季為 20%。我們第四季手術量的成長主要得益於美國手術量成長 18% 和美國境外市場手術量成長 24%。2018 年全年整體手術量成長約 18%，而 2017 年為 16%，其中美國市場成長 17%，美國境外市場成長 22%。

In the U.S., Q4 and full year procedure results were consistent with recent trends. Q4 growth was again driven by growth in U.S. general surgery and thoracic procedures, augmented by continued contributions from growth in mature, gynecologic and urologic procedures. For the full year, approximately 753,000 procedures were performed in the U.S. For the full year, 2018 U.S. general surgery procedures increased approximately 32% to 325,000 procedures. Hernia repair, both ventral and inguinal, continued to contribute the most incremental cases in the quarter and year, with colorectal procedures continuing to show strong growth. Growth in practice-based procedures, including cholecystectomy and bariatric surgery, increased as the year progressed.

在美國，第四季和全年手術結果與近期趨勢一致。第四季度的成長再次由美國普通外科和胸腔外科手術的成長推動，成熟婦科和泌尿外科手術的持續成長也為此做出了貢獻。2018 年全年，美國共進行了約 753,000 例手術。 2018 年全年，美國一般外科手術量成長約 32%，達 325,000 例。疝氣修補術（包括腹股溝疝氣和腹股溝疝氣）在本季度和本年度繼續貢獻了最多的新增病例，而結直腸手術也繼續保持強勁增長勢頭。隨著一年的推進，包括膽囊切除術和減肥手術在內的實踐性手術量增加。

In U.S. gynecology, full year 2018 year-over-year growth increased to mid-single digits, driven by higher benign hysterectomy volumes. Fourth quarter 2018 U.S. gynecology procedure growth was slightly above the full year growth rate, likely reflecting increasing seasonality in these benign procedures, partially offset by modest headwinds in hysterectomy for cancer, a mature category where da Vinci surgery is standard of care.

在美國婦科領域，2018 年全年同比增長率達到個位數中段，這主要得益於良性子宮切除術數量的增加。2018 年第四季美國婦科手術成長率略高於全年成長率，這可能反映出這些良性手術的季節性日益增強，但部分被子宮癌切除術的輕微不利因素所抵消，子宮癌切除術是一個成熟的領域，達文西手術是該領域的標準治療方法。

In the fourth quarter, we continued to see favorable surgical consolidation trends as our da Vinci surgery data indicate that practicing da Vinci surgeons performed more da Vinci hysterectomies and an increasing proportion of U.S. gynecology procedures are being performed by higher volume physicians.

第四季度，我們繼續看到手術整合的良好趨勢，我們的達文西手術數據顯示，執業達文西外科醫生進行了更多達文西子宮切除術，而且越來越多的美國婦科手術是由手術量較大的醫生進行的。

Full year 2018 U.S. urology procedures grew approximately 8%. Q4 2018 growth was at a rate largely consistent with the full year results, driven by prostatectomy volumes. As a mature procedure category, we believe that our U.S. prostatectomy volumes have been tracking to the broader prostate surgery market, which has benefited from recent macro trends. In other U.S. procedures, adoption of lobectomies and other thoracic procedures was again solid during the fourth quarter.

2018 年全年美國泌尿外科手術量成長約 8%。2018 年第四季的成長速度與全年業績基本一致，主要受攝護腺切除手術量所推動。作為一個成熟的手術類別，我們認為，我們在美國進行的前列腺切除手術量與更廣泛的前列腺手術市場的發展趨勢相符，而前列腺手術市場也受益於近期的宏觀趨勢。在美國其他手術方面，肺葉切除術和其他胸腔外科手術在第四季度再次保持穩定。

Full year 2018 OUS procedures grew 22%, consistent overall with 23% growth in 2017. Q4 OUS procedure growth trends were mostly in line with the full year results. Fourth quarter OUS procedure volume grew approximately 24% compared with 21% for the fourth quarter of 2017 and 23% last quarter. Fourth quarter 2018 OUS procedure growth was driven by continued growth in dVP procedures and earlier stage growth in kidney cancer procedures, general surgery and gynecology.

2018 年全年 OUS 手術量成長了 22%，與 2017 年 23% 的成長率基本持平。第四季 OUS 手術量成長趨勢與全年結果基本一致。第四季 OUS 手術量成長約 24%，而 2017 年第四季成長 21%，上一季成長 23%。2018 年第四季 OUS 手術量的成長主要得益於 dVP 手術量的持續成長以及腎癌早期手術、一般外科手術和婦科手術量的成長。

Q4 procedure growth in Japan was consistent with Q3, at a rate over 40% as procedures were performed within the set of 12 additional procedures approved for reimbursement, effective April 1. Procedure growth in China, again, moderated in Q4, as da Vinci system capacity expansion was constrained by system quota requirements.

日本第四季手術量成長與第三季持平，成長率超過 40%，這主要得益於 4 月 1 日生效的 12 項新增報銷手術的批准。而中國第四季手術量成長再次放緩，因為達文西手術系統的產能擴張受到系統配額要求的限制。

As Gary mentioned, over 1,500 peer reviewed clinical articles regarding da Vinci surgery were published in 2018 and over 16,000 have been published to date. Each quarter, on these calls, we highlight certain recently published studies that we deem to be notable. However, to gain a more complete understanding of the body of evidence, we encourage all stakeholders to thoroughly review the extensive detail of scientific studies that have been published over the years.

正如 Gary 所提到的，2018 年發表了 1500 多篇關於達文西手術的同行評審臨床文章，迄今為止已發表了 16,000 多篇。每個季度，我們都會在這些電話會議上重點介紹一些我們認為值得關注的近期發表的研究。然而，為了更全面地了解證據體系，我們鼓勵所有利害關係人徹底審查多年來發表的大量科學研究的細節。

In December of 2018, a manuscript was published by the Journal of Gastric Cancer titled, "Clinical advantages of robotic gastrectomy for clinical stage I and II gastric cancer: A multi-institutional prospective single-arm study." This study was one of the largest multi-center prospective studies for gastric cancer, which included 330 patients across 15 institutions in Japan. This study was designed to show the safety, effectiveness and economic efficiency of da Vinci surgery for gastric cancer and was in support of the MHLW's Senshin Iryo B process, which led to the recent addition of gastrectomy to reimburse status in Japan.

2018 年 12 月，《胃癌雜誌》發表了一篇題為「機器人胃切除術治療臨床 I 期和 II 期胃癌的臨床優勢：一項多中心前瞻性單臂研究」的論文。這項研究是規模最大的胃癌多中心前瞻性研究之一，納入了日本 15 家機構的 330 名患者。這項研究旨在證明達文西手術治療胃癌的安全性、有效性和經濟效益，並支持厚生勞動省的「醫療服務B」流程，促成了日本最近將胃切除術納入健保報銷範圍。

The main hypothesis of the study was to demonstrate a reduction in morbidity associated with robotic surgery compared to laparoscopy. The hypothesis was confirmed as the results showed a reduction in the morbidity rate to 2.45% for robotic procedures compared to 6.4% for the historical lap control group. Patient characteristics and surgical outcomes were compared between the prospective arm, the robotic group and the historical control, the laparoscopic group. Preoperative differences were noted in both groups as the robotic group contained more patients of younger age but also contained more complex patients with higher co-morbid conditions. The robotic arm had lower clinical staging while no differences were noted in pathological staging between the groups.

研究的主要假設是證明與腹腔鏡手術相比，機器人手術可以降低相關併發症的發生率。假設得到了證實，結果顯示，機器人手術的發生率降低至 2.45%，而歷史腹腔鏡對照組的發生率為 6.4%。比較了前瞻性研究組（機器人組）和歷史對照組（腹腔鏡組）的患者特徵和手術結果。兩組患者術前有差異，機器人組患者年齡較輕，但病情也較複雜，合併症較多。機器手臂的臨床分期較低，而各組之間的病理分期則沒有差異。

In the directional analysis, the robotic-assisted cohort was noted to have significantly lower intraoperative blood loss. Shorter duration of hospital stay, 9 days versus 13 days, with comparable operative time. The office of the study concluded that the significant reduction in morbidity might help demonstrate reduced total cost of care of da Vinci surgery, to be likely the same amount as for laparoscopy. In conclusion, the robotic group reduced the morbidity rate when compared to the findings of the lap group. Robotic surgery might be safe, feasible and effective for gastric cancer.

在方向性分析中，機器人輔助組術中出血量明顯低於對照組。住院時間縮短至 9 天，而傳統手術為 13 天，手術時間相近。研究辦公室得出結論，發病率的顯著降低可能有助於證明達文西手術的總護理成本降低，其金額可能與腹腔鏡手術相同。總之，與腹腔鏡手術組相比，機器人手術組的發生率降低。機器人手術對於胃癌來說可能是安全、可行且有效的。

I will now turn to our financial outlook for 2019. Starting with procedures. As described in our announcement earlier this month, 2018 total da Vinci procedures grew approximately 18% to roughly 1,037,000 procedures performed worldwide. As communicated previously, during 2019, we anticipate full year procedure growth within a range of 13% to 17%. We expect 2019 procedure growth to continue to be driven by U.S. general surgery and procedures outside of the United States, where we are still in the early stages of adoption. We expect similar seasonal timing of procedures in 2019 as we've experienced in previous years, with Q1 being the seasonally weakest quarter as patient deductibles are reset.

接下來，我將談談我們對2019年的財務展望。首先從流程入手。正如我們本月稍早發布的公告中所述，2018 年達文西手術總量增加了約 18%，達到全球約 1,037,000 例。如同先前所溝通的，我們預計 2019 年全年手術量成長將在 13% 至 17% 之間。我們預計 2019 年手術量的成長將繼續由美國普通外科手術以及美國以外地區的手術量推動，在這些地區，我們仍處於早期採用階段。我們預計 2019 年的手術季節性時間表與往年類似，第一季通常是季節性最弱的季度，因為患者的自付額會重新計算。

With respect to revenue, as we have mentioned previously, capital sales are ultimately driven by procedure growth, catalyzing hospitals to establish or expand robotic system capacity. Capital sales can vary substantially from period-to-period based upon many factors, including U.S. health care policy, hospital capital spending cycles, reimbursement and government quotas, product cycles, economic cycles and competitive factors.

就收入而言，正如我們之前提到的，資本銷售最終是由手術量的成長所驅動的，這促使醫院建立或擴大機器人系統容量。資本銷售額會因多種因素而隨時間發生顯著變化，包括美國醫療保健政策、醫院資本支出週期、報銷和政府配額、產品週期、經濟週期和競爭因素。

Within this framework, we'd expect 2019 capital placement seasonality to generally follow historical patterns by quarter. During the fourth quarter of 2018, 84 of the 290 or 29% of the systems shipped were under operating leases. We expect that the proportion of systems placed via operating leases will vary from quarter-to-quarter and could trend up in the future.

在此框架下，我們預計 2019 年的資本配置季節性將大致遵循按季度劃分的歷史模式。2018 年第四季度，出貨的 290 套系統中有 84 套（佔 29%）是透過經營租賃方式交付的。我們預計透過經營租賃方式安置的系統比例將逐季度變化，並且未來可能會呈現上升趨勢。

Turning to gross profit. Our full year 2018 pro forma gross profit margin was 71.5%. In 2019, we expect our pro forma gross profit margin to be within a range of between 70% and 71% of net revenue. Our actual gross profit margin will vary quarter-to-quarter depending largely upon product, regional and trade-in mix and the impact of new product introductions.

接下來計算毛利。我們 2018 年全年以備考計算的毛利率為 71.5%。2019 年，我們預計我們的備考毛利率將佔淨收入的 70% 至 71%。我們的實際毛利率會因產品、地區和以舊換新組合以及新產品推出的影響而逐季度變化。

Turning to operating expenses. As Gary and Marshall outlined, we will be following through on and expanding our investments in 2019. We expect to grow pro forma 2019 operating expenses between 20% and 28%, above 2018 levels. We expect our noncash stock compensation expense to range between $310 million and $340 million in 2019 compared to $261 million in 2018. We expect other income, which is comprised mostly of interest income, to total between $120 million and $130 million in 2019.

接下來談談營運費用。正如 Gary 和 Marshall 所概述的那樣，我們將在 2019 年繼續推動並擴大我們的投資。我們預計 2019 年的備考營運費用將比 2018 年的水準成長 20% 至 28%。我們預計 2019 年的非現金股票補償支出將在 3.1 億美元至 3.4 億美元之間，而 2018 年為 2.61 億美元。我們預計 2019 年其他收入（主要包括利息收入）總額將介於 1.2 億美元至 1.3 億美元之間。

With regard to income tax, consistent with our 2018 results, we estimate our 2019 pro forma income tax rate to be between 19% and 20% of pretax income. That concludes our prepared comments. We will now open the call to your questions.

關於所得稅，根據我們 2018 年的業績，我們預計 2019 年的預計所得稅稅率為稅前收入的 19% 至 20%。我們的發言到此結束。現在開始回答各位的問題。

(Operator Instructions) And our first question will be from the line of David Lewis, Morgan Stanley.

（操作員說明）我們的第一個問題來自摩根士丹利的戴維·劉易斯。

Maybe I'll start financial then work to Gary for strategic. So just, Marshall, and maybe a little bit for Gary as well. Just thinking about the spending breakdown for 2019, 2 questions and then I'll just do one follow-up. On financial pieces, Marshall, any sense of R&D relative to SG&A? We're sort of assuming you continue to grow R&D at a similar rate to 2018 and the material step-up in spending relative to our model's more SG&A? And can you just sort of walk us through a couple of the components there in R&D and SG&A that are driving the majority of the spend. And then I had a quick follow up for Gary.

也許我會先從財務方面入手，然後再向 Gary 尋求策略上的協助。所以，就給馬歇爾，也許也給加里一點。我正在考慮 2019 年的支出明細，有兩個問題，然後我再做一個後續問題。關於財務方面，馬歇爾，研發支出與銷售、管理及行政費用之間有關係嗎？我們大致假設你們的研發投入將繼續以與 2018 年類似的速度增長，並且研發支出相對於我們模型中更多的銷售、一般及行政費用將大幅增加？您能否簡要介紹研發和銷售、管理及行政費用中佔支出大部分的幾個組成部分？然後我又給加里提了個後續問題。

Yes, I think the step-up in spend is maybe slightly weighted towards SG&A but pretty even across the categories. The elements of SG&A are, as I discussed, the expansion OUS and the investments we're making in China, India and Taiwan, those are commercial organizations and that appears in SG&A. Of course, SG&A will grow a lot of the costs that fluctuate with revenue such as sales compensation and incentive compensations flow through SG&A. However, in the R&D area, we will continue to invest in SP, Ion, and vision and advanced instruments. And then as I said, we'll be accelerating some of our investments in digital capabilities or informatics.

是的，我認為支出成長可能略微偏向銷售、一般及行政費用，但各類別之間的成長相當均衡。正如我之前討論過的，SG&A 的組成部分包括 OUS 的擴張以及我們在中國、印度和台灣的投資，這些都是商業組織，這些都會體現在 SG&A 中。當然，銷售、一般及行政費用 (SG&A) 中會包含許多隨收入波動而增加的成本，例如銷售報酬和激勵性報酬，這些都計入 SG&A。然而，在研發領域，我們將繼續投資 SP、離子、視覺和先進儀器。正如我所說，我們將加快數位化能力或資訊科技的投資。

Okay, very helpful, Marshall. And then Gary, there's been some media reports about one of your competitors drawing [instruments] from a much larger company and I'd say barriers to entry is perhaps the most common incoming question we get from investors. So I wonder if you could help us articulate what is the Intuitive moat as you see it? Or are investors asking the wrong question? And they should be more focused on TAM expansion?

好的，馬歇爾，你幫了我大忙。加里，媒體報道說你的一個競爭對手從一家規模更大的公司引進了[儀器]，我想說，准入門檻可能是我們從投資者那裡收到的最常見的問題。所以我想知道您能否幫我們闡述一下您眼中的直覺護城河是什麼？或者，投資人是不是問錯問題了？他們應該更專注於擴大目標市場規模嗎？

I think a little bit of both that are going on, I think in the competitive world. On the first side, how are customers are going to choose, I think customers appreciate choice and will expect it from us and from others and I think they'll evaluate competitive offerings. For us, we focus a lot on understanding what the workflow environment is, understanding the total cost, not just the constituent cost of price of the system or price of the instruments and accessories, it's really total cost to use the product. Stability, usability, supply chain stability, all of those things, I think, are valued when people are putting a fair amount of their surgical volume onto a platform and I think it will take some time for folks to fully absorb and understand that. And I think also, there's some nice effects about surgeons training surgeons. There's a large installed base of surgeons, they interact with each other through surgical societies. They proctor each other and I think that, that allows a compound cycle of learning that's been effective. To the question of, what does it do as some of the other larger competitors declare their desire to enter. I do think it validates, for the broader market, the things we believed for many years, and have been investing towards for many years. So I think it's a signal to everybody that these technologies and approaches are going to be important to the future. That said, there are smart people in all these organizations and outside of our company. And we'll see. We have evaluated many of the competitive concepts that we see out there, often making them for ourselves and evaluating them over the years. We really make our decisions based on what we think the customer needs in as a forward look, and as a result, I think we may be wrong about some of our decisions but we've tried to be well informed about our decisions.

我認為這兩種情況都有一些，尤其是在競爭激烈的世界中。首先，顧客會如何選擇？我認為顧客喜歡選擇，並且期望我們和其他公司都能提供選擇，我認為他們會評估競爭對手的產品。對我們來說，我們非常注重了解工作流程環境，了解總成本，而不僅僅是系統價格或儀器和配件價格等構成成本，而是使用該產品的總成本。我認為，當人們將相當一部分手術量轉移到一個平台上時，穩定性、可用性、供應鏈穩定性等因素都非常重要，我認為人們需要一些時間才能完全理解和接受這一點。而且我認為，外科醫生培訓外科醫生也會產生一些很好的效果。外科醫生群體龐大，他們透過外科協會相互交流。他們互相監督，我認為這可以形成一個有效的學習循環。至於當其他一些規模更大的競爭對手宣布有意進入市場時，它會採取什麼行動。我認為這驗證了我們多年來所相信並多年來一直投資於更廣泛的市場的事情。所以我認為這向所有人發出一個信號，那就是這些技術和方法對未來至關重要。也就是說，所有這些組織以及我們公司以外都有聰明人。我們拭目以待。我們已經評估了市面上許多具有競爭力的概念，通常我們會自己進行開發，並在多年的時間裡對其進行評估。當我們做決定時，確實會考慮客戶的未來需求，因此，我認為我們的一些決定可能是錯誤的，但我們一直努力做到對決策有充分的了解。

And our next question is from the line of Bob Hopkins, Bank of America.

下一個問題來自美國銀行的鮑伯霍普金斯。

I have sort of 2 similar lines of questioning here. First, just to follow-up a little bit on the comments on spend in 2019. For '18, there was a 17% increase. For '19, you're talking about a -- at the midpoint, a 24% increase. I mean, that's roughly $75 million. I was wondering if you could kind of lay out, how much of that is the investment in China and Taiwan and going direct? And then also, how would you just sort of characterize that incremental $75 million and the growth rate you're experiencing this year? Is this more of kind of onetime increase in the growth of expenses? Or could this be sort of a growth rate that we'd experience for another couple of years?

我這裡有兩個類似的問題。首先，我想稍微補充一下關於 2019 年支出狀況的評論。2018年增長了17%。2019 年，你指的是──中點而言，成長 24%。我的意思是，那大約是7500萬美元。我想請您詳細說明一下，其中有多少是投資中國大陸和台灣，又有多少是直接投資？那麼，您如何描述今年新增的 7,500 萬美元以及您所經歷的成長率呢？這是否屬於一次性支出成長？或者，這會不會是我們未來幾年都要經歷的那種成長率？

Yes. So I think, Bob, these are multiyear investments and as Gary referred to in his script, if you go back and you look at sort of what we said we did in Japan, the investments were made early on and -- but you continue to make those investments over time to get to a point of where you might see a real return from them. And in the case of Japan, we've been investing in Japan for 10 years and we're now seeing the fruits of that investment in terms of a 12-procedure reimbursement. So I wouldn't characterize these as a onetime event. I think, we'll continue to invest in some of those things for quite some time. As far as how this -- you came up with $75 million, how the -- how you would proportion the pieces, I think I pretty much laid it out for David. There's a chunk of spending associated with the expansion OUS in China, India and Taiwan that will -- you'll see that primarily in the SG&A line. But there's an equal set of investments being made in terms of informatics as well as investments to scale the business, investments in expansion and automation of the manufacturing group, so.

是的。所以我覺得，鮑勃，這些都是多年投資，正如加里在他的劇本中提到的那樣，如果你回顧一下我們在日本所做的工作，你會發現這些投資是在早期進行的，而且——但隨著時間的推移，你會繼續進行這些投資，直到達到能夠從中獲得真正回報的階段。就日本而言，我們已經在日本投資了 10 年，現在我們看到了這項投資的成果，即 12 項手術的報銷。所以我不會把這些事件定性為一次性事件。我認為，我們會繼續在這些領域進行相當長一段時間的投資。至於你是如何籌集到 7500 萬美元的，以及你會如何分配各個部分，我想我已經把一切都告訴大衛了。與中國、印度和台灣的海外擴張相關的支出將佔很大一部分——你主要會在銷售、一般及行政費用中看到這一點。但同時，在資訊科技、業務規模擴張、製造集團的擴張和自動化等方面也投入了同等規模的投資。

Okay, I appreciate that. And then one for Gary. Just a question on competition, I'll frame it just a little bit differently. J&J, Medtronic both continue to suggest that sometime late in 2020, they'll bring some sort of technology to the market in robotic form. They both suggested they're going to have lower-cost systems. They haven't given us much details but in my view, both have sort of implied that their systems will be geared towards converting lap-focused surgeons to robotic platform. So my question to you is, I realize you don't comment much on your pipeline, but I was just curious if you could comment, do you see potential value in advancing lap through robotics? And is this a priority for Intuitive today?

好的，謝謝。然後，再給加里一個。關於競爭，我有個問題，我換個方式問。強生公司和美敦力公司都繼續表示，他們將在 2020 年稍後以機器人形式向市場推出某種技術。他們都表示將採用成本較低的系統。他們沒有透露太多細節，但在我看來，他們都暗示他們的系統將致力於將專注於腹腔鏡手術的外科醫生轉變為機器人手術平台。所以我的問題是，我知道你很少評論你的生產線，但我只是好奇你是否可以發表一下看法，你認為透過機器人技術推進圈速提升是否有潛在價值？這是否是 Intuitive 目前的工作重點？

I do believe that some advanced MIS surgeons are becoming increasingly open to the use of robotic surgery and intelligent surgery. And we see it today in the market. We see bariatric surgeons interested in our technologies and that's a domain that is high laparoscopic penetration. So I believe there's an opportunity there. I would separate the idea of capital being the only thing to think about as an opportunity to pursue that growing idea in advanced laparoscopy. And what I'd say is that I think physicians are going to balance multiple criteria. They're going to look at total cost to treat. So the capital, the cost to the service that capital, the instruments and accessories, the outcomes that they get from it, efficiencies in human capital time -- or human labor time in the OR and they're going to balance that. And I think all of those are up for discussion when you think about trade-offs between advanced laparoscopy and intelligent surgery. We think there's an opportunity there. We will pursue that opportunity. When I hear folks kind of over-rotate to just capital costs on systems, I kind of think about how excited are people to jump aboard a just-good-enough commercial airliner. For sure, if you're flying commercial airline, you want the lowest total cost per passenger mile but you can get that a lot of different ways, and cheapening the capital, maybe not the best way. We evaluate all of those elements, we've thought about them deeply and we've made investments to pursue what we think is the right leadership position here.

我相信一些先進的微創外科醫生越來越願意接受機器人手術和智慧手術。如今我們在市場上也看到了這一點。我們看到減重外科醫師對我們的技術很感興趣，而減重手術領域正是腹腔鏡技術滲透率很高的領域。所以我認為這裡存在著機會。我認為，不應僅將資本視為追求先進腹腔鏡技術這一新興理念的唯一途徑。我想說的是，我認為醫生會權衡多種因素。他們會考慮治療的總成本。所以，資本、服務成本（包括資本、儀器和配件）、從中獲得的成果、人力資本時間效率（或手術室的人力時間）等等，他們都要權衡這些因素。我認為，在考慮先進腹腔鏡技術和智慧手術之間的權衡時，所有這些都值得討論。我們認為那裡存在著機會。我們將抓住這個機會。當我聽到人們過度關注系統方面的資本成本時，我就會想，人們對乘坐一架僅僅夠用的商用客機有多興奮。當然，如果你搭乘商業航班，你肯定希望每位乘客每英里的總成本最低，但你可以透過許多不同的方式實現這一點，而降低資本成本可能不是最好的方法。我們評估了所有這些因素，我們深入思考了它們，並且我們進行了投資，以追求我們認為在這裡正確的領導地位。

Our next question is from the line of Tycho Peterson, JPMorgan.

我們的下一個問題來自摩根大通的泰科·彼得森。

I want to maybe just pick up where you left off on some of these new initiatives. You talked about the first clinical use case for augmented reality this year. Can you talk a little bit about how you think about commercializing that, where you see the key application areas? And then similarly, on the informatics investments, can you talk a little bit about what you're hoping to accomplish there?

我想繼續推進你之前的一些新舉措。您談到了今年擴增實境技術的首個臨床應用案例。您能否談談您如何考慮將其商業化，以及您認為其主要應用領域是什麼？同樣地，關於資訊科技投資，您能否談談您希望在這方面取得哪些成就？

Sure, those two are related but we'll start with augmented reality or mixed reality, and that's something we have been working on for some time and the world has been interested in. The idea here is to use multiple sources of information. Preoperative: CT scans or MRI scans; intraoperative: other imaging like ultrasound or fluorescence imaging, molecular imaging, and combine them in ways that allow the surgeon or physician to see things differently. It is embedded and inherent in Ion already, that some of that core capability is required. We're also bringing some of that core capability to our da Vinci systems. In the beginning, it will be around preoperative imaging and some intraoperative imaging mixed together for the surgeon in real-time. First, I'd expect first clinical uses this year and the beginnings of the study that go around that. I don't think it will be a meaningful revenue contributor in the near term, but I think it's one of the things that can really change outcomes. Efficiency in the procedure and outcomes, now that remains to be proven, but we're excited about it. That's one leg of our thoughts around informatics and you've heard us talk about this over the years from strengthening our cloud computing capabilities. We Internet-connected our systems a decade ago to a partnership and then an increased and closer investment with InTouch Health around routing of data quickly in low latency and real-time, to internal capabilities around managing data lakes and providing for customers, off-line processing that allows them to compare their programs and take advantage of some advances in machine learning. Those are the types of elements that we're bringing to bear. It's nice, we have a foothold, we have some brilliant scientists who are advancing and leading that cause and we think we have discrete, deliverable steps that we can do and then validate, that will start bringing real value to the market.

當然，這兩者是有連結的，但我們將從擴增實境或混合實境開始，這是我們一直在研究的領域，也是全世界都感興趣的領域。這裡的理念是利用多種資訊來源。術前：CT掃描或MRI掃描；術中：其他影像方式，如超音波或螢光成像、分子影像，並將它們結合起來，使外科醫生或醫生能夠以不同的方式觀察情況。Ion 本身就具備一些核心功能，這是它固有的特性。我們還將其中一些核心功能引入我們的達文西手術系統。初期，主要採用術前影像和一些術中影像結合的方式，供外科醫師即時參考。首先，我預計今年將出現首次臨床應用，並開始進行相關的研究。我認為短期內它不會帶來可觀的收入，但我認為它是能夠真正改變結果的事情之一。手術流程和結果的效率還有待驗證，但我們對此感到興奮。這是我們圍繞資訊學思考的一個方面，多年來，您也一直聽到我們談論如何加強雲端運算能力。十年前，我們透過網路將系統連接到 InTouch Health，並與其建立了合作夥伴關係。隨後，我們加大了與 InTouch Health 的合作力度，圍繞低延遲和即時快速路由數據，以及管理數據湖的內部能力，並為客戶提供離線處理，使他們能夠比較各自的程序並利用機器學習方面的一些進步。這就是我們正在運用的要素類型。很好，我們已經站穩腳跟，我們有一些傑出的科學家正在推進和引領這項事業，我們認為我們可以採取一些具體的、可執行的步驟，然後進行驗證，這將開始為市場帶來真正的價值。

And then I guess, a follow-up on Ion, a couple of questions here. Any risk of timelines slipping with the government shutdown, I mean, now that you've submitted the 510(k)? And then should we expect additional clinical data to come out this year? And it sounds like, for the gross margin commentary, you're not expecting any real impacts on -- negative impact on gross margins with the roll out, can you confirm that?

然後，我想就 Ion 做個後續調查，這裡有幾個問題。政府停擺會不會導致進度延誤？我的意思是，既然你已經提交了 510(k) 申請。那麼，我們是否可以預期今年會有更多臨床數據公佈？聽起來，就毛利率而言，您預計此次推廣不會對毛利率產生任何實際的負面影響，您能確認一下嗎？

Let me speak to the first 2 and I'll let Marshall speak to the last one on margin. There's always a risk that things slow down. We are in engaged contact with FDA. And so far, we're feeling pretty good about it but I can't speak to what the long-term implications will be in terms of shutdown dynamics. In terms of clinical data, there'll be, if things proceed the way we hope, we'll start collecting additional data as they comes out. In terms of when that gets published, I think it will depend on the timing of the clearance and the speed with which some of the installs happen. We think that the demand pipeline for Ion looks really good. The scientific response to FDA's questions, we feel good about. And the engineering team and supply chain team bringing those early systems up looks really good, too. So I'm really pleased with the internal team's performance and the set up of the activities. With regard to margin impact, Marshall?

讓我先跟前兩位說說，然後讓馬歇爾在場邊跟最後一位說。總是會有事情進展放緩的風險。我們與美國食品藥物管理局（FDA）保持密切聯繫。到目前為止，我們感覺還不錯，但我無法預測從長遠來看，停工動態會產生怎樣的影響。就臨床數據而言，如果事情進展順利，我們將開始收集後續公佈的更多數據。至於何時發布，我認為這將取決於批准的時間以及一些安裝工作的完成速度。我們認為 Ion 的需求前景非常好。我們對FDA提出的問題所得到的科學答案感到滿意。負責早期系統上線的工程團隊和供應鏈團隊看起來也做得非常好。我對內部團隊的表現和活動的安排非常滿意。關於利潤率影響，馬歇爾？

Yes, Ion will be rolled out in a measured fashion to create a good foundation. And so the consequences of -- both on the revenue and the gross margin line will be very small.

是的，Ion 將以穩健的方式逐步推出，以奠定良好的基礎。因此，對收入和毛利率的影響將非常小。

Okay, and if I could just ask one last one. On the cadence of placements in China you're expecting, now that you've had a little bit of time to digest the quota, anything to think about in the first half of the year here?

好的，我可以再問最後一個問題嗎？關於你預期在中國的實習安排節奏，現在你已經有時間消化配額資訊了，對於今年上半年有什麼需要考慮的嗎？

Yes. So the quota, just to recap for everybody, 154 systems. Keep in mind that 154 systems is for surgical robots. If there were to be competitors that got their product approved in China, they would share in that quota. So it's not just a quota for us. The quota has been released. However, there are tendering processes that the hospitals have to go through, just to remind you the last time we got a quota in 2013, most of the systems were shipped near the end of 2015, so it took a while. The -- what I would say -- and then finally, the other implication is that there was a 25% tariff on the robots that the Chinese have imposed. We think that there's high interest in robotics in China. So I don't know what that 25% -- how that 25% will affect their desire to buy. What I would say is that the pattern of placements will be few in the first half and more near the end of the quota period, which is 2020.

是的。所以，為了方便大家回顧一下，配額是 154 個系統。請注意，154 系統指的是手術機器人。如果其他競爭對手的產品在中國獲得批准，他們將分享這些配額。所以這不僅僅是我們的配額。配額已發放。但是，醫院必須經過招標流程。提醒一下，我們上次在 2013 年獲得配額時，大部分系統直到 2015 年底才發貨，所以花了一段時間。我想說的是——最後，另一個意思是，中國對機器人徵收了 25% 的關稅。我們認為中國對機器人技術有著濃厚的興趣。所以我不知道這25%會如何影響他們的購買意願。我想說的是，安置人數在上半年會比較少，而在配額期末（即 2020 年）會比較多。

Our next question is from the line of Larry Biegelsen, Wells Fargo.

下一個問題來自富國銀行的 Larry Biegelsen。

One on SP and one strategic question for you, Gary. So on SP, I heard the commentary upfront, about a few hundred procedures. Any themes you would highlight? And remind us again of when we can expect the full launch.

一個關於SP的問題和一個策略性的問題想問你，Gary。所以在SP上，我提前聽到了評論，大約有幾百個手術。您想重點強調哪些主題？請再次提醒我們何時可以全面發布。

With regard to early themes, the feedback has been that usability on the new platform, it's got a little slightly different set of operating principles, has been a positive surprise. The -- also, the physician excitement about its ability to reach into small places and some of the flexibility it exhibits relative to setup and access has been a really positive surprise for us, which has been great. So that's been good, I think pacing, demand looks really good. We're, for sure, supply constrained, relative to demand. And the pacing there will really be around a couple of things: one, is we want to get our supply chain partners ready for real volumes so we've knocked down some of the issues that make it -- take them a while to produce things, we want to solve some of the manufacturing bottlenecks. The second thing is we want some of the additional indications that give our customers a little more flexibility with how they can use the product. So that will pace it, we don't have a timeline yet for you on those 2 things. Both of them have a little bit of uncertainty in them, with the FDA review of submissions being one and working down some of the technical bottlenecks is the other. I don't see any insurmountable technical challenges, I think it's just work. But so far, so good, and we're feeling like they're meeting the plan we set.

關於早期主題，回饋是新平台的可用性（它採用了一套略有不同的操作原則）帶來了一個積極的驚喜。此外，醫生們對它能夠深入狹小空間以及在設置和訪問方面所表現出的靈活性感到興奮，這讓我們感到非常驚喜，這真是太好了。所以我覺得這很好，節奏把握得很好，需求看起來也非常好。可以肯定的是，相對於需求而言，我們的供應是受限的。而這裡的節奏實際上將圍繞著兩件事：一是，我們希望讓我們的供應鏈合作夥伴為真正的產量做好準備，所以我們已經解決了一些導致生產耗時較長的問題，我們希望解決一些製造瓶頸。第二點是，我們希望提供一些額外的指示，讓我們的客戶在使用產品時有更大的靈活性。所以事情會按部就班地進行，我們目前還沒有這兩件事的具體時間表。兩者都存在一些不確定性，一是FDA對申請資料的審查，二是克服一些技術瓶頸。我看不出有什麼無法克服的技術難題，我認為這只是工作問題。但到目前為止一切順利，我們感覺他們正在按照我們所製定的計劃進行。

And Gary, as you know, we're seeing procedures in the U.S. moving to the outpatient and ASC settings. Do you believe your current Gen 4 offering and leasing option provide adequate terms for expansion into this environment?

加里，如你所知，我們看到美國的許多手術都在轉移到門診和日間手術中心。您認為您目前的第四代產品和租賃方案是否足以滿足您拓展到當前市場環境的需求？

When you think about freestanding centers, there's kind of 2 dimensions on which you think about freestanding surgery centers. One of them are hospital-owned outpatient departments. We are already well used and appreciated in those settings. So that's the physical structure is kind of the same. It's just how the ownership and operations are organized. Freestanding centers that are owned by group practices, not hospital owned, have a little bit different reimbursement and economics. We actually do see some of them starting to express interest and adopt robotics. I think that -- as we were saying earlier in the call, which procedures go there depends both on the reimbursement of the procedure and the efficiencies with which products get used. And I think that for the right settings, Gen 4 can be quite strong.

提到獨立手術中心，人們通常會從兩個方面來考慮。其中之一是醫院所屬的門診部。我們在這些環境中已經得到了充分利用和讚賞。所以它們的物理結構基本上相同。這只是所有權和運作的組織方式而已。由集團診所擁有的獨立醫療中心（而非醫院擁有的醫療中心）在報銷和經濟方面略有不同。我們確實看到其中一些人開始對機器人技術表現出興趣並採用機器人技術。我認為——正如我們之前在電話中所說，哪些程式會進行到那裡取決於該程式的報銷情況以及產品的使用效率。我認為，在合適的條件下，第四代處理器可以非常強大。

Our next question is from the line of Amit Hazan, Citigroup.

我們的下一個問題來自花旗集團的 Amit Hazan。

Let me just start with system or a unit growth question first. Totally understanding the macro comments you made about that, but if I look at the data, look at the numbers, second year of accelerating growth, lots of drivers kind of seeming to be accelerating at the same time, trade-ins, operating leases, new products, procedure growth accelerating. So a lot's happening that's accelerating. And after that, very little, really nothing to tell me that growth trends are going to change that much. So help me out and tell me, outside of the macro issues, why would unit growth trends change much in 2019?

我先從系統或單位成長問題開始。我完全理解你對此所做的宏觀評論，但如果我看一下數據，看一下數字，這是增長加速的第二年，很多驅動因素似乎都在同時加速，例如以舊換新、經營租賃、新產品、流程增長都在加速。所以很多事情正在加速發生。在那之後，幾乎沒有任何跡象表明成長趨勢會發生如此大的變化。那麼，請幫我分析一下，拋開宏觀因素不談，為什麼2019年單位成長趨勢會發生很大變化？

Yes, I mean regarding procedures, like we said in the prepared comments, it's really the procedure growth that drives demand for capital placements. You mentioned a number of other factors, things like trade-ins, leasing programs, new product introductions. Things like that can have an effect on the results either but we talk about these things possibly fluctuating quarter-to-quarter and it comes down to just laying out your model and your frame of thought and working backwards from the installed base and working at the installations. But there's a lot of -- the factors you described, are what's in the world.

是的，我的意思是，就手術流程而言，正如我們在準備好的評論中所說，正是手術流程的成長推動了對資金投入的需求。您還提到了其他一些因素，例如以舊換新、租賃計劃、新產品推出等。諸如此類的事情也可能對結果產生影響，但我們討論的是這些事情可能會每季度波動，歸根結底，就是製定你的模型和思路框架，從已安裝的基礎倒推，並在安裝過程中開展工作。但是，你所描述的這些因素，正是世界上存在的許多因素。

And mature procedures will moderate growth for sure. And we also know that in some cases, for example, there was a publication of a couple of articles about cervical cancer in New England Journal and that can change procedure growth rates too. So -- and create a headwind. So there's a little bit of puts and takes here. In general, we are feeling like the business is strong and there's strong momentum but there are some things that will moderate as well.

成熟的流程肯定會減緩成長速度。我們也知道，在某些情況下，例如，《新英格蘭醫學雜誌》上發表了幾篇關於子宮頸癌的文章，這也會改變手術成長率。所以——製造逆風。所以這裡有一些拉鋸戰。總的來說，我們感覺業務發展強勁，勢頭良好，但也有一些因素會趨於緩和。

And I thought I'd follow-up on the operating lease side. In the U.S. in particular, where, obviously, I think it's up above 30% of units sold in '18. I think it was 20% of units sold in '17. So we're starting to see kind of a trend line. And I do get what you're saying with volatility. But the question, I think, for us, especially as we start to model or try to model your system revenue number accurately for the year, is how to think about that trend for '19 and even '20. It seems like you're focusing more on it, you're offering more programs and that trend line could continue so we could kind of be towards the mid-30% to 40% range in the U.S. in '19. Are there other things that I should be considering for why that wouldn't happen?

我想就經營租賃方面的情況再做進一步說明。尤其是在美國，顯然，我認為 2018 年銷量中超過 30% 的份額都超過了 30%。我認為是 2017 年銷量的 20%。所以我們開始看到某種趨勢線了。我明白你說的波動性問題。但我認為，對我們來說，尤其是當我們開始模擬或嘗試準確地模擬你們今年的系統收入數字時，問題在於如何看待 2019 年甚至 2020 年的趨勢。看來你們越來越重視這方面，提供了更多項目，而且這種趨勢可能會繼續下去，所以到 2019 年，美國的這一比例可能會達到 30% 到 40% 左右。還有其他什麼因素會導致這種情況不會發生嗎？

Well, it's been a successful program. I mean, it's been a way for us to offer hospitals an opportunity to expand their capacities without the initial capital investment. So it's been very successful. I'm not sure the numbers completely jive with what you said. We were 25% of placements in Q3 and 29% in Q4 were under operating leases. So you saw that step up quite a bit in the last couple of quarters. And so our comments are like, okay, we're here now, it's likely to fluctuate quarter-to-quarter from where we ended the year. And then over the long term, it could increase.

嗯，這個專案很成功。我的意思是，這讓我們有機會為醫院提供無需初始資本投資即可擴大其容量的機會。所以它非常成功。我不太確定這些數字是否完全符合你所說的。第三季度，我們有 25% 的房產採用經營租賃方式；第四季度，這一比例為 29%。所以你可以看到，在過去的幾個季度裡，這個數字已經有了相當大的提升。因此，我們的評論是，好吧，我們現在的情況是，它可能會與年底的情況相比，每個季度都有波動。從長遠來看，這種情況可能會加劇。

We believe that operating leases are a good thing. We would, if having the choice, place a system under an operating lease rather than sell the system. It reduces its fluctuation, like you said, it stabilizes sort of the revenue stream, if you will. It also -- and in terms of if there were an upgrade cycle, what we've seen in studies is that the upgrade cycle is quicker when there's leases versus purchased product. So we think it's positive in a number of ways. However, it's up to customers. We really leave it to customers to decide what is best for them and we will fulfill that. And so it's hard for this to predict exactly where the customer will go and to what level we'll wind up with leases versus purchase.

我們認為經營租賃是件好事。如果可以選擇，我們會選擇以經營租賃的方式處置系統，而不是出售系統。正如你所說，它可以減少波動，穩定收入來源。此外，就升級週期而言，我們在研究中發現，租賃產品的升級週期比購買產品的升級週期更快。所以我們認為這在很多方面都是正面的。然而，最終決定權在於顧客。我們完全尊重客戶的意願，讓他們自己決定什麼對他們最好，我們會盡力滿足他們的需求。因此，很難準確預測客戶會走向何方，以及租賃與購買最終會達到怎樣的水平。

Our next questions from the line of Rick Wise, Stifel.

接下來，我們將向 Stifel 公司的 Rick Wise 提出問題。

Gary, maybe turning back to the acquisition of your da Vinci business in India and Taiwan again. I heard you clearly, these are long-term investments that will take a long time to play out. I'd be curious to hear more about your thoughts about the relative size of the opportunities in India and Taiwan. Is this sort of -- you mentioned Japan as a proxy a little bit, but do India and Taiwan match up with China and Japan in terms of magnitude? I mean, I assume you must think the opportunity there is significant. Just maybe help us think about that and frame it for us.

Gary，或許應該重新考慮收購你在印度和台灣的達文西業務。我聽得很清楚，這些都是長期投資，需要很長時間才能見效。我很想聽聽您對印度和台灣市場機會相對規模的看法。這算是一種──你剛才提到日本可以作為參照，但印度和台灣在規模上能與中國和日本相提並論嗎？我的意思是，我猜你一定認為那裡的機會非常重要。或許您能幫我們思考一下，並幫我們理清思緒。

Clearly, the strategic motivation behind India and Taiwan are a little bit different. With regard to Taiwan, in terms of [absolute size], it's not going to be a huge part of the business. However, it's an influential market. We -- the distributor there that we were working with was well-built and we think that it's a group that does good surgery and has good influence in the region. I think it's important to serve that customer base well. But it's not a massive financial impact by any means nor do we expect it to be. India has, I think, a fair amount of runway. Where it is today and where it might be in a decade can be quite different. And so here, the idea is it will take some time to build our capabilities in India but we also think it's an economy that's been growing, there's a strength in the surgical community in India, both there and globally. And so it's an important long-term market for us. We think that financially, of course, it can become a significant part of Intuitive's business over the years. And the point of the -- of illustrating some of the Japanese example is that building a real presence and building the organization and the trust within the health care community in those markets takes time. So if you want to get there in a decade, then you better start. And that's really what's driven us in those 2 markets.

顯然，印度和台灣背後的戰略動機略有不同。就台灣而言，從絕對規模來看，它不會成為我們業務的重要組成部分。然而，這是一個很有影響力的市場。我們——我們當時合作的那家經銷商實力雄厚，我們認為這是一個手術做得很好、在該地區有良好影響力的集團。我認為好好服務好這部分客戶群非常重要。但這絕對不是一筆巨大的經濟損失，我們也不認為會造成巨大的經濟損失。我認為，印度還有相當大的發展空間。它現在所處的位置和十年後可能出現的位置可能會有很大的不同。因此，我們認為在印度建立能力需要一些時間，但我們也認為印度的經濟一直在成長，印度的外科界實力雄厚，無論是在印度國內還是全球。因此，這對我們來說是一個重要的長期市場。我們認為，從財務角度來看，隨著時間的推移，它當然可以成為 Intuitive 業務的重要組成部分。舉一些日本的例子是為了說明，在這些市場中建立真正的影響力、建立組織以及在醫療保健界建立信任都需要時間。所以，如果你想在十年內實現目標，那就最好現在就開始行動。而這正是我們在這兩個市場取得成功的真正動力。

Just as a follow-up on a different topic. You highlighted, obviously, some puts and takes in terms of growth, procedure growth, and you mentioned specifically slowing mature procedure growth in some countries. Maybe just expand on that? Is this just you've penetrated the market and it's slowing? Or is there something else going on? Maybe just give us a little more color there.

只是想就另一個話題做個後續討論。顯然，您強調了成長、手術量成長方面的一些利弊，並且特別提到了一些國家成熟手術量成長放緩的情況。或許可以就此展開討論？是不是你們已經打入市場，但現在成長速度放緩了？還是有其他原因？或許可以再添加一些色彩。

In several countries, we are a substantial share of the surgical market, think of United States prostatectomy or partial nephrectomy in the United States or hysterectomies for certain conditions. And as a result, we see that part really growing at the demographic trends rather than a changing share of approach trends. And that's true in the U.S. It's true in some countries in Europe, with regard to prostatectomy and some of the urologic procedures. In Japan, we're already quite highly penetrated in prostatectomy and increasingly so in nephrectomy. So that's was the -- what's some of the detail or examples of what underlies the more general comment. Just one more questioner, please.

在一些國家，我們佔據了外科手術市場相當大的份額，例如美國的前列腺切除術、部分腎切除術或針對某些疾病的子宮切除術。因此，我們看到這部分內容實際上是隨著人口趨勢的增長而增長，而不是隨著方法趨勢的變化而增長。在美國是這樣，在歐洲的一些國家，就前列腺切除術和一些泌尿外科手術而言，情況也是如此。在日本，攝護腺切除術的普及率已經相當高，腎切除的普及率也不斷提高。所以，這就是——那麼，支撐這一更普遍評論的一些細節或例子是什麼？請再問一個問題。

And that question is from the line of Richard Newitter.

這個問題出自理查紐維特之口。

I wanted to start off on the percentage of operating leases and flexible financing arrangements. That's clearly increasing as a percent of the total placements. Could you characterize for us what the -- what the utilization rate differences are on the systems that are getting placed under those types of contracts versus the rest of the installed base? I would imagine it's higher, but can you quantify it at all?

我想先談談營業租賃和彈性融資安排的比例。很明顯，這一比例在總安置人數中正在上升。您能否為我們描述一下，根據這些類型的合約部署的系統與其餘已安裝系統的利用率差異是什麼？我估計會更高，但你能量化一下嗎？

We do quantify it. We monitor it closely and there is not a marked difference between what the utilization rates are on leases versus purchase product.

我們會對其進行量化。我們密切關注，租賃產品的利用率與購買產品的利用率之間沒有明顯差異。

Okay. And then just on the follow-up to the last question, Rick's question. As you think about the low end and the high end of your 2019 procedure growth range, is there -- is the slowing mature procedure growth commentary kind of meant to be throughout the entire range? Or is that contemplated at the low end instead of the high end?

好的。然後，接著是上一個問題的後續問題，也就是瑞克提出的問題。在考慮 2019 年手術增長範圍的低端和高端時，是否存在——成熟手術增長放緩的評論似乎適用於整個範圍？或者，這是在低端市場而非高端市場考慮的？

Yes, some level of moderation, particularly, in the U.S. is part of the trend and obviously, more moderation at the lower end and less moderation at the higher end. But the range will be largely -- the range itself is largely reflective -- the biggest factor's going to be the breadth and pace of growth in U.S. general surgery, our largest category now, then the mature procedures and some other factors regarding growth in China, the timing of placements of new systems and the pace of adoption of reimbursed procedures in Japan.

是的，一定程度的節制，尤其是在美國，是這種趨勢的一部分，而且很明顯，低端市場更加節制，而高端市場則較少節制。但價格範圍在很大程度上——價格範圍本身在很大程度上反映了——最大的因素將是美國普通外科手術的增長廣度和速度，這是我們目前最大的類別，其次是成熟的手術以及與中國增長相關的其他一些因素、新系統的部署時間以及日本報銷手術的採用速度。

Well, thank you. Thank you for the questions. That was our last one. As we've said previously, while we focus on financial metrics such as revenues, profits and cash flow during these conference calls, our organizational focus remains on increasing value by enabling surgeons to improve surgical outcomes and reduce surgical trauma. We've built our company to take surgery beyond the limits of the human hand, and I assure you that we remain committed to driving the vital few things that truly make a difference.

謝謝。謝謝大家的提問。那是我們最後一個。正如我們之前所說，雖然我們在這些電話會議中關注的是收入、利潤和現金流等財務指標，但我們組織的重點仍然是透過幫助外科醫生改善手術結果和減少手術創傷來增加價值。我們創立這家公司的目的是為了突破人手的極限，實現外科手術的目標。我向你們保證，我們將持續致力於推動那些真正能帶來改變的關鍵因素。

This concludes today's call. We thank you for your participation and support on this extraordinary journey to improve surgery and we look forward to talking to you again in 3 months.

今天的電話會議到此結束。感謝您參與並支持我們這段非凡的外科手術改進之旅，我們期待在 3 個月後再次與您交流。

Thank you. Ladies and gentlemen, that does conclude your conference. We do thank you for joining. You may now disconnect. Have a good day.

謝謝。女士們、先生們，本次會議到此結束。非常感謝您的參與。您現在可以斷開連線了。祝你有美好的一天。