直覺手術 (ISRG) 2019 Q1 法說會逐字稿

Ladies and gentlemen, thank you for standing by. Welcome to the Intuitive Surgical Q1 2019 Earnings Release Call. (Operator Instructions) And as a reminder, this conference 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2019年第一季財報發布電話會議。（操作說明）再次提醒，本次會議正在錄音。

I'd now like to turn the conference over to Calvin Darling, Senior Director of Finance, Investor Relations. Please go ahead.

現在我將把會議交給財務高級總監兼投資者關係主管卡爾文·達林。請繼續。

Thank you. Good afternoon, and welcome to Intuitive Surgical first quarter earnings conference call. With me today, we have Gary Guthart, our CEO; and Marshall Mohr, our Chief Financial Officer.

謝謝。下午好，歡迎參加直覺外科公司第一季財報電話會議。今天和我在一起的有我們的執行長 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 4, 2019. 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 2019 年 2 月 4 日提交的 10-K 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「投資者關係」頁面下的「最新動態」欄位中找到。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 first 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一季業績亮點，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 first 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；Marshall 將回顧我們第一季的財務表現；然後我將討論流程和臨床亮點，並提供我們 2019 年的最新財務展望。最後，我們將舉行問答環節。

With that, I'll turn it over to Gary.

接下來，我將把麥克風交給蓋瑞。

Let's first start -- this first quarter was a solid start to 2019 for Intuitive. Customer response to our products and services is healthy with continued growth in their use of da Vinci to deliver high-quality, minimally-invasive surgery to our broad base of patients.

首先，對於 Intuitive 來說，2019 年第一季是一個穩健的開局。客戶對我們產品和服務的回饋良好，他們越來越多地使用達文西手術系統為我們廣泛的患者群體提供高品質、微創的手術。

As I've said in the past, 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. We have a substantial opportunity and there is significant work to be done.

正如我過去所說，我認為傑出的產品設計、機器人技術、先進的影像技術和資訊學才剛開始在外科手術和更廣泛的急診幹預中佔據一席之地。我們面臨著巨大的機遇，同時也有大量的工作要做。

Global procedure growth was strong at approximately 18% in the first quarter of 2019, progress of growth remained consistent with our trailing several quarters, with growth in general surgery accounting for strength in the United States. Growth in Japan continues to be healthy with strength in urology, gastrectomy and colorectal procedures. Growth in China met our expectations given constraints on capital placements.

2019 年第一季全球手術量成長強勁，約 18%，成長動能與過去幾季保持一致，其中美國普通外科手術的成長是強勁成長的主要原因。日本的成長動能依然強勁，泌尿科、胃切除術和大腸直腸手術等領域表現突出。考慮到資本配置的限制，中國的成長符合我們的預期。

Placements of new systems in the quarter was strong with growth in total placements rising 27% from Q1 of 2018. Net of trade-ins and retirements, our da Vinci installed base again grew 13% over Q1 2018 to approximately 5,110.

本季新系統的部署情況強勁，總部署量比 2018 年第一季成長了 27%。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 2018 年第一季再次成長了 13%，達到約 5,110 台。

The mix of systems placements between our flagship Xi System and our value X System generally aligned with our strategy regionally. Trade-ins of earlier generation systems increased this quarter as customers pursued the features of our generation 4 systems and some hospitals seek to standardize.

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。本季度，由於客戶追求我們第四代系統的功能，以及一些醫院尋求標準化，早期一代系統的以舊換新數量有所增加。

As we discussed on our previous earnings calls, customers are interested in leasing, including usage-based models. The proportion of systems placed under operating leases increased again from 29% in Q4 2018 to 33% in Q1 of this year. The increase in trade-ins, leasing and usage-based models aligns with our strategy in supporting customers. It allows them greater flexibility to have the right systems in the right care delivery environments. For the investor, it can make revenue modeling for systems harder to evaluate relative to prior quarters as trade-ins impact our reported ASP and leasing defers revenue to future quarters. Marshall will take you through greater detail later in the call.

正如我們在先前的財報電話會議上討論的那樣，客戶對租賃很感興趣，包括按使用量計費的租賃模式。2018 年第四季度，以經營租賃方式部署的系統比例為 29%，而今年第一季度，這一比例再次上升至 33%。以舊換新、租賃和按使用量計費模式的增加，符合我們支援客戶的策略。這使他們能夠更靈活地在合適的醫療服務環境中部署合適的系統。對於投資者而言，與前幾季相比，由於以舊換新會影響我們報告的平均售價，而租賃將收入推遲到未來幾個季度，因此評估系統收入模型可能會更加困難。馬歇爾稍後會在通話中詳細講解。

Turning to expenses, we described our plans for increased investment in 2019 as we launch new platforms, strengthen our computational capabilities and invest in projects that support future scale and provide leverage opportunities as we grow. Over the past year, we've seen our increased flexibility with customers catalyze growth, which in turn enables us to invest in manufacturing efficiencies that lower our costs. Our spending fell near the top end of the range of projections we shared with you last quarter, supported by procedure growth above the top end of our procedure guidance range.

談到支出，我們描述了 2019 年增加投資的計劃，包括推出新平台、加強運算能力以及投資支持未來規模和在我們發展過程中提供槓桿機會的項目。過去一年，我們透過提高與客戶的合作彈性，促進了業務成長，進而使我們能夠投資於提高生產效率，從而降低成本。由於手術量增長超過了我們上季度向您顯示的預測範圍的上限，我們的支出接近了預測範圍的上限。

Financial highlights of our first quarter are as follows: procedures grew approximately 18% for the first quarter of last year; we placed 235 da Vinci surgical systems, up from 185 in the first quarter of 2018; our installed base again grew 13% from a year ago; revenue for the quarter was approximately $974 million, up 15%; pro forma gross profit margin was 71.2% compared to 71.6% in the first quarter last year; instrument and accessory revenue increased to $552 million, up 20%; total recurring revenue in the quarter was $747 million, growing 20% over Q1 of 2018 and representing 77% of total revenue. We generated a pro forma operating profit of $362 million in the quarter, up 4% from the first quarter last year and pro forma net income was $312 million, up 9%. As you know, we measure our efforts by their ability to positively impact the quadruple aim: better outcomes, better patient experience, better care team experience, and lower total cost to treat per patient episode.

我們第一季的財務亮點如下：手術量較去年同期成長約 18%；我們安裝了 235 台達文西手術系統，高於 2018 年第一季的 185 台；我們的裝置量較去年同期再次成長 13%；本季營收約 9.74 億美元，成長 15%； 5.52 億美元，成長 20%；本季經常性收入總額為 7.47 億美元，較 2018 年第一季成長 20%，佔總營收的 77%。本季我們實現了 3.62 億美元的備考營業利潤，比去年第一季成長了 4%；備考淨利潤為 3.12 億美元，成長了 9%。如您所知，我們衡量自身努力的標準是：能否對四重目標產生正面影響：更好的治療效果、更好的患者體驗、更好的護理團隊體驗以及更低的每次患者治療總成本。

Real progress requires more than minimally invasive tools and more than digital technologies. These technologies are necessary, but not sufficient. 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. While we've made significant progress over our history, we believe continuous improvement is required, and we have deployed our investments toward these aims.

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。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、智慧且與雲端連接的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。雖然我們在過去的發展歷程中取得了顯著的進步，但我們相信需要不斷改進，我們也已將投資用於實現這些目標。

We design instruments and accessories to enable repeatable high-quality surgeries that are efficient and cost-effective relating to total cost to treat. Our team is in the process of launching several sophisticated products in pursuit of the same, and customers are now adopting them broadly.

我們設計的儀器和配件能夠實現可重複的高品質手術，並且在治療總成本方面既高效又經濟。為了實現這一目標，我們的團隊正在推出幾款先進的產品，目前客戶正在廣泛採用這些產品。

Our 60-millimeter stapler is now in full launch and is used primarily in abdominal surgeries. Our second generation 45-millimeter stapler has recently received 510(k) clearance, incorporating several of the learnings from our 80-millimeter line. Surgeon response has been strong and adoption of our stapling line is encouraging. We also launched our third generation vessel sealer. Its adoption has likewise been strong.

我們的 60 毫米縫合器現已全面上市，主要用於腹部手術。我們第二代 45 毫米訂書機最近獲得了 510(k) 認證，其中融合了我們 80 毫米系列產品的一些經驗。外科醫生反應強烈，我們縫合器生產線的採用情況令人鼓舞。我們也推出了第三代血管密封機。它的普及程度也同樣很高。

Turning to the systems, we are in our first phase launch of da Vinci SP. We installed 6 systems in Q1, constrained in the quarter by manufacturing availability and bringing our clinical installed base of SP to 21. Roughly 800 procedures had been performed to date (07.36). Recall, we have 2 cleared indications for SP: urologic and transoral surgery. Surgeon and patient feedback have been positive for usability and patient experience in these early days of launch. Going forward, we expect continued progress in strengthening our production performance to support SP launch at scale.

說到系統方面，我們目前正處於達文西SP系統的第一階段發布階段。第一季我們安裝了 6 套系統，由於生產能力的限制，本季我們完成了安裝，使我們的 SP 臨床安裝基礎達到 21。截至目前，已進行了約 800 例手術（07.36）。請記住，SP 有 2 個明確的適應症：泌尿外科手術和經口手術。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。展望未來，我們期望在提升生產能力方面取得持續進展，以支援SP的大規模發布。

As we've described in the past, we are also pursuing additional clinical indications for SP and have engaged regulatory agencies regarding their requirements. The combination of additional indications for SP and production readiness at scale will pace the speed of SP commercial deployment.

正如我們之前所描述的那樣，我們也在尋求 SP 的其他臨床適應症，並已就​​監管機構的要求與其進行了溝通。SP 的更多適應症和大規模生產的準備將加快 SP 商業部署的速度。

In flexible diagnostics, our Ion platform is focused on the need for definitive early diagnosis of suspicious lesions for lung cancer. Ion received FDA clearance in the first quarter. With 510(k) clearance, we have initiated our next phase focused on clinical use, customer feedback and production optimization. First cases on the cleared system were performed at the end of Q1, and we plan a measured rollout this year. We do not anticipate material revenues from Ion in 2019.

在靈活診斷方面，我們的 Ion 平台專注於對肺癌可疑病變進行明確的早期診斷。Ion在第一季獲得了FDA的批准。在獲得 510(k) 許可後，我們已啟動下一階段，專注於臨床應用、客戶回饋和生產優化。首批在已獲批准的系統上進行的案例於第一季末完成，我們計劃今年逐步推廣。我們預期 2019 年 Ion 不會帶來實質收入。

In our cloud computing and informatics efforts, we routinely deliver programmatic insights to customers using our systems, which have been smart and connected for the past decade. We received FDA clearance for our Auris augmented reality product in first quarter and anticipate first clinical use in 2019, focused on several high-volume da Vinci institutions that will lead clinical evaluation and analysis. We do not anticipate any revenue from Auris in 2019.

在我們的雲端運算和資訊學工作中，我們經常使用我們的系統向客戶提供程式化見解，這些系統在過去十年中一直保持著智慧和互聯互通的特性。我們在第一季度獲得了 FDA 對 Auris 擴增實境產品的批准，預計將於 2019 年首次進行臨床應用，重點是幾家大型達文西手術中心，這些中心將主導臨床評估和分析。我們預計 Auris 在 2019 年不會帶來任何收入。

In closing, our business fundamentals are strong and for the balance of the year, our focus remains in completing the tasks we set for ourselves: 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 focused procedures and countries.

最後，我們的業務基本面依然強勁，在今年餘下的時間裡，我們將繼續專注於完成我們為自己設定的任務：首先，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，推動智能手術創新；最後，支持在我們重點關注的手術和國家進行額外的臨床和經濟驗證。

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

現在我將把電話交給馬歇爾，他將回顧財務要點。

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

午安.我將以非GAAP備考財務報表的形式，介紹我們業績的亮點。我稍後會在發言中總結我們按GAAP準則執行的業績。我們的備考業績與GAAP業績的核對錶已發佈在我們的網站上。

Key business metrics for the first quarter were as follows: first quarter 2019 procedures increased approximately 18% compared with the first quarter 2018 and decreased approximately 1% 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. First quarter system placements of 235 systems increased 27% compared with 185 systems last year and decreased from the 290 system placements in our seasonally stronger fourth quarter.

第一季的關鍵業務指標如下：2019 年第一季手術量較 2018 年第一季度增長約 18%，較上一季度下降約 1%；手術量的增長繼續由美國的普通外科手術和全球的泌尿外科手術推動。Calvin將在本次通話中稍後詳細介紹手術進展。第一季系統安裝量為 235 套，比去年同期的 185 套成長了 27%，但比往年同期（第四季）的 290 套有所下降。

We expanded our installed base of da Vinci systems by 13% to approximately 5,110 systems, which is consistent with the fourth quarter and slightly higher than the 12.6% increase last year. Utilization of current clinical systems in the field, measured by procedures per system, grew in the mid-single digits.

我們將達文西手術系統的安裝量擴大了 13%，達到約 5110 套系統，與第四季持平，略高於去年 12.6% 的增幅。以每個系統的操作次數衡量，目前臨床系統在現場的使用率成長了中等個位數。

Our revenue overview is as follows. First quarter 2019 revenue was $974 million, an increase of 15% compared with $848 million for the first quarter of 2018, and a decrease of 7% compared with the seasonally stronger fourth quarter revenue of $1.047 billion.

我們的收入概覽如下。2019 年第一季營收為 9.74 億美元，比 2018 年第一季的 8.48 億美元成長了 15%，比季節性成長較為強勁的第四季營收 10.47 億美元下降了 7%。

Instrument and accessory revenue of $552 million increased 20% compared with last year, which is higher than procedure growth, primarily reflecting increased use of our advanced instruments and customer buying patterns. Instrument and accessory revenue realized per procedure was approximately $1,960, an increase of 2% compared with the first quarter of 2018 and an increase of 4% compared with last quarter.

儀器及配件收入為 5.52 億美元，比去年增長 20%，高於手術量增長，這主要反映了我們先進儀器的使用量增加以及客戶購買模式的改變。每台手術的器械和配件收入約為 1,960 美元，比 2018 年第一季成長 2%，比上一季成長 4%。

Systems revenue for the first quarter 2019 was $248 million, an increase of 6% compared with the first quarter of 2018 and a decrease of 27% compared with last quarter. The variation between 6% systems revenue growth and the 27% system placements growth reflects greater proportion of operating leases, a greater proportion of system trade-ins, a greater proportion of X systems, a higher mix of distributor placements and volume-based discounts provided to customers purchasing multiple systems.

2019 年第一季系統營收為 2.48 億美元，比 2018 年第一季成長 6%，比上一季下降 27%。系統收入成長 6% 與系統安裝量成長 27% 之間的差異反映了經營租賃比例的增加、系統以舊換新比例的增加、X 系統比例的增加、經銷商安裝比例的增加以及向購買多個系統的客戶提供的基於數量的折扣。

We completed 78 operating lease transactions, representing 33% of total placements compared with 43 or 23% of total placements in the first quarter of 2018, and 84 or 29% of total placements last quarter. As of March 31, we have 423 operating leases outstanding and realized approximately $20 million of revenue related to these arrangements in the quarter compared with $10 million last year and $16 million last quarter.

我們完成了 78 筆經營租賃交易，佔總交易量的 33%，而 2018 年第一季完成了 43 筆，佔總交易量的 23%，上一季完成了 84 筆，佔總交易量的 29%。截至 3 月 31 日，我們有 423 份未結清的經營租賃合同，本季度與這些安排相關的收入約為 2000 萬美元，而去年同期為 1000 萬美元，上一季為 1600 萬美元。

Operating leases create a future source of recurring revenue and reduce the volatility of system revenue. While the increased number of operating systems placed in the quarter dampen short-term revenue growth for the quarter in which they are placed.

經營租賃創造了未來的經常性收入來源，並降低了系統收入的波動性。雖然本季部署的作業系統數量增加會抑制該季度的短期收入成長。

Operating leases include usage-based financing that we provide to certain experienced hospitals. We believe that our leasing alternatives align with customer objectives and have enabled faster market adoption. Relative to systems purchased over the lease period, we earn a small premium, reflecting the time value of money and in the case of usage-based arrangements, the risk that those systems may not achieve anticipated usage levels. The proportion of these types of arrangements could increase long term and will be lumpy quarter-to-quarter.

營業租賃包括我們向某些經驗豐富的醫院提供的基於使用量的融資。我們相信，我們的租賃方案符合客戶的目標，並能更快被市場接受。與租賃期間購買的系統相比，我們獲得了少量溢價，這反映了貨幣的時間價值，並且在按使用量計費的情況下，也反映了這些系統可能無法達到預期使用水準的風險。從長遠來看，這類安排的比例可能會增加，並且每季的比例會波動較大。

36% of the current quarter system placements involved trade-ins, reflecting customer desire to access or standardize on our fourth-generation technology. This is an increase in the proportion of trade-ins compared to 31% in the first quarter of 2018 and 28% last quarter. Trade-in activity can be lumpy and difficult to predict.

本季系統安裝中有 36% 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。與 2018 年第一季的 31% 和上一季的 28% 相比，以舊換新的比例增加。以舊換新活動可能波動較大，難以預測。

67% of the systems placed in the quarter were da Vinci Xis. 25% were da Vinci X systems compared with 73% da Vinci Xis and 18% da Vinci Xs last quarter. Six of the systems placed were SP systems. Our rollout of the SP surgical system is measured, putting systems in the hands of experienced da Vinci users, while we optimize training pathways in our supply chain. As mentioned by Gary, SP production was constrained in the first quarter.

在本季安裝的系統中，67% 為達文西 Xi 手術系統。25% 為達文西 X 系統，而上一季為 73% 為達文西 Xi，18% 為達文西 X。其中安裝的六套系統是SP系統。我們對 SP 手術系統的推廣採取循序漸進的方式，將系統交給經驗豐富的達文西用戶，同時優化供應鏈中的訓練途徑。正如 Gary 所提到的，SP 的產量在第一季受到了限制。

Globally, our average selling price, which excludes the impact of operating leases and lease buyouts was approximately $1.31 million compared with $1.49 million last year and $1.46 million last quarter. The changes compared with prior periods primarily reflect a greater portion of trade-in transactions, volume-based incentives providing customers purchasing multiple systems, a greater proportion of X Systems and higher proportion of distributor sales.

在全球範圍內，我們的平均售價（不包括營業租賃和租賃買斷的影響）約為 131 萬美元，而去年同期為 149 萬美元，上一季為 146 萬美元。與前期相比，這些變化主要反映了以舊換新交易比例的增加、為購買多個系統的客戶提供的基於數量的激勵措施、X 系統比例的增加以及分銷商銷售額比例的提高。

Outside of the U.S., results were as follows. OUS procedures grew approximately 21% compared with the first quarter of 2018 and increased 6% compared with last quarter. First quarter revenue outside of the U.S. of $282 million increased 3% compared with the first quarter of 2018 and decreased 8% compared with last quarter. The 3% year-over-year revenue growth primarily reflects a greater proportion of X systems, a higher mix of distributor arrangements, and a greater proportion of operating leases. Outside the U.S., we placed 81 systems in the first quarter compared with 73 in the first quarter of 2018 and 115 systems last quarter. Current quarter system placements included 49 into Europe, 13 into Japan, 8 into Brazil and 3 into China.

美國以外地區的結果如下。與 2018 年第一季相比，OUS 手術量增加了約 21%，與上一季相比增加了 6%。第一季美國以外的營收為 2.82 億美元，與 2018 年第一季相比成長 3%，與上一季相比下降 8%。3% 的年收入成長主要反映了 X 系統佔比的增加、經銷商安排組合的增加以及經營租賃佔比的增加。在美國以外，我們第一季安裝了 81 套系統，而 2018 年第一季為 73 套，上一季為 115 套。在當前季度製度下的就業分配包括：49人進入歐洲，13人進入日本，8人進入巴西，3人進入中國。

36 or 44% of the systems placed in the first quarter were X systems compared with 19% last year and 30% last quarter. 11 of the system placements were operating leases compared with one last year and 15 last quarter. Placements outside 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 limitation.

在第一季安裝的系統中，有 36 個（即 44%）是 X 系統，而去年同期為 19%，上一季為 30%。11 個系統部署方案為經營租賃，去年同期為 1 個，上季為 15 個。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，而有些市場的銷售則受到政府限制。

Moving on to gross margin and operating expenses. Pro forma gross margin for the first quarter of 2019 was 71.2% compared with 71.6% for the first quarter of 2018 and 71.8% last quarter. The decrease compared with the first quarter of 2018 and last quarter primarily reflects lower system ASPs and a higher mix of advanced instruments, partially offset by improvements in manufacturing efficiency. 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 product costs and improve manufacturing efficiency.

接下來分析毛利率和營運費用。2019 年第一季的備考毛利率為 71.2%，而 2018 年第一季為 71.6%，上一季為 71.8%。與 2018 年第一季和上一季相比，下降主要反映了系統平均售價降低和先進儀器的佔比增加，部分被製造效率的提高所抵消。未來的利潤率將根據我們新產品的組合、系統和儀器及配件收入的組合、系統平均售價以及我們進一步降低產品成本和提高生產效率的能力而波動。

Pro forma operating expenses increased 27% compared with the first quarter of 2018 and decreased 2% compared with last quarter. Fourth quarter 2018 operating expenses included a $25 million contribution to the newly formed Intuitive Foundation. Excluding the contribution to the foundation, pro forma operating expenses increased 5% compared with last quarter. In order of magnitude of increase, first quarter expenses reflect costs associated with expansion of our OUS markets, spending on our informatics capabilities and investment in our infrastructure in order to scale the business.

與 2018 年第一季相比，以備考計算的營運費用增加了 27%，與上一季相比下降了 2%。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。不計入對基金會的捐款，以備考計算的營運費用比上一季增加了 5%。按成長幅度排序，第一季支出反映了與拓展海外市場相關的成本、資訊能力方面的支出以及為擴大業務規模而對基礎設施進行的投資。

Our pro forma effective tax rate for the first quarter was 19.8% compared with our expectations of 19% to 20%. Our tax rates will fluctuate with changes in the mix of U.S. and OUS income and changes in taxation made by local authorities and with the impact of onetime items.

第一季的預期實際稅率為 19.8%，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 first quarter 2019 pro forma net income was $312 million or $2.61 per share compared with $288 million or $2.44 per share for the first quarter of 2018 and $353 million or $2.96 per share for the fourth quarter 2018.

2019 年第一季度，我們的備考淨收入為 3.12 億美元，即每股 2.61 美元，而 2018 年第一季為 2.88 億美元，即每股 2.44 美元，2018 年第四季為 3.53 億美元，即每股 2.96 美元。

I will now summarize our GAAP results. GAAP net income was $307 million or $2.56 per share for the first quarter of 2019, compared with GAAP net income of $288 million or $2.44 per share for the first quarter of 2018, and GAAP net income of $293 million or $2.45 per share for the fourth quarter of 2018. The adjustments between pro forma and GAAP net income are outlined and quantified on our website. It include excess tax benefits associated with employee stock awards, employee equity and IP charges, and legal settlements.

現在我將總結一下我們的GAAP業績。2019 年第一季 GAAP 淨利為 3.07 億美元，即每股 2.56 美元；而 2018 年第一季 GAAP 淨利潤為 2.88 億美元，即每股 2.44 美元；2018 年第四季 GAAP 淨利潤為 2.93 億美元，即每股 2.45 美元。網站上列出了備考淨收入與GAAP淨收入之間的調整情況，並進行了量化說明。其中包括與員工股票獎勵、員工股權和智慧財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 $5.1 billion compared with $4.8 billion at December 31, 2018. The increase generally reflects cash generated from operations partially offset by investments in working capital and infrastructure.

本季末，我們的現金和投資總額為 51 億美元，而 2018 年 12 月 31 日為 48 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。

In the quarter, we grew inventory by approximately $60 million to $468 million, representing approximately 140 days 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 or other matters. With the growth in the business and our focus on efficiency and scale, we expect capital expenditures will increase to over $250 million in 2019.

本季度，我們的庫存增加了約 6,000 萬美元，達到 4.68 億美元，相當於約 140 天的庫存。我們持續增加庫存，以因應業務成長，並降低因貿易、供應商或其他事項可能造成的中斷風險​​。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 年資本支出將增加到 2.5 億美元以上。

In January, our Board of Directors increased our stock buyback authorization to $2 billion. We did not repurchase any shares in the quarter.

今年一月，我們的董事會將股票回購授權額度提高至 20 億美元。本季我們沒有回購任何股票。

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

接下來，我將把發言權交給 Calvin，他將回顧手術流程，並更新我們對 2019 年的展望。

Thank you, Marshall. Our overall first quarter procedure growth was 18% compared to 15% during the first quarter of 2018 and 19% last quarter. Our Q1 procedure growth was driven by 17% growth in U.S. procedures and 21% growth in OUS markets.

謝謝你，馬歇爾。我們第一季的整體手術量成長了 18%，而 2018 年第一季為 15%，上一季為 19%。第一季手術量成長主要得益於美國手術量成長 17% 和美國境外市場手術量成長 21%。

In the U.S., Q1 procedure results were generally consistent with recent trends. Q1 growth was again driven by growth in U.S. general surgery, thoracic and benign gynecology procedures. In general surgery, first quarter hernia repair and colorectal procedure growth remained strong, while growth in other general surgery procedures such as cholecystectomy, bariatric, and liver and pancreatic cases also contributed to growth.

在美國，Q1 手術結果大致上與近期趨勢一致。第一季的成長再次得益於美國一般外科、胸腔外科和良性婦科手術的成長。在一般外科領域，第一季疝氣修補術和結直腸手術的成長依然強勁，而其他一般外科手術（如膽囊切除術、減肥手術以及肝臟和胰臟手術）的成長也促進了成長。

First quarter U.S. gynecology continued to grow in the mid-single digits, driven by benign hysterectomy procedures. Our data continues to indicate an increasing proportion of overall gynecology procedures are being performed by gynecologic oncologist. In addition, our recently launched Vessel Sealer Extend instrument is increasingly being adopted by gynecologists.

第一季美國婦科手術持續維持個位數中段的成長，這主要得益於良性子宮切除手術的成長。我們的數據顯示，婦科腫瘤醫師執行的婦科手術比例持續上升。此外，我們近期推出的血管封閉器擴展型器械也越來越受到婦科醫師的青睞。

U.S. urology first quarter growth moderated a bit in Q1, driven by prostatectomy, which moved closer to the underlying incident rate for prostate cancer. As a mature procedure category, we believe that our U.S. prostatectomy volumes have been tracking to the broader prostate surgery market. In other U.S. procedures, adoption of lobectomies and other thoracic procedures was, again, solid in the first quarter.

美國泌尿科第一季的成長放緩，主要原因是前列腺切除術的發生率接近前列腺癌的基本發生率。作為一個成熟的手術類別，我們認為我們在美國的前列腺切除手術量與更廣泛的前列腺手術市場趨勢一致。在美國其他手術方面，肺葉切除術和其他胸腔外科手術的發展在第一季再次保持穩健。

First quarter OUS procedure volume grew approximately 21% compared with 18% for the first quarter 2018 and 24% last quarter. First quarter 2019 OUS procedure growth was driven by continued growth in dVP procedures and earlier stage growth in kidney cancer procedures, general surgery and gynecology.

與 2018 年第一季的 18% 和上一季的 24% 相比，第一季 OUS 手術量增加了約 21%。2019 年第一季 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手術、一般外科手術和婦科手術早期階段的成長。

Two weeks ago, we attended the Society of American Gastrointestinal and Endoscopic Surgeons or SAGES conference in Baltimore. SAGES is one of the largest general surgery meetings each year, attended by many of the world's leading general surgeons. We were encouraged by the emerging consensus view regarding the value of robotic-assisted approaches in general surgery procedures.

兩週前，我們參加了在巴爾的摩舉行的美國胃腸內視鏡外科醫師協會（SAGES）會議。SAGES是每年規模最大的一般外科會議之一，吸引了許多世界頂尖的一般外科醫師參加。我們對機器人輔助手術在一般外科手術中的價值逐漸達成的共識感到鼓舞。

Our booth was highly visited by surgeons interested in hands-on access to the full breadth of our generation 4 platform, including the da Vinci Xi, X and SP systems on the floor. And our advanced instrumentation, including the SureForm surgical stapler. The SAGES conference emphasizes clinical evidence, and I will share with you one of the e-posters presented at the event, analyzing real-world evidence. 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.

我們的展位吸引了許多外科醫生前來參觀，他們對親身體驗我們第四代平台的全系列產品很感興趣，包括現場的達文西 Xi、X 和 SP 系統。還有我們先進的儀器設備，包括 SureForm 手術縫合器。SAGES 會議強調臨床證據，我將與大家分享本次活動中展示的一張電子海報，該海報分析了真實世界的證據。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。

At this year's SAGES, Dr. Elizabeth Raskin from Loma Linda University, presented research titled: Reducing Variability and Outcomes, Conversion Rate Analysis of Minimally Invasive Sigmoidectomy. The study used the premier healthcare database, selecting data from institutions performing at least 100 laparoscopic-assisted or robotic-assisted sigmoidectomy cases between 2013 and 2015. Data for 8,821 patients from 75 hospitals were analyzed. The median conversion rate for minimally-invasive surgery to open surgery across the entire sample was 10.85%. The data was split between higher conversion rate hospitals above the median and lower conversion rate hospitals below the median.

在今年的 SAGES 會議上，來自洛馬琳達大學的 Elizabeth Raskin 博士發表了題為“減少變異性和結果，微創乙狀結腸切除術的轉化率分析”的研究。該研究使用了首屈一指的醫療保健資料庫，選取了 2013 年至 2015 年間至少進行過 100 例腹腔鏡輔助或機器人輔助乙狀結腸切除術的機構的數據。分析了來自 75 家醫院的 8,821 名患者的數據。整個樣本中微創手術轉為開放性手術的中位數轉換率為 10.85%。數據分為轉換率高於中位數的醫院和轉換率低於中位數的醫院兩類。

Among patients from the higher conversion rate hospitals, the conversion rate for lab procedures was 18.41% compared to 11.33% robotic assisted. Among patients from lower conversion rate hospitals, the conversion rate for lab-assisted cases was 7.33% compared to 2.89% for the robotic cases. After adjusting for variables, the lap patients in the higher conversion rate hospitals had 75% more risk of converting to open approach.

在轉換率較高的醫院的患者中，實驗室手術的轉換率為 18.41%，而機器人輔助手術的轉換率為 11.33%。在轉換率較低的醫院的患者中，實驗室輔助手術的轉換率為 7.33%，而機器人手術的轉換率為 2.89%。在調整各種變數後，轉化率較高的醫院的腹腔鏡手術患者轉為開腹手術的風險高出 75%。

In the lower conversion group, laparoscopic approach was found to be 2.5x more likely to be converted to open compared to the robotic-assisted approach. While we are encouraged by the lower da Vinci conversion rates relative to laparoscopy, this study highlights that there is still significant remaining opportunity for surgeons to drive conversion rates meaningfully lower, which has the potential to improve outcomes and patient experience. Furthermore, as evidenced by the large gap between the higher and lower conversion rate hospitals, there remains significant opportunity to reduce the variability of outcomes across care teams.

在轉化率較低的組別中，與機器人輔助手術相比，腹腔鏡手術轉化為開腹手術的可能性高出 2.5 倍。儘管達文西手術的轉換率相對於腹腔鏡手術較低，這令我們感到鼓舞，但這項研究強調，外科醫生仍有很大的機會將轉換率顯著降低，這有可能改善手術效果和患者體驗。此外，從轉換率較高和較低醫院之間的巨大差距可以看出，仍有很大的機會來減少不同護理團隊之間的結果差異。

I will now turn to our financial outlook for 2019, starting with procedures. On our last call, we forecast full year 2019 procedure growth within a range of 13% to 17%. We are now refining our estimate to the upper half of that range and estimate full year 2019 procedure growth of 15% to 17%.

接下來，我將談談我們對 2019 年的財務展望，首先從流程說起。上次電話會議上，我們預測 2019 年全年手術量成長將在 13% 至 17% 之間。我們現在將估計值調整到該範圍的上半部分，並估計 2019 年全年手術量增加 15% 至 17%。

With respect to revenue, as we have mentioned previously, in mature markets, capital sales are ultimately driven by procedure growth, catalyzing hospitals to establish or expand robotic system capacity. Capital sales revenue 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. Indeed, the impact of leasing, trade-in and product mix are reflected in our systems revenue results for Q1. While these factors are aligned with our strategy and positive business levers, the revenue result was lower than historical norms relative to the number of systems placed.

就收入而言，正如我們之前提到的，在成熟市場中，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。資本銷售收入會因多種因素而隨時間而顯著變化，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。事實上，租賃、以舊換新和產品組合的影響已反映在我們第一季的系統收入表現。雖然這些因素與我們的策略和積極的業務槓桿相符，但相對於部署的系統數量而言，收入結果低於歷史平均。

Looking forward, we expect continued variation by quarter and we expect to continue to see meaningful proportions of capital placements involving trade-ins and/or these structured as operating leases.

展望未來，我們預計各季度將繼續出現波動，並且我們預計將繼續看到相當比例的資本配置涉及以舊換新和/或以經營租賃形式進行的配置。

Turning to gross profit. We continue to 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.

接下來討論毛利。我們仍然預計，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 are expanding our investments in 2019. Given our results in the first quarter, we expect to grow pro forma 2019 operating expenses between 24% and 28% above 2018 levels compared to the 20% to 28% range forecast on our last call. We expect our noncash stock compensation expense to range between $320 million and $340 million in 2019 compared with $310 million to $340 million forecast on our last call.

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 年擴大投資。鑑於我們第一季的業績，我們預計 2019 年的備考營運費用將比 2018 年的水準成長 24% 至 28%，而我們在上次電話會議上預測的成長範圍為 20% 至 28%。我們預計 2019 年的非現金股票補償支出將在 3.2 億美元至 3.4 億美元之間，而上次電話會議上我們預測的支出為 3.1 億美元至 3.4 億美元。

We continue to expect other income, which was comprised mostly of interest income to total between $120 million and $130 million in 2019. With regard to income tax, we continue to estimate our 2019 pro forma income tax rate to be between 19% and 20% of pretax income.

我們繼續預期其他收入（主要包括利息收入）在 2019 年總額將在 1.2 億美元至 1.3 億美元之間。關於所得稅，我們繼續預期 2019 年的預計所得稅稅率為稅前收入的 19% 至 20%。

That concludes our prepared remarks. We will now open the call to your questions.

我們的發言稿到此結束。現在開始回答各位的問題。

(Operator Instructions) Our first question will come from Tycho Peterson at JPMorgan.

（操作員說明）我們的第一個問題將來自摩根大通的泰科·彼得森。

Maybe I will start with bariatric. Obviously, a lot of excitement coming out of SAGES on the opportunity around bariatric. Gary, can you maybe just talk about the ramp and any infraction you're seeing between gastric bypass leads reviews? And if we think about the 180,000 niche procedures in the U.S., what do you think the adoption curve looks like over the next couple of years?

或許我會先做減肥手術。顯然，SAGES 對減重手術帶來的機會感到非常興奮。Gary，你能不能談談坡道以及你在胃旁路手術結果審查中發現的任何違規行為？如果我們考慮美國 18 萬種小眾手術，您認為未來幾年它們的普及曲線會是什麼樣的呢？

Well, thank you. For starters on bariatrics, we're excited about the long-term opportunity. And as you described, there's interest in all of the procedures' subcategories you've laid out. I'll, in a minute, turn it over to Calvin and speak a little bit about sizing. Where we are in terms of commercial focus, the commercial team is largely focused now on hernia and colorectal procedures. We see some early interest in bariatrics and we'll support that early interest, but we'll -- we'd like to make sure we satisfy the hernia markets and the colorectal markets we're in today, and then we'll pivot over time to support bariatrics more broadly. Calvin, you might speak to...

謝謝。首先，就減重手術而言，我們對長期發展前景感到興奮。正如你所描述的，你列出的所有程式子類別都引起了人們的興趣。我一會兒會把麥克風交給卡爾文，讓他談談尺寸問題。就商業重點而言，我們的商業團隊目前主要專注於疝氣和結直腸手術。我們看到人們對減肥手術產生了一些初步興趣，我們會支持這種初步興趣，但是——我們希望確保滿足我們目前所處的疝氣市場和結直腸市場的需求，然後隨著時間的推移，我們會轉向更廣泛地支持減肥手術。卡爾文，你或許可以和…談談。

Yes. Tycho, you're right. I mean, the 180,000 is about right in aggregate, but there's a lot of different types of procedures within that category from sleeve gastrectomies, to the full bypasses, to the redo procedures you mentioned where I think there's some clear benefits to robotic approach for those complex surgeries. At this point in time, we've seen some very nice early-stage adoption. Obviously, based upon the patient benefits, but also, there's some pretty significant surgeon benefit as well from an ergonomic standpoint. So it's a nice foundation that's building and at this point, as Gary mentioned, we haven't focused the team entirely there.

是的。泰科，你說得對。我的意思是，180,000 這個數字總體上差不多，但這個類別中包含很多不同類型的手術，從袖狀胃切除術到全胃旁路手術，再到你提到的翻修手術，我認為對於這些複雜的手術來說，機器人輔助手術顯然有一些優勢。目前來看，我們已經看到了一些非常好的早期應用案例。顯然，這不僅對患者有益，而且從人體工學的角度來看，對外科醫生也有相當大的益處。所以這是一個正在建立的良好基礎，正如 Gary 所提到的，目前我們還沒有將團隊的全部精力都投入到這方面。

And then on China, Gary, you characterized the market as still being constrained. You only had kind of 3 systems this quarter. Can you talk about your latest thinking on the quota impact? And when do you think things start to free up there a little bit?

然後談到中國，Gary，你認為中國市場仍然受到限制。這個季度你們只有大約3個系統。您能否談談您對配額影響的最新看法？你覺得那裡的情況什麼時候會開始好轉？

Marshall, why don't you take us through that?

馬歇爾，你跟我們講解一下吧？

Sure. So just to replay, the quota is 154 systems for robotic systems. That is a quota that is available to anybody that has approval to sell robotic systems. So if there were to be another company that came along that got approval through CFDA, they would also be able to share in that quota. The quota has been distributed to provinces. The provinces are responsible for identifying the specific hospitals. And then to the hospitals that have to launch a tendering process. All of that takes time and the tendering processes can take quite a bit of time. And in fact, if you replay back to when we got to 2015 -- or the 2013 quota, it took till near the end of 2015 when we saw majority of those systems get done. So what we had told you before was that you should plan on fewer systems early and more systems later. And in fact, the 3 systems that were done this quarter were not done within that quota. So we have not seen any systems from the quota yet.

當然。再說一遍，機器人系統的配額是 154 套系統。任何獲得銷售機器人系統許可的人都可以獲得這個配額。因此，如果之後有另一家公司通過了CFDA的批准，他們也可以分享這個配額。配額已分配給各省。各省負責確定具體醫院。然後是那些必須啟動招標程序的醫院。所有這些都需要時間，招標過程可能需要相當長的時間。事實上，如果我們回顧到 2015 年——或 2013 年的配額，就會發現直到 2015 年底，我們才看到大部分系統完成。所以我們之前告訴你們，前期應該少建一些系統，後期再建一些系統。事實上，本季完成的3個系統都沒有在配額內完成。所以，我們還沒有看到任何配額內的系統。

Okay. And then just last one on Ion. Now that you're out on the market, how do we think about the kind of data collection window here? And what time frame would we start to see some publications? Could we see some by the back half of the year? And then, can you maybe talk to your supply chain optimization efforts and then where you are on that?

好的。然後就是Ion上的最後一個。既然你們已經進入市場，我們該如何考慮資料收集窗口期呢？我們大概什麼時候才能看到一些出版品？我們能否在下半年看到一些成果？那麼，您能否談談貴公司在供應鏈優化方面所做的努力，以及目前進展如何？

Sure. I think we'll be gathering 2 sets of data. Some are position preference and workflow data and the other is outcomes over time. I imagine you'll see various interim publications toward the end of the year. It will take some time to get the full set written and reviewed that may come after '19, but I think you'll see updates from key customers as we go through the year.

當然。我認為我們會收集兩組數據。一部分是職位偏好和工作流程數據，另一部分是隨時間的結果。我想你會看到年底前會有一些中期出版物。完成全部內容的撰寫和審核還需要一些時間，可能會在 2019 年之後進行，但我認為隨著時間的推移，你會看到主要客戶的更新。

In terms of manufacturing optimization, so far so good. A lot of this is really just starting to create the manufacturing process and lines to build things at a little bit bigger scale and incorporate learnings and update tolerances and other kinds of validation work. So far, so good. I think the team is doing a nice job there.

就生產製造優化而言，目前為止一切順利。很多工作實際上只是開始創建製造流程和生產線，以便以更大的規模生產產品，並融入經驗教訓，更新公差和其他類型的驗證工作。到目前為止，一切都很好。我認為團隊在那裡做得很好。

And next, we go to Bob Hopkins with Bank of America.

接下來，我們連線美國銀行的鮑伯霍普金斯。

Just 2 for me. First, Marshall, to start out, I just want to get your latest thinking on operating leases. Obviously, it's accelerated up to 33% replacements. I guess the way I'd ask the question is would you be surprised if that moved up to 50%? Or do you think we're kind of getting close to a top here with 1/3 of the placements?

我只要2個。首先，馬歇爾，我想先了解你對經營租賃的最新看法。顯然，更換率已經加快到 33%。我想這樣問：如果這個比例上升到 50%，你會感到驚訝嗎？還是你認為我們已經接近頂峰了，因為我們佔據了三分之一的席位？

Yes. We introduced leasing and other alternatives, financing alternatives, a few years ago. And we did that in the face of what we thought would be customer demand. And in fact, we think it's played out quite well. And that we have been able to allow customers to expand more quickly their install base. I think -- so it's really customer driven, the demand. And having said that, if it were my choice, I'd find that leases and the alternatives that we're providing customers are favorable to us and that it creates a recurring revenue stream, eliminate some of the volatility of system placement revenue. And I think, in the long term, it will enhance any type of upgrade cycle that might come along. So it's hard for me to predict exactly how far it will go, but again, if it were my choice, I'd like to see it go further.

是的。幾年前，我們推出了租賃和其他融資方案。我們這樣做，是違背了我們認為的客戶需求。事實上，我們認為結果相當不錯。而且，我們已經能夠幫助客戶更快地擴大其安裝基礎。我認為——所以這真的是由顧客需求所驅動的。話雖如此，如果由我來選擇，我會認為租賃以及我們為客戶提供的其他方案對我們有利，因為它能創造持續的收入來源，消除系統部署收入的一些波動性。而且我認為，從長遠來看，它將促進任何可能的升級週期。所以我很難準確預測它會發展到什麼程度，但話說回來，如果由我來選擇，我希望它能走得更遠。

But it doesn't -- it seems like it's going to go higher from here. I mean, it clearly seems like there's no momentum in that, and I don't think it's that big of a deal. I'm just curious to hear your thoughts as to where we might be headed.

但事實並非如此——它似乎還會繼續上漲。我的意思是，很明顯這件事並沒有任何進展，而且我認為這也不是什麼大事。我只是好奇想聽聽你們對我們未來發展方向的看法。

Yes. I've given you my thoughts.

是的。我已經把我的想法告訴你了。

Well, it's hard to predict what the anchor point is. Likely, a little more from here.

嗯，很難預測錨點在哪裡。可能還會再加一點。

Okay. And then, one last question, Gary. You guys -- or for Marshall, you spend at the high end of the guidance this quarter. And it was particularly, the R&D spend I think, was up 38%, now annualizing at roughly $400 million. I was just wondering if you could just go into a little more detail on where that incremental R&D spending is going? And I know we talked about it last quarter but any incremental details on where that big uptick in R&D spending is going would be helpful.

好的。最後一個問題，加里。你們——或者對馬歇爾來說，你們本季的支出達到了預期範圍的上限。尤其是研發支出，我認為成長了 38%，現在每年大約達到 4 億美元。我只是想問一下，您能否更詳細地說明一下新增的研發支出都用在了哪些方面？我知道我們上個季度討論過這個問題，但如果能提供一些關於研發支出大幅成長的具體細節，將會很有幫助。

Yes. It's a fair question. So first, just total spending in context. The bigger component of the increase was actually expanding our field teams outside the U.S. So on a percentage basis, R&D grew. On an absolute basis, it was actually investments in commercial teams and field teams in Asia that drove the biggest side. With breaking down the R&D, to answer your question, in kind of priority order, computational capability and informatics, both in the product and back in the office is the largest uptick, followed by ION, followed by Advanced Instrument investments, followed by Imaging investments. Those are the ones that are responsible for growth down that pathway. And we think we're on a front foot there and making progress where we are, and we're putting those investments out to support our future growth. But that's the rough priority order.

是的。這是一個很合理的問題。首先，讓我們來看看總支出狀況。成長的主要部分實際上是我們擴大了美國以外的現場團隊。因此，從百分比來看，研發投入成長了。從絕對意義上講，最大的成長實際上是對亞洲商業團隊和現場團隊的投資。要回答你的問題，從研發的角度來看，按優先順序排序，運算能力和資訊學（包括產品和辦公室的運算能力和資訊學）的成長幅度最大，其次是 ION，再次是先進儀器投資，最後是影像投資。正是這些因素推動了該領域的成長。我們認為我們在這方面處於領先地位，並在我們所處的領域取得了進展，我們正在進行這些投資以支持我們未來的成長。但這只是大致的優先順序。

And next, we have David Lewis with Morgan Stanley.

接下來，我們請到摩根士丹利的戴維·劉易斯。

Just a couple of questions for me. And Marshall, I wanted to come back to this dynamic of systems mix more broadly. I mean you gave a lot more detail on systems mix this quarter than we've heard in the last several quarters, Calvin highlighted this in guidance. So I think it's going to create this notion of something (inaudible) cyclically, this is just a weird quarter or structurally, there is different dynamics we should be considering for 2019 and beyond. So can you just talk in more detail, you talked about trade-ins x distributors, volume-based discounting. So it does seem like mix dynamics shifted more maturely this quarter than, perhaps, in the last 2 to 3 quarters. I wonder if you could just highlight what changed and what's driving some of those changes?

我還有幾個問題想問。還有馬歇爾，我想更廣泛地探討一下系統混合的這種動態。我的意思是，本季你提供的系統組合細節比過去幾季多得多，卡爾文在業績指引中也強調了這一點。所以我認為這會造成一種（聽不清楚）週期性的概念，這只是一個奇怪的季度，或者從結構上來說，我們應該考慮2019年及以後的不同動態。能詳細說說嗎？你剛才提到了以舊換新 x 經銷商、基於數量的折扣。因此，本季的產品組合動態似乎比過去兩到三個季度更加成熟。我想請您重點介紹一下發生了哪些變化，以及推動這些變化的原因是什麼？

Sure. So to be clear, there was a shift. You're right, that we've seen an increase in the trade-ins, the percentage of trade-ins. And as I said earlier, it was 36% compared to 28% a year ago. And what we're seeing is just customers wanting to avail themselves to the fourth-generation technology...

當然。所以說，情況確實發生了轉變。你說得對，我們已經看到以舊換新的數量增加了，以舊換新的比例也增加了。正如我之前所說，這一比例為 36%，而一年前為 28%。我們看到的是，客戶們都想使用第四代技術…

And standardize to have multiple systems.

並實現多系統標準化。

And standardize their portfolio. And then we've seen more multisystem deals, and some of that has to do with what Gary was just talking about, their desire to expand their base. And as they are doing that, they would rather deal with one set of I&A, one set of training protocol and so forth and so they standardize on the platform. So the 2 are somewhat intertwined. We also saw a greater proportion of X systems, and that's been kind of a volatile statistic, actually. If you go back in time since we introduced X, and it's jumped around a little bit. But indeed, we introduced X with the intention of being able to deliver a lower cost product to geographies where reimbursements are lower. And in fact, in Europe, we saw 45% of the systems sold were Xs, which is exactly the market we targeted for. So these are all things that we think are positive trends, and leasing as well as I spoke to earlier. But the confluence of them all this quarter did drive systems revenue to only grow 6% and also ASPs be a little lower.

並規範他們的投資組合。然後我們看到了更多多系統交易，其中一些與 Gary 剛才提到的有關，即他們希望擴大用戶群。而且，在進行這些操作時，他們寧願處理一套 I&A、一套培訓協議等等，因此他們在平台上實現了標準化。所以這兩者之間有多少有些關聯。我們也看到 X 系統的比例增加，但實際上，這是一個波動較大的統計數據。如果回顧我們引入 X 以來的時間線，你會發現它已經發生了一些變化。但事實上，我們推出 X 的目的是為了能夠向報銷額較低的地區提供成本較低的產品。事實上，在歐洲，我們發現售出的系統中有 45% 是 X 型，這正是我們所瞄準的市場。所以這些都是我們認為的正面趨勢，租賃也是如此，就像我之前提到的。但本季所有這些因素的綜合作用導致系統收入僅成長了 6%，平均售價也略有下降。

If you were looking out into the future for the rest of this year, it's more likely, given the trend in trade-ins and the trend in the multisystem arrangements that will be closer to, let's say, the ASPs we saw this quarter than we saw for the whole of last year. If you go back to last year, we were pretty much around $1.45 million on a consistent basis last year. And so that's where I think we are and where we're going.

如果展望今年剩餘時間的未來，考慮到以舊換新的趨勢和多系統安排的趨勢，更有可能的是，平均售價會更接近我們本季看到的水平，而不是去年全年的水平。如果回顧去年，我們去年的收入基本上穩定在 145 萬美元左右。所以，我認為這就是我們目前的處境和未來的方向。

I don't want to put words in your mouth, Marshall, but it sounds like this trade-in dynamics has been going for 6 to 8 quarters. That's sort of been there. The x mix number can move around quarter-by-quarter. So it sounds like the only incremental new piece of information is some of these larger system orders. Is that a fair characterization of what's probably the incremental new piece of information?

馬歇爾，我不想替你說話，但聽起來這種以舊換新的局面已經持續了 6 到 8 個季度了。那件事一直都存在。x 混合數可以按季度變動。所以聽起來唯一的新增資訊就是這些較大的系統訂單。這種描述是否適當地概括了可能新增的這則訊息？

True. Yes.

真的。是的。

Okay. Very helpful. Just 2 more for me, and I'll jump back in queue. One, Gary, you mentioned some SP manufacturing constraints here in the first quarter? Are those resolved? And sort of what's the pace to resolve them? And then, maybe for Calvin, just -- there's been a lot of -- your channel dynamics around women's health, more broadly women's health, general surgery breast in your gynecological FDA letters. Any impact on the impacting underlying base targeted on either those 2 letters or channel disruption? Those 2 questions.

好的。很有幫助。再給我兩個，我就重新排隊。蓋瑞，你剛才提到第一季SP的生產製造方面存在一些限制？這些問題解決了嗎？那麼，解決這些問題的速度大概是多少呢？然後，也許對卡爾文來說，只是——有很多——你的頻道動態圍繞著女性健康，更廣泛地說是女性健康，普通外科乳房，以及你的婦科FDA信件。這兩個字母或管道中斷是否會對受影響的基礎客戶群產生影響？這兩個問題。

Okay. On the SP side, the manufacturing constraint was a mechanical thing, having to do with frictions and rails and the way these things pull together. I think the team has got it. I think we'll meet our SP shipment client for the year. So I think they're knocking it down. It's just a timing issue there. With regard, I'll start on the broader one. With regard to FDA environment as it relates to medical devices and on women's health, clearly, they're signaling a more conservative approach and are speaking about it broadly across the industry. With regard to Intuitive, that may change some future data requirements and it may introduce some uncertainty and timelines for indications of kind of the things we're interested in over time. With regard to what it looks like in the installed base and things like cyclical perplexity, Calvin, I'll turn that back to you.

好的。在SP方面，製造方面的限制是機械方面的，與摩擦力、軌道以及這些零件如何連接在一起有關。我覺得團隊已經做到了。我認為我們今年能夠滿足SP貨運客戶的要求。所以我認為他們要把它拆掉。這只是時間安排上的問題。關於這一點，我先從比較廣泛的方面談起。就 FDA 在醫療器材和女性健康方面的環境而言，顯然，他們正在發出更保守的信號，並且在整個行業中廣泛討論這個問題。就 Intuitive 而言，這可能會改變未來的一些數據需求，並可能為我們感興趣的事物的指示帶來一些不確定性和時間表。至於安裝基礎的情況以及週期性困惑之類的問題，卡爾文，我會把這個問題交還給你。

Yes. And as it relates to the -- there actually -- the FDA action relates to the use of mesh intended for transvaginal or pelvic organ prolapse. There are actually various methods of medical management for pelvic organ prolapse including observation, history management and surgery. da Vinci sacrocolpopexy is a minimally invasive method of abdominal surgery, so not transvaginal. And so since our procedure is abdominal, we don't think that this action is going to negatively impact our sacrocolpopexy volumes. Last year, we did something like 15,000 to 20,000 cases in that category, and we were about 40% of the market.

是的。至於與此相關的——實際上——FDA 的行動與用於經陰道或骨盆器官脫垂的網片的使用有關。實際上，骨盆腔器官脫垂的治療方法有很多種，包括觀察、病史管理和手術。達文西骶骨陰道固定術是一種微創腹部手術方法，因此不是經陰道手術。因此，由於我們的手術是在腹部進行的，我們認為這項行動不會對我們的骶骨陰道固定術的手術量產生負面影響。去年，我們在這個類別中完成了大約 15,000 到 20,000 個案例，佔據了約 40% 的市場份額。

And our next question is from Larry Biegelsen with Wells Fargo.

下一個問題來自富國銀行的拉里·比格爾森。

One for Gary, one for Marshall. I'll start with the one for Gary. Intuitive has launched a new system every, call it, 6 to 7 years. Do you expect to maintain that cadence? I think it's been about 5 years since you launched Xi. And what can you tell us about how you're thinking about enhancing Xi? And should we expect a low-cost system, perhaps for the ASE setting? And I have one follow-up.

一個給加里，一個給馬歇爾。我先從給加里的那個開始。Intuitive 公司大約每 6 到 7 年就會推出一個新系統。你預計會保持這種節奏嗎？我想，距離你推出 Xi 已經大約 5 年了。那麼，您能否告訴我們，您打算如何強化 Xi 系統？我們是否可以期待一種低成本的系統，或許可以用於 ASE 環境？我還有一個後續問題。

With regard to innovation cadence, we continue to be committed to innovation. On exact cadences, we won't predict timelines because it's uncertain based on what kind of technologies we're developing and based on the regulatory environment. But you can be assured that we are committed to bringing the market, things that help our customers solve their problems. With regard to the specific question of economics and price points, you can see our history -- historically, X and Xi, and what we've done there, but just frankly, we routinely assess and balance customer needs, the features that they're interested in to achieve their aims and the price points, and we explore and invent broadly. We don't dispose what our specific plans are or timing for competitive reasons.

在創新節奏方面，我們將繼續致力於創新。我們不打算預測具體的進度，因為這取決於我們正在開發的技術類型以及監管環境，所以進度是有不確定性的。但您可以放心，我們致力於為市場帶來能幫助客戶解決問題的產品。關於經濟和價格點的具體問題，您可以看看我們的歷史——從歷史上看，X 和 Xi，以及我們在那裡所做的一切，但坦白地說，我們經常評估和平衡客戶需求、他們感興趣的實現其目標的功能以及價格點，並且我們廣泛地探索和創新。出於競爭原因，我們不會透露具體計劃或時間表。

Understood. And Marshall, based on your guidance for procedure growth and OpEx growth in 2019, you're operating margin will likely decline. So how do you want investors to think about your operating margin beyond 2019, especially in 2020, when we could start to see new competition?

明白了。馬歇爾，根據你對 2019 年手術量成長和營運支出成長的預測，你的營業利潤率可能會下降。那麼，您希望投資人如何看待您2019年以後的營業利潤率，尤其是在2020年，屆時我們可能會看到新的競爭出現？

Sure. We haven't provided guidance beyond this year. And I think what we said at the beginning of this year was you would see a decline in our operating margins, given the level of increased spending that we were going to embark on. Calvin gave you the guidance for increased operating spending. As you know, it did not change from our previous guidance. So I think that's all I really have to say about that.

當然。我們尚未提供今年以後的業績指引。我認為我們在今年年初就說過，鑑於我們將要增加的支出水平，你們將會看到我們的營業利潤率下降。卡爾文為你們提供了增加營運支出的指導。如您所知，這與我們先前的指導方針並無改變。所以我想我關於這件事就沒什麼好說的了。

Yes. I'd add something. I think as we look out, the opportunity for improvement in acute interventions in surgery with the kinds of things we do, robotics, informatics, imaging, advanced imaging, we think it's substantial. And as a result, we take a long-term view. We think these are multiyear developments, multiyear investments, but ultimately, the size of that opportunity is quite large. And as a result, we try not to tune it perfectly quarter by quarter or year by year, but really, look over the very long term.

是的。我還要補充一點。我認為，展望未來，透過我們所做的機器人技術、資訊學、影像技術、高階影像技術等，外科手術中的急性幹預措施有很大的改進空間。因此，我們採取長遠的眼光。我們認為這些都是需要多年才能完成的發展項目和多年才能完成的投資項目，但最終，這個機會的規模相當大。因此，我們盡量不去逐季度或逐年地進行完美調整，而是專注於長遠發展。

Next, we will go to Amit Hazan with Citigroup.

接下來，我們將連線花旗集團的 Amit Hazan。

Let me start with procedures for the quarter. Just big picture, it looked to us like a state of comp-adjusted slowdown in growth in the U.S. and OUS. And I'm just wondering, I want to make sure we're not missing anything, but is there anything to call out that was off trend? I heard you say prostate, we got that one, but if there's any other headwinds that you saw in the quarter on a year-over-year basis, that would have kind of driven a slight slowdown. Is there anything there at all?

首先，我來介紹一下本季的各項流程。從宏觀角度來看，我們認為美國和美國境外經濟成長經同業調整後出現放緩。我只是想確認一下，有沒有什麼東西是過時的、需要特別指出的？我聽你說到了前列腺，我們明白了，但是如果你在本季度同比中看到任何其他不利因素，那都可能導致略微放緩。那裡到底有什麼東西嗎？

No. I think the comment is pretty much reflective that we were on trend in most of the major growth drivers in general surgery and continuation of what we've seen before. And you can look at the Q1 comp, but then another thing to look at is workplace. So we had one fewer operating day in the first quarter, just due to timing of weekends is partially offset by Easter. So I think you overcame that a little bit too. So I don't think there's anything more to add to that.

不。我認為這條評論很好地反映了我們在普通外科的大多數主要成長驅動因素方面都符合趨勢，並且延續了我們以前看到的情況。你可以看看第一季的薪資狀況，但也要看看工作場所的狀況。因此，由於週末時間安排的原因，我們第一季少了一個營業日，但復活節部分抵消了這一影響。所以我覺得你在這方面也克服了一些困難。所以我覺得沒什麼好補充的了。

Okay. Good. And then, secondly, I want to ask about the da Vinci Sis. So we spent some time with a few of your customers this quarter. And they basically told us that you guys are -- sent them a letter that you're sunsetting the da Vinci Si, and its instruments by 2024. And so I just want to see if we could, first of all, get a confirmation of that. And also, some context for how many Sis are still out there and how you'd expect it to play out in terms of the replacement cycle?

好的。好的。其次，我想問關於達文西姊妹的問題。所以本季我們花了一些時間與貴公司的幾位客戶交流。他們基本上告訴我們，你們——給他們發了一封信，說你們將在 2024 年前停用達文西 Si 及其儀器。所以，我首先想確認一下這一點。另外，能否提供一些背景信息，說明目前還有多少 Sis 處於活躍狀態，以及您預計在更替週期中會如何發展？

Yes. I'll let Calvin speak to the number of Sis that are out there. Indeed, we did put a letter out. The letter really talked about discontinuation of stapling in certain energy instruments, specifically. And that those would be coming to an end in 2020. We also indicated that we would discontinue annual service pricing in 2025. The -- having said that, we're committed to supporting Si. We'll continue to deliver instruments and accessories even beyond the end date of 2024. And we will even provide services beyond 2024, just not in the form of annual service, but rather, in the form of time and materials.

是的。我會讓卡爾文來談談有多少姊妹在場。我們確實發出了一封信。信中主要談到了停止在某些能源儀器中使用訂書釘。這些項目將於 2020 年結束。我們也曾表示，我們將於 2025 年停止收取年度服務費。儘管如此，我們仍致力於支持 Si。即使超過 2024 年的截止日期，我們仍將繼續交付儀器和配件。我們甚至會在 2024 年之後繼續提供服務，只是不再是按年提供服務，而是按時間和材料提供服務。

Yes. In terms of the installed base, we just turned the -- crossed the line here this quarter. The slight majority are now da Vinci Xi systems. But still, nearly half are Si and previous models. And we talked a lot about trade-in cycle and the impact in a number of trade-ins so there's still a significant number of Si and previous out there.

是的。就安裝基數而言，我們剛剛在本季度跨越了這條線。目前略佔多數的是達文西Xi系統。但即便如此，仍有近一半是 Si 及之前的型號。我們討論了很多關於以舊換新周期以及對許多以舊換新交易的影響，所以目前市面上仍然有大量的 Si 和之前的車型。

Next, we have JP McKim with Piper Jaffray.

接下來是 JP McKim 和 Piper Jaffray。

I wanted to ask one on SP. I think you said there was around 800 procedures performed in that platform to date. Maybe if you could just talk about whether those were procedures that would've been done robotically previously? Or if it is expanding the market a little bit? And then maybe your thought on other indications this year, and some rough timing around when those could happen.

我想問一個關於SP的問題。我想你說過，到目前為止，該平台已經完成了大約 800 例手術。或許您可以談談這些手術以前是否都是透過機器人完成的？或者說，它是否在稍微擴大市場規模？然後，您可能可以談談您對今年其他跡象的看法，以及這些跡象可能出現的大致時間。

Thanks for the question. The bulk of the procedures so far were in urology would likely have been done robotically anyway. Indication -- the additional indication we got in transoral robotic surgery was relatively recent. That will grow in time. That will likely be a small expansion relative to what's being done robotically. The next likely procedure for us to pursue is a colorectal indication. That will not occur in 2019. We will do a lot of the work, but I do not anticipate an additional clearance in '19 for colorectal, but it's likely next on deck that we expect to be more expansive than substituting.

謝謝你的提問。到目前為止，大部分的手術都是泌尿科手術，而這些手術原本很可能都是透過機器人輔助完成。適應症－我們在經口機器人手術中獲得的額外適應症是相對較新的。隨著時間的推移，這種情況會逐漸改善。與目前機器人完成的工作相比，這可能只是一個很小的擴充。接下來我們可能需要進行的手術是大腸直腸手術。2019年不會發生這種情況。我們會做很多工作，但我預計 2019 年不會再有針對大腸癌的額外批准，但接下來我們可能會著手進行比替代療法更廣泛的推廣。

That's helpful. And there's clearly a push to get everything under the fourth generation, just in terms of the program you talked about earlier. But maybe, if you could talk about strategically, how important that is for you as a company either just to standardize manufacturing more? Or ahead of competition to get more and more customers standardized on this fourth-generation platform.

那很有幫助。很明顯，目前正努力將所有東西推進到第四代，就像你之前提到的那個項目一樣。但是，如果您能從策略角度談談，對於貴公司而言，提高生產標準化程度有多重要？或者搶在競爭對手之前，讓越來越多的客戶採用這種第四代平台。

Our primary motivation is that the fourth gen is well optimized to the kinds of things our customers do. So our first motivation is we think it's beneficial for them, particularly things like advanced instruments and stapling and so on. We're at more mature products and those kind of advanced instruments. And in that sense, you see the trading numbers go up and some of the ASP conversations, we think we want to be aligned with our customers to both standardize and get the right access to the right technologies in the right place. We think that helps them. We think that helps us, and if we're helping both sides, we think that's good for our competitive position over time.

我們的主要動機是，第四代產品針對我們客戶的各種需求進行了很好的最佳化。所以我們的第一個動機是，我們認為這對他們有益，特別是像是高級儀器和訂書機之類的東西。我們現在使用的是更成熟的產品和這類先進的儀器。從這個意義上講，你會看到交易量上升，以及一些關於平均售價的討論，我們認為我們希望與客戶保持一致，既要實現標準化，又要確保客戶在合適的地方獲得合適的技術。我們認為這對他們有幫助。我們認為這對我們有好處，如果我們能幫助雙方，我們認為從長遠來看，這對我們的競爭地位是有利的。

We go now to Larry Keusch with Raymond James.

現在我們連線 Raymond James 的 Larry Keusch。

Gary, just one relative to hernia. You obviously indicated that you still have the sales organization very much focused in the general surgical area on hernia and colorectal, and you're not ready yet to quite get going on bariatric yet with meaningful field support. So just on hernia itself since that remains a focal point, can you help us think a little bit sort of what inning we're in at this point as you look U.S.? And I guess the follow-on question is, what will it take to really start to drive general surgical procedures in Europe because again, still being dominated by urology?

Gary，只是疝氣的親。您顯然表示，您的銷售組織仍然非常專注於普通外科領域的疝氣和結直腸手術，並且您還沒有準備好在減肥手術領域提供有意義的現場支援。既然疝氣本身仍然是焦點，您能否幫我們思考一下，就您觀察美國的情況而言，我們現在處於什麼階段？那麼接下來的問題是，要真正推動歐洲的一般外科手術發展，需要做些什麼？因為目前歐洲的普通外科手術仍以泌尿科為主導。

Yes. I think in the hernia markets, I think we're in the end of the early innings is kind of where I'd put it. I think starting to enter more mainstream use. How far it goes, depends a little bit on clinical condition. As you know, not every hernia is the same, not every patient is the same in terms of comorbidities. So assessing total size of the market and applicability is always a bit of an estimate. But I don't think we're half-way done yet, and that's why we have our sales force focused the way it is.

是的。我認為在疝氣市場，我們現在正處於早期階段的尾聲。我認為它正開始被更主流的用戶群體使用。療效能達到什麼程度，在一定程度上取決於臨床狀況。如您所知，並非所有疝氣都一樣，每個患者在合併症方面也不盡相同。因此，評估市場總規模和適用性始終帶有一定的估計性。但我認為我們還沒有完成一半，這就是為什麼我們的銷售團隊要專注於此。

Second half of the question, I'm sorry? Europe and urology. So on European side, we're starting to see some early interest in general surgery and visceral surgery. Certainly, on the more complex procedure side, we see interest in procedures that are done where the underlying causes cancer also has interest. There may be an opportunity in benign general surgery as well. The economics may be slightly different and that may require a slightly different adjustment from the company that made sure we satisfy that market. Early on, we have work to do to finish urology. We're not done yet. And then, we're looking at the next indications in the more complex side as the next step.

問題的後半部分，不好意思？歐洲與泌尿科。因此，在歐洲方面，我們開始看到人們對一般外科和內臟外科產生了一些初步興趣。當然，在更複雜的手術方面，我們看到人們對那些針對癌症根本原因的手術很感興趣。良性普通外科領域也可能存在機會。經濟狀況可能略有不同，這可能需要公司做出略有不同的調整，以確保我們滿足該市場的需求。早期，我們還有一些工作要做，才能完成泌尿科的工作。我們還沒完成。接下來，我們將著眼於更複雜方面的下一個跡象，作為下一步。

Okay. Perfect. And then, one quick one for Marshall, just on the operating leases. I know it's still early in the experience in terms of ramping those up. They did ramp relatively consistently through to last year, I guess, the 2Q was down a little bit, but should we think about any seasonality just in the operating lease percentages given what you know today?

好的。完美的。然後，再快速問馬歇爾一個關於經營租賃的問題。我知道就提升這些能力而言，現在還處於經驗的早期階段。他們的成長動能一直比較穩定，直到去年，第二季略有下降，但考慮到你目前所了解的情況，我們是否應該考慮經營租賃百分比的季節性因素？

No. I don't think we've seen enough of a pattern to know whether there's any kind of seasonality to it. I suppose that there's the possibility that there's some seasonality associated with hospital budgeting cycles and so forth. But again, we haven't seen any particular patterns we'd point out at this point.

不。我認為我們還沒有看到足夠的規律來判斷它是否存在任何季節性。我認為，這可能與醫院預算週期等因素有一定的季節性關係。但是，目前我們還沒有發現任何值得指出的具體法則。

And next in queue, we have Richard Newitter at SVB Leerink.

接下來是 SVB Leerink 的 Richard Newitter。

I have two. First one for you, Gary. Just on -- I appreciate that maybe you're not as focused with the commercial focus to move into bariatrics with hernia and colorectal priorities now. But with the introduction of the 60-millimeter stapler, have you noticed any kind of inflection in the demand curve, at least, with respect to interest in bariatrics? And are we nearing that point where you would start to allocate the resources there? And then I have a follow-up.

我有兩個。首先是給你的，加里。順便提一下——我知道您可能沒有像現在這樣專注於商業利益，而是把重點放在了減肥手術上，而不是疝氣和結直腸疾病的治療上。但隨著 60 毫米訂書機的推出，您是否注意到需求曲線出現了任何拐點，至少在人們對減肥手術的興趣方面？我們是否即將達到開始向那裡分配資源的階段？然後我還有一個後續問題。

Remember, in terms of sequencing to activate a market, there is optimizing the product set to get them there, there's helping build the partnering networks and the capacity for training and team training. So there's some pre-work, and then there's the building of the sales force competencies and support, customer base. So we're engaged in the pre-work. First, from the products and now into building the pathways and engaging those who will lead. So we're excited about it. I think there's real interest and there's real long-term opportunity and it's really just a question of timing. In terms of results, I wouldn't call anything out. One way or another, showing strength or weakness. I think we're really in a building capacity phase before we expect more out of the commercial team.

記住，在激活市場的順序方面，包括優化產品組合以吸引他們，幫助建立合作夥伴網絡以及培訓和團隊培訓能力。所以有一些前期準備工作，然後是銷售團隊能力建立和支持，以及客戶群的建立。所以我們現在正在進行前期準備工作。首先，從產品入手，現在轉向建立路徑並吸引領導者。所以我們對此感到很興奮。我認為市場確實存在興趣，也存在真正的長期機遇，現在的問題只是時機。就結果而言，我不會特別指出什麼。無論哪種方式，都展現了力量或弱點。我認為我們現在確實處於能力建構階段，之後才能對商業團隊提出更高的要求。

Okay. And just as we think about a higher proportion of systems getting placed under these flexible financing arrangements, minimum volume committed -- commit arrangements, I'm just curious, a straight operating lease model, one would've thought, hey, some of these systems maybe are more susceptible or the customers are more susceptible to a trialing phenomenon as competitors come into the market. But the more I hear you talk about these and the multisystem sales in these volume commitments, I'm wondering, does that just raise the switching costs as we think of a higher percentage of systems getting placed in there?

好的。正當我們考慮將更高比例的系統納入這些靈活的融資安排和最低承諾量安排時，我很好奇，如果採用直接的經營租賃模式，人們可能會認為，嘿，隨著競爭對手進入市場，這些系統或客戶可能更容易受到試用現象的影響。但是，我越聽你談論這些以及這些批量承諾中的多元銷售，我就越想知道，隨著更多比例的系統被納入其中，這是否會提高轉換成本？

Well, first of all, when you say volume commitments, they are not volume commitments. They are targets that we establish, but we don't have a volume commitment per se. Second, I think there are costs to switch, of course, that go beyond the system itself, training surgeons and staff as well as protocols on how you set up the -- how you set up the OR, how you manage the product and how use the product and so I think those are barriers as well. As far switching costs associated with the system itself, you do run a risk with the some of the variations we're putting out there in financing that it may be easier for our customer to switch out. But we think that broadening the base now and getting the commitment of the surgeons and getting them trained so that we increase the barrier on that front is a better route to go.

首先，你說的銷售承諾，其實不是銷售承諾。這些都是我們設定的目標，但我們本身並沒有銷售承諾。其次，我認為轉換的成本當然不只係統本身，還包括培訓外科醫生和工作人員，以及關於如何設置手術室、如何管理產品以及如何使用產品的規程，所以我認為這些也是障礙。至於與系統本身相關的轉換成本，我們推出的一些融資方案確實存在風險，因為這可能會讓我們的客戶更容易轉換方案。但我們認為，現在擴大基礎，爭取外科醫生的承諾，並對他們進行培訓，從而提高這方面的門檻，才是更好的途徑。

And next, we have Craig Bijou with Cantor Fitzgerald.

接下來，我們邀請了 Cantor Fitzgerald 的 Craig Bijou。

I wanted to ask on Japan. I appreciate the comment that procedural growth was still strong. But I wanted to see, is it -- are you still seeing some of the growth that you saw in the last couple of quarters? Just -- how should we think about where exactly or I guess, how strong that growth is with the new procedures?

我想問一些關於日本的問題。我同意關於程序性成長依然強勁的觀點。但我很想知道，你們是否仍然看到過去幾季所看到的成長勢頭？那麼──我們該如何思考，在新流程下，這種成長究竟在哪裡，或者說，這種成長有多強勁？

Yes. We're full year now, right? We got clearance for those 12 new procedures April 1, 2018. And even after full year, it's still fairly early. And so we're focused on things like we were talking about, the training support, proctoring network, building a solid foundation of surgeons, the OR teams and really emphasizing the clinical outcomes. We talked about, back in Q3 of '18, procedure growth moving above the 40% line in Japan, that continued in Q4. And in fact, here in Q1 of 2019, it kind of held onto that kind of rate of growth.

是的。現在已經滿一年了，對吧？我們於 2018 年 4 月 1 日獲得了這 12 項新程序的批准。即使一年過去了，現在也還為時過早。因此，我們專注於我們剛才討論過的培訓支援、指導網絡、建立堅實的外科醫生基礎、手術室團隊，並真正強調臨床結果。我們在 2018 年第三季討論過，日本的手術量成長超過了 40%，這一趨勢在第四季度得以延續。事實上，在 2019 年第一季度，它基本上保持了這種成長速度。

And maybe just a follow-up on Japan, I know you added 13 systems in the quarter, but maybe just help us get a sense for what the demand -- or I guess, system demand is. I know that -- I believe that utilization of the Japan systems was one of your lower geographic regions. So just maybe a little color there.

關於日本市場，我想跟進一下。我知道你們本季新增了 13 個系統，但能否幫我們了解需求情況──或者說，系統需求狀況？我知道——我相信日本系統的使用率是你們地理區域中較低的一個。所以，或許可以加一點色彩。

Yes. I think what we've said before and we're still on that same page is that, the systems are utilized poorly at this point and there is the opportunity to increase the number of procedures that can be done on them. However, the 12 procedures that were improved last year are not necessarily all done at the same hospitals so you've seen us sell systems because there are hospitals that do those procedures that were not doing prostatectomies or nephrectomies and now want to do robotic surgery. So it's hard for us to gauge exactly how much more -- how many more systems we can sell given the opportunity in front of us. The number of procedures being performed that had previously been approved, which was prostatectomy and nephrectomy was around 25,000 to 30,000 and these additional 12 procedures was 200,000, although they were highly laparoscopically penetrated, and so it's also difficult to know how many of those will actually adopt or switch.

是的。我認為我們之前說過，而且我們現在仍然堅持這個觀點，那就是，目前這些系統沒有充分利用，有機會增加可以在這些系統上執行的手術數量。然而，去年改進的 12 項手術並不一定都在同一家醫院進行，所以你會看到我們銷售系統，因為有些醫院以前不做前列腺切除術或腎切除術，現在想做機器人手術。因此，我們很難準確評估，鑑於擺在我們面前的機會，我們還能賣出多少套系統。先前獲準進行的手術數量（前列腺切除術和腎切除術）約為 25,000 至 30,000 例，而新增的 12 項手術數量為 200,000 例，儘管這些手術大多採用腹腔鏡進行，因此也很難知道其中有多少人會真正採用或改用腹腔鏡手術。

Our final question will come from Imron Zafar with Deutsche Bank.

最後一個問題來自德意志銀行的伊姆龍·紮法爾。

First, on U.S. general surgery, I'm curious if you could give us some insight on how much of the growth you're seeing is coming from higher penetration within your existing users versus new general surgeons embracing robotics?

首先，關於美國普通外科手術，我很好奇您能否向我們介紹一下，您觀察到的增長有多少來自於現有用戶滲透率的提高，又有多少來自於新晉普通外科醫生對機器人技術的接受？

Yes. You just look at what we're selling. The large majority of capital is -- are going into existing customers. They were expanding their programs and we're working with them as thoughtfully as we can with analytics and insights and expanding programs to build them out in the hospitals. So a large part of the remaining opportunity and procedures that are currently adopting are in the hospitals or hospital networks that we have established relationships. Yes. We still have some greenfield opportunities to be sure, but in terms of proportion, it's heavy on existing.

是的。你看看我們賣的是什麼就知道了。大部分資金都流向了現有客戶。他們正在拓展項目，我們正在盡我們所能地與他們合作，運用分析和洞察力，拓展項目，以便在醫院中推廣這些項目。因此，目前剩餘的大部分機會和正在採用的程序都存在於我們已經建立合作關係的醫院或醫院網絡中。是的。我們當然還有一些全新的開發機會，但就比例而言，現有專案仍然佔據主導地位。

Question may have been asked from the point of surgeon themselves, more from a surgeon or newly trained surgeons and it's clearly a balanced mix of both.

這個問題可能是從外科醫生的角度提出的，更多的是從外科醫生或新晉外科醫生的角度提出的，顯然兩者兼而有之。

Okay. And then, can you just talk about the long-term opportunity for a mastectomy? I know you have a clinical study ongoing -- or is getting underway. And is it fair to assume that that's more of an SP opportunity rather than the multiport?

好的。那麼，您能否談談乳房切除術的長期益處呢？我知道你們正在進行一項臨床研究——或者即將開始。是否可以合理地假設，這更多的是 SP 的機會，而不是多個連接埠的機會？

Not ready to characterize anything yet. And we know that there are some folks who are interested in it who are starting to work through what studies might look like, but we are not yet prepared to talk about what the long-term looks like there.

目前還無法對任何事物做出定義。我們知道有些人對此感興趣，並且已經開始研究相關的研究方案，但我們還沒有準備好討論長期發展前景。

Okay. And then one just -- one last quick one for Marshall. There's been a pretty sizable increase in your headcount since the third quarter. I think it's up like 800 something. I assume some of that is just headcount accretion from some of your distributor acquisitions late last year, but can you just talk about what geographies those hires are targeting?

好的。然後，就最後一個——最後一個給馬歇爾的快速鏡頭。自第三季以來，貴公司員工人數有了相當大的成長。我想應該漲到800多了吧。我猜想其中一部分是由於去年底收購了一些分銷商而增加的人員，但您能否談談這些招聘的目標地區？

The two greatest increases, one is what you characterize, which is that we took on distributor headcounts. So specifically, over the last year, we've added over 300 heads associated with our growth in Asia-Pacific. And the second area is really manufacturing headcount, and we bring manufacturing headcount in to -- on a temporary basis at first, and then we hire them in boluses. And in fact, we hired a bolus of them in the last 6 months.

兩項最大的成長，一項正如您所說，是我們增加了分銷商的人員數量。具體來說，在過去一年裡，我們新增了 300 多名員工，這與我們在亞太地區的業務成長有關。第二個方面其實是生產人員數量，我們先以臨時方式引進生產人員，然後逐步增加他們的招募規模。事實上，在過去的6個月裡，我們大量招募了這類人才。

Well, thank you. That was our last question. In closing, we believe there's a substantial and durable opportunity to fundamentally improve surgery and acute interventions. Our teams continue to work closely with hospitals, physicians and care teams in pursuit of what our customers have termed the quadruple aim: better more predictable patient outcomes, better experiences for patients, better experiences for care teams, and ultimately, a lower total cost of care.

謝謝。這是我們最後一個問題。最後，我們認為，從根本上改善外科手術和急診幹預措施存在著巨大且持久的機會。我們的團隊繼續與醫院、醫生和護理團隊密切合作，追求客戶所稱的四重目標：更好的、更可預測的患者治療效果，更好的患者體驗，更好的護理團隊體驗，以及最終更低的醫療總成本。

We believe that accomplishing the same takes the integration of 3 elements: first, a deep understanding of human interactions across the continuum of care; second, smart and connected systems imaging and instruments that augment care teams; and third, the ability to measure impact through analytical insights and translation of these insights into action that drives positive change.

我們認為，要實現這一目標，需要整合三個要素：首先，深入了解整個護理過程中的人際互動；其次，智慧互聯的系統成像和儀器能夠增強護理團隊的能力；第三，能夠透過分析洞察來衡量影響，並將這些洞察轉化為推動積極變革的行動。

We believe value creation in surgery and acute care is foundationally human. It flows from respect for and understanding of patients and care teams, their needs and their environment. Thank you for your support on this extraordinary journey. We look forward to talking with you again in 3 months.

我們認為，外科手術和急診護理中的價值創造本質上是人性的。它源自於對病人和照護團隊、他們的需求以及他們所處環境的尊重和理解。感謝您在這段非凡旅程中給予的支持。我們期待三個月後再次與您交談。

That does conclude our conference for today. Thank you for your participation, and for using AT&T Teleconference. You may now disconnect.

今天的會議就到此結束。感謝您的參與，也感謝您使用AT&T電話會議服務。您現在可以斷開連線了。