直覺手術 (ISRG) 2019 Q3 法說會逐字稿

Ladies and gentlemen, thank you for standing by, and welcome to the Intuitive Surgical Q3 2019 Earnings Release Call. (Operator Instructions) And as a reminder, this conference is being recorded.

女士們、先生們，感謝各位的耐心等待，歡迎參加 Intuitive Surgical 2019 年第三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 would now like to turn the conference over to our host, Mr. Calvin Darling, Senior Director of Finance, Investor Relations. Please go ahead, sir.

現在我謹將會議交給我們的主持人，財務高級總監兼投資者關係主管卡爾文·達林先生。請繼續，先生。

Thank you. Good afternoon, and welcome to Intuitive's third 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 Intuitive 第三季財報電話會議。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, and 10-Q filed on July 22, 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. 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.

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 表格和於 2019 年 7 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。請注意，本次電話會議的音訊回放將在我們網站intuitive.com的「投資者關係」頁面下的「最新動態」欄位中提供。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 third quarter results as described in our press release announced earlier today, followed by a question-and-answer session. Gary will present the quarter's business and operational highlights. Marshall will provide a review of our third 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.

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三季度業績亮點，然後進行問答環節。Gary 將介紹本季的業務和營運亮點。馬歇爾將對我們第三季的財務表現進行回顧。然後我將討論流程和臨床亮點，並提供我們最新的 2019 年財務展望。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。

Thank you for joining us today. Intuitive has been enabling customers in their delivery of high-quality minimally invasive surgery for 20 years. And we believe the adoption of robotics and computer-aided interventions is early relative to its long-term potential. 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. This third quarter of 2019 was another solid one for Intuitive in pursuit of these aims. Our performance in the quarter is a reflection of our progress with procedures and system placements showing continued strength.

感謝您今天蒞臨。20年來，Intuitive一直致力於幫助客戶進行高品質的微創手術。我們認為，相對於其長期潛力而言，機器人技術和電腦輔助幹預措施的採用還處於早期階段。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。2019 年第三季對於 Intuitive 而言，在實現這些目標方面又是一個穩健的季度。本季業績反映了我們在流程和系統部署方面的進展，並展現出持續強勁的勢頭。

For the quarter, global procedure growth was nearly 20%, aided by an increase of approximately a surgery day relative to Q3 of 2018. Growth again centered on general surgery in the United States with positive contributions to the global growth rate from Germany, Korea and Japan. China procedure growth continues to be limited by installed base growth. Total procedure growth in China is responding positively considering the release of system quota and subsequent placements.

本季全球手術量成長近 20%，這得益於與 2018 年第三季相比，手術日增加了約一天。美國的普通外科手術再次成為成長的焦點，德國、韓國和日本也對全球成長率做出了積極貢獻。中國手術量的成長仍受到現有手術量成長的限制。考慮到系統配額的釋放和隨後的安置，中國整體手術量成長呈現積極態勢。

In the United States, year-over-year procedure growth for the quarter was 18%. General surgery again accounted for the largest increase year-over-year, accompanied by solid growth in urology and stable growth in gynecology. We also saw strength in bariatrics and cholecystectomy.

在美國，該季度手術量年增了 18%。普通外科手術再次成為同比增長幅度最大的科目，泌尿外科手術也實現了穩健增長，婦科手術則保持了穩定增長。我們也看到了減重手術和膽囊切除術的優勢。

Hernia repair and cholecystectomy growth rates were solid in the quarter. Improvements in system utilization by customers and alternative capital placement models are having a positive impact on our business. Our U.S. sales force productivity improved in the quarter as our new team members gained experience. Calvin will take you through global procedure dynamics in more detail later in the call.

本季疝氣修補術和膽囊切除術的成長率表現穩健。客戶系統利用率的提高和替代資本配置模式對我們的業務產生了積極影響。本季度，隨著新團隊成員經驗的積累，我們美國銷售團隊的生產力有所提高。Calvin 將在稍後的通話中更詳細地向您介紹全域流程動態。

With regard to our installed base, placement of new systems in the quarter was solid with growth in total placements rising 19% from Q3 of 2018. Net of trade-ins and retirements, our da Vinci installed base grew 12% over Q3 2018 to approximately 5,406. The mix of system placements this quarter moved towards our flagship Xi Systems, and trade-ins were healthy. The proportion of systems placed under operating leases was 33% this quarter compared with 32% last quarter. As a reminder, total placements and the percentage of systems placed under lease or usage-based arrangements can vary substantially quarter-to-quarter.

就我們的已安裝基礎而言，本季新系統的安裝情況穩健，總安裝量較 2018 年第三季成長了 19%。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 年第三季增加了 12%，達到約 5,406 台。本季系統部署組合向我們的旗艦產品 Xi 系統傾斜，以舊換新狀況良好。本季以經營租賃方式部署的系統比例為 33%，而上季為 32%。需要提醒的是，總部署量以及以租賃或按使用量計費方式部署的系統百分比可能會逐季度發生較大變化。

Turning to expenses. We are investing in building our capability in international regions, launching new platforms, strengthening our computational capabilities and executing projects that support future sale and provide leverage opportunities as we grow. Our spending is on track with our expectations. It is supported by solid procedure growth, capital placements and product cost reductions.

接下來談談費用。我們正在投資建立我們在國際地區的能力，推出新平台，加強我們的運算能力，並執行支援未來銷售和在我們發展過程中提供槓桿機會的專案。我們的支出符合預期。其發展得益於穩健的業務成長、資金投入和產品成本降低。

Financial highlights for our third quarter results were as follows: Procedures grew nearly 20% over the third quarter of last year. We placed 275 da Vinci Surgical Systems, up from 231 in the third quarter of 2018. Our installed base grew 12% from a year ago. Revenue for the quarter was approximately $1.1 billion, up 23%. Pro forma gross profit margin was 72% compared to 71.5% in the third quarter last year. Instrument and accessory revenue increased to $606 million, up 25%. Total recurring revenue in the quarter was $817 million, growing 24% over Q3 of 2018 and representing 72% of total revenue. We generated a pro forma operating profit of $462 million in the quarter, up 18% from the third quarter of last year. Pro forma net income was $409 million, up 21%. And we repurchased 70 million in shares at an average price of $493 per share.

第三季財務業績亮點如下：手術量比去年第三季成長近 20%。我們安裝了 275 台達文西手術系統，高於 2018 年第三季的 231 台。我們的用戶基數比一年前成長了12%。本季營收約 11 億美元，成長 23%。經調整後的毛利率為 72%，去年第三季為 71.5%。儀器及配件收入增至 6.06 億美元，成長 25%。本季經常性收入總額為 8.17 億美元，比 2018 年第三季成長 24%，佔總營收的 72%。本季我們實現了 4.62 億美元的備考營業利潤，比去年第三季成長了 18%。以備考計算，淨收入為 4.09 億美元，成長 21%。我們以每股 493 美元的平均價格回購了 7,000 萬股股票。

Turning to our investments in products. I'll start first with systems. We are in our Phase 1 launch of da Vinci SP as we work to expand clinical clearances and build SP products at scale. In the quarter, we proactively held shipments on SP endoscopes and limited new system installations for a limited time as we investigated a robustness concern on the SP endoscope. We resumed shipping endoscopes and systems in the quarter. Given the slowdown on endoscopes, we installed 4 systems to bring our installed base with SP to 38. Customer response and early clinical results using SP remain encouraging. In addition, utilization rates for SP in Korea, where clinical indications are the broadest, are at Xi levels already, a testament to surgeons' engagement and our teams' skill and design for usability.

接下來談談我們在產品上的投資。我先從系統講起。我們正處於達文西 SP 的第一階段上市階段，努力擴大臨床審批範圍並大規模生產 SP 產品。本季度，我們主動暫停了 SP 內視鏡的出貨，並在一段時間內限制了新系統的安裝，以便調查 SP 內視鏡的穩定性問題。本季我們恢復了內視鏡和系統的出貨。鑑於內視鏡市場成長放緩，我們安裝了 4 套系統，使我們的 SP 系統安裝達到 38 套。使用 SP 的客戶回饋和早期臨床結果仍然令人鼓舞。此外，在臨床適應症最廣泛的韓國，SP 的使用率已達到 Xi 水平，證明了外科醫生的參與度以及我們團隊在可用性方面的技能和設計。

With regard to additional indications for SP, we have been in discussion with FDA regarding data requirements for a colorectal indication. We expect this to require an IDE trial that includes follow-up analysis. This implies we do not expect a third indication of SP in the U.S. in 2020. While we had planned for a smoother launch of SP and product availability and new indication time lines, our teams are focused on building at scale and satisfying regulatory requirements for additional indications. Interest in SP is healthy and clinical outcomes are encouraging, forming the basis of our belief in the long-term potential of the platform to improve care. The combination of additional indications for SP and our readiness for deployment at larger scale pace the speed of our SP commercial expansion.

關於 SP 的其他適應症，我們一直在與 FDA 討論大腸直腸適應症的數據需求。我們預計這將需要進行一項包含後續分析的IDE試驗。這意味著我們預期 2020 年美國不會出現第三次 SP 指標。雖然我們原本計劃更順利地推出 SP 產品，並確保產品供應和新適應症的時間表，但我們的團隊目前專注於大規模生產，並滿足其他適應症的監管要求。人們對 SP 的興趣良好，臨床結果也令人鼓舞，這構成了我們對該平台在改善護理方面具有長期潛力的信念的基礎。SP 的其他適應症以及我們大規模部署的準備，加快了 SP 商業擴張的速度。

In flexible diagnostics, our Ion platform is focused on the need for accurate and timely biopsies to support definitive early diagnosis of suspicious lesions. Since our 510(k) clearance in Q1 of this year, we initiated our first phase launch focused on clinical use, customer feedback and production optimization. First cases on the cleared system were performed at the end of Q1. There are now 9 systems in the field performing cases with the total case experience in the hundreds. To date, the rollout is meeting our expectations with a mix of clinical trial sites and commercial sites. User feedback during this initial launch period has been strong.

在靈活診斷方面，我們的 Ion 平台專注於準確及時的活檢，以支持對可疑病變進行明確的早期診斷。自今年第一季獲得 510(k) 許可以來，我們啟動了第一階段的上市計劃，重點是臨床應用、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。目前現場共有 9 個系統正在處理案例，累計案例經驗達數百例。到目前為止，該計畫的推廣工作符合我們的預期，包括臨床試驗點和商業試驗點。在產品發布初期階段，使用者回饋非常正面。

For instruments and accessories, our team moved to full United States launch of our 45-millimeter SureForm stapler and obtained clearance for it in Japan and Korea in the quarter. We also obtained 510(k) clearance for new a Curved-Tip SureForm 45-millimeter stapler and a new Gray reload designed to staple thin structures. Recall that surgical stapling is a family of products that help surgeons in a range of procedures covering parts of the body from the rectum to the thoracic cavity. Robotically held staplers are a sophisticated technology, and our team is doing an excellent job filling out the product portfolio.

在儀器和配件方面，我們的團隊在本季度全面推出了 45 毫米 SureForm 訂書機，並獲得了在日本和韓國的許可。我們還獲得了 510(k) 許可，用於生產新型彎頭 SureForm 45 毫米訂書機和一種新型 Gray 裝訂片，該裝訂片設計用於訂薄結構。請記住，外科縫合器是一系列產品，可幫助外科醫生進行各種手術，涵蓋從直腸到胸腔的身體部位。機器人手持式訂書機是一項複雜的技術，我們的團隊在完善產品組合方面做得非常出色。

Our experience has shown that procedure adoption occurs when the holistic needs of the care team are met, when the right system and imaging products come together with the right instruments and accessories. Stapling is another example of this synergy with surgeon adoption of generation 4 da Vinci Systems with SureForm staplers gaining momentum.

我們的經驗表明，當醫療團隊的整體需求得到滿足，當合適的系統和影像產品與合適的儀器和配件結合在一起時，手術流程就會被採納。縫合術是這種協同作用的另一個例子，外科醫生採用第四代達文西系統和 SureForm 縫合器正變得越來越流行。

Turning to imaging and analytics. We are working on computing and real-time cloud technologies to allow for tests from telementoring to augmented reality. We now have over 20 active telementoring sites that together have supported hundreds of cloud-enabled, real-time surgery sessions as we progress in building our real-time cloud capabilities. Feedback on the utility of these sites for case observations and mentoring has been supported. In augmented reality, we are working through logistics and installation of our first IRIS accounts to gather customer and clinical feedback. We expect first clinical cases on the IRIS System in the next few months. Lastly, our surgical simulation products have become widely adopted in the installed base with more than 3,200 da Vinci simulators in the field.

轉向影像處理和分析。我們正在研究運算和即時雲端技術，以實現從遠端指導到擴增實境的各種測試。我們現在擁有 20 多個活躍的遠端指導站點，這些站點共同支援了數百次基於雲端的即時手術，我們正不斷建立我們的即時雲端能力。已收到關於這些網站在案例觀察和指導方面的實用性的回饋。在擴增實境領域，我們正在努力完善首批 IRIS 帳戶的物流和安裝，以收集客戶和臨床回饋。我們預計未來幾個月內將出現 IRIS 系統的首批臨床病例。最後，我們的手術模擬產品已在已安裝用戶群中廣泛應用，目前已有超過 3,200 台達文西模擬器投入使用。

Before turning the time over to Marshall, let's step back and consider Intuitive's evolution over the past few years. Over this period, general surgeons have increased their adoption of our offerings, underpinned by improvements in the quadruple aim and procedures they perform, from colon and rectal procedures to hernia repair, cholecystectomy and bariatric surgery. General surgery procedures span a broad range of complexity and economics.

在將時間交給馬歇爾之前，讓我們回顧一下 Intuitive 在過去幾年中的發展歷程。在此期間，一般外科醫生越來越多地採用我們的產品，這得益於他們所執行的四重目標和手術的改進，從結腸和直腸手術到疝氣修補術、膽囊切除術和減肥手術。普通外科手術涵蓋了廣泛的複雜程度和經濟成本。

At the same time, we've extended our reach into key countries to support the adoption of robotic-assisted surgery into their health care environments. We have flexed our company to better serve these customers with the launch of new systems, new instruments and updates to our software, along with changes to our sales and support models and pricing structures. Given the large global opportunity to pursue the quadruple aim, we believe the next few years for the company will be dynamic. We will guide the company to meet our customers' clinical and economic needs across this wide range of procedures and geographies. Doing so will involve continued investment in innovation for both technology and economic models, and we see a path to do both.

同時，我們已將業務拓展到重點國家，以支援在其醫療保健環境中採用機器人輔助手術。為了更好地服務這些客戶，我們調整了公司營運方式，推出了新系統、新儀器和軟體更新，並改變了銷售和支援模式以及定價結構。鑑於實現四重目標的巨大全球機遇，我們相信公司未來幾年將充滿活力。我們將引導公司滿足客戶在各種手術流程和地理範圍內的臨床和經濟需求。這樣做需要持續投資於技術和經濟模式的創新，我們看到了實現這兩點的途徑。

For the balance of the year, our focus remains in completing the task we set for ourselves. First, supporting adoption of da Vinci in general surgery and in key procedures in global markets; second, launching our da Vinci -- I'm sorry, our SP and Ion platforms; third, driving intelligent surgery innovation; and finally, supporting additional clinical and economic validation and our focused procedures in countries.

今年剩餘時間裡，我們的重點仍然是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得到應用；其次，推出我們的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得到應用；其次，推出我們的達文西——抱歉，是我們的SP和Ion平台；第三，推動智慧手術創新；最後，支持在各國進行額外的臨床和經濟驗證以及我們重點關注的手術。

I'll now turn the call over to Marshall, who'll 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 will describe the highlights of our performance on a non-GAAP or pro forma basis. I will also summarize our GAAP performance later in my prepared remarks. A reconciliation between our pro forma and GAAP results is 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。我稍後將在準備好的發言稿中總結我們的GAAP表現。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。

Key business metrics for the third quarter are as follows: Third quarter 2019 procedures increased nearly 20% compared with the third quarter of 2018 and increased approximately 2% compared with last quarter. There was one more operating day in the third quarter of 2019 compared with the third quarter of 2018. Excluding the impact of the extra operating day, we would have been in line with our full year average growth. 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.

第三季的關鍵業務指標如下：2019 年第三季手術量比 2018 年第三季成長了近 20%，比上一季成長了約 2%。2019 年第三季比 2018 年第三季多了一個營業日。如果排除額外營業日的影響，我們的成長率將與全年平均成長率持平。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。

Third quarter system placements of 275 systems increased 19% compared with 231 systems last year and increased 1% compared with 273 systems last quarter. We expanded our installed base of da Vinci systems by 12% to approximately 5,406 systems. The growth rate compares with 13% in both the last quarter and last year. Utilization of clinical systems in the field, measured by procedures per system, grew approximately 6%, which is higher than the 4% growth last quarter and below the 7% growth last year.

第三季系統安裝量為 275 套，比去年同期的 231 套成長了 19%，比上一季的 273 套成長了 1%。我們將達文西手術系統的安裝量擴大了 12%，達到約 5,406 套系統。這一成長率與上一季和去年同期的13%相比有所下降。臨床系統在現場的利用率（以每個系統的手術量衡量）成長了約 6%，高於上一季的 4% 成長率，但低於去年的 7% 成長率。

Our revenue overview is as follows: Third quarter 2019 revenue was $1.1 billion, an increase of 23% compared with $921 million for the third quarter of 2018 and an increase of 3% compared with $1.1 billion last quarter. Instrument and accessory revenue of $606 million increased 25% compared with last year, which is higher than procedure growth primarily reflecting customer buying patterns and increased usage of our advanced instruments. Instrument and accessory revenue realized per procedure was approximately $1,980, an increase of 4% compared with the third quarter of 2018 and an increase of 3% compared with last quarter. Systems revenue for the third quarter of 2019 was $339 million, an increase of 23% compared with the third quarter of 2018 and a decrease of 2% compared with last quarter. Relative to the third quarter of 2018, systems revenue reflected higher system placements, higher ASPs and higher lease-related revenues.

我們的營收概況如下：2019 年第三季營收為 11 億美元，比 2018 年第三季的 9.21 億美元成長了 23%，比上一季的 11 億美元成長了 3%。儀器及配件收入為 6.06 億美元，比去年增長 25%，高於手術量增長，這主要反映了客戶的購買模式和我們先進儀器的使用量增加。每台手術的器械和配件收入約為 1,980 美元，比 2018 年第三季成長 4%，比上一季成長 3%。2019 年第三季系統營收為 3.39 億美元，比 2018 年第三季成長 23%，比上一季下降 2%。與 2018 年第三季相比，系統收入反映了更高的系統安裝量、更高的平均售價和更高的租賃相關收入。

We completed 92 operating lease transactions, representing 33% of total placements compared with 58 or 25% of total placements in the third quarter of 2018, and 88 or 32% of total placements last quarter. As of September 30, we have 560 operating leases outstanding and realized approximately $27 million of revenue related to these arrangements in the quarter compared with $14 million last year and $25 million last quarter. 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.

我們完成了 92 筆經營租賃交易，佔總交易量的 33%，而 2018 年第三季完成了 58 筆，佔總交易量的 25%，上一季完成了 88 筆，佔總交易量的 32%。截至 9 月 30 日，我們有 560 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 2700 萬美元，而去年同期為 1400 萬美元，上一季為 2500 萬美元。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，但本季投入使用的作業系統數量的增加會抑制該季度短期收入的成長。

Operating leases include usage-based financings that we provide to certain hospitals with advanced robotics experience. We believe that our lease financing 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 operating lease and usage-based arrangements will likely increase long term and will vary quarter-to-quarter. We recognized $20 million of lease buyout revenue in the third quarter compared with $27 million last quarter and $8 million last year. Lease buyout revenue has varied significantly from quarter-to-quarter and will likely continue to do so.

經營租賃包括我們向某些擁有先進機器人技術的醫院提供的基於使用量的融資。我們相信，我們的租賃融資方案符合客戶的目標，並促進了市場更快接受我們的方案。與租賃期間購買的系統相比，我們獲得了一筆小額溢價，這反映了貨幣的時間價值；而對於按使用量計費的安排，則反映了這些系統可能無法達到預期使用水平的風險。從長遠來看，經營租賃和按使用量計費的安排的比例可能會增加，並且每個季度都會有所不同。第三季我們確認了 2,000 萬美元的租賃買斷收入，而上一季為 2,700 萬美元，去年同期為 800 萬美元。租賃買斷收入每季波動較大，而且這種情況可能會持續下去。

116 or 42% of current quarter system placements involve trade-ins, reflecting customer desire to access or standardize in our fourth generation technology and contributing to an Xi installed base growth of 41% year-over-year. This is an increase compared with 65 or 28% of system placements in the third quarter 2018 and 103 or 38% last quarter. Trade-in activity can fluctuate and be difficult to predict. However, prior product trade-in -- however, given prior product trade-in cycles, we expect the proportion of installed base traded in, in future quarters to decrease over time. 79% of the systems placed in the quarter were da Vinci Xis and 17% were da Vinci X Systems compared with 74% da Vinci Xis and 20% da Vinci Xs last quarter.

本季系統安裝中有 116 套（佔 42%）涉及以舊換新，這反映出客戶希望獲得或標準化我們的第四代技術，並促成 Xi 系統安裝基礎年增 41%。與 2018 年第三季 65 台（佔 28%）的系統安裝量和上一季 103 台（佔 38%）的系統安裝量相比，這是一個成長。以舊換新活動可能會出現波動，難以預測。然而，鑑於以往的產品以舊換新周期，我們預計未來幾季以舊換新的已安裝基數的比例會隨著時間的推移而下降。本季安裝的系統中，79% 為達文西 Xi 系統，17% 為達文西 X 系統；而上一季度，達文西 Xi 系統佔 74%，達文西 X 系統佔 20%。

We sold 3 Ion systems in the quarter. Ion system placements are excluded from our overall systems count and will be reported separately. Procedures and other information associated with Ion are excluded from our prepared remarks and will be reported separately when they become more substantive.

本季我們售出了3套離子系統。離子系統安裝數量不計入我們的系統總數，將單獨報告。與 Ion 相關的程序和其他資訊不包含在我們準備好的發言稿中，當這些資訊變得更加實質時，我們將另行報告。

4 of the systems placed in the third quarter were SP systems. Third quarter SP placements were impacted by our decision to hold shipments of endoscopes as Gary outlined. Our rollout of SP surgical system will continue to be measured, putting systems in the hands of experienced da Vinci users while we optimize training pathways in our supply chain.

第三季安裝的系統中有 4 套是 SP 系統。正如 Gary 所概述的那樣，由於我們決定暫停內視鏡的發貨，第三季 SP 的部署受到了影響。我們將繼續穩定地推進 SP 手術系統的推廣，在優化供應鏈訓練途徑的同時，將系統交給經驗豐富的達文西用戶使用。

Globally, our average selling price, which excludes the impact of operating lease revenue and lease buyouts, was approximately $1.57 million compared with $1.45 million last quarter and $1.54 million last quarter.

在全球範圍內，我們的平均售價（不包括經營租賃收入和租賃買斷的影響）約為 157 萬美元，而上一季為 145 萬美元，上一季為 154 萬美元。

Similar to the second quarter, our mix of systems and customers in the third quarter was very favorable relative to prior periods. We had a high mix of Xi versus X and Si systems. We also had a low mix of distributor versus direct sales. Finally, in the third quarter of 2019, we had fewer multisystem arrangements where we provided volume discounts. The mix of systems, customers and the size of arrangements will vary over time. We expect system ASPs to be in the range of the midpoint of the first 2 quarters of this year.

與第二季類似，第三季我們的系統和客戶組合相對於前幾季而言非常有利。我們擁有大量 Xi 與 X 和 Si 系統。此外，我們的經銷商銷售比例也較低，直接銷售的比例較低。最後，在 2019 年第三季度，我們提供批量折扣的多系統安排有所減少。系統、客戶和合作規模的組合會隨著時間而改變。我們預計系統平均售價將處於今年前兩個季度的中位數水準。

Outside of U.S., results were as follows: OUS procedures grew approximately 23% compared with the third quarter of 2018 and increased 1% compared with last quarter. Third quarter revenue outside of the U.S. of $332 million increased 36% compared with the third quarter of 2018 and increased 6% compared with last quarter. The increase compared with the prior year reflects increased system instruments and accessories revenue of $37 million or a 32% growth and increased system revenue of $40 million or 50% growth. The increase of instrument and accessory revenue was primarily driven by procedure growth and customer buying patterns. The increase in systems revenue primarily is a result of the increased ASPs reflecting favorable geographic and product mix.

在美國以外，結果如下：與 2018 年第三季相比，美國境外手術量成長了約 23%，與上一季相比成長了 1%。第三季美國以外的營收為 3.32 億美元，比 2018 年第三季成長 36%，比上一季成長 6%。與前一年相比，成長反映了系統儀器和配件收入增加 3,700 萬美元，成長 32%；以及系統收入增加 4,000 萬美元，成長 50%。儀器及配件收入的成長主要受手術量成長及顧客購買習慣改變的驅動。系統收入的成長主要是由於平均售價的提高，這反映了有利的地域和產品組合。

Outside of the U.S., we placed 90 systems in the third quarter compared with 75 in the third quarter of 2018 and 80 systems last quarter. Current quarter system placements included 36 into Europe, 27 into Japan and 10 into China. 59% of the systems placed in the quarter were da Vinci Xis and 33% were da Vinci X Systems compared with 43% da Vinci Xis and 48% da Vinci Xs last year. 21 of the system placements in the quarter were operating leases compared with 9 last year and 12 last quarter. Placements outside of the U.S. will continue to vary as some of the OUS markets are in early stages of adoption, some markets are highly seasonal, reflecting budget cycles or vacation patterns. And some -- and sales into some markets are constrained by government limitations.

在美國以外，我們第三季安裝了 90 套系統，而 2018 年第三季為 75 套，上一季為 80 套。在當前季度製度下的就業分配包括：36人進入歐洲，27人進入日本，10人進入中國。在本季安裝的系統中，59% 為達文西 Xi 系統，33% 為達文西 X 系統，而去年同期達文西 Xi 系統佔比為 43%，達文西 X 系統佔 48%。本季系統部署中有 21 個是經營租賃，而去年同期為 9 個，上季為 12 個。美國以外的職位安排將繼續有所不同，因為一些美國以外的市場仍處於早期採用階段，一些市場具有很強的季節性，反映了預算週期或度假模式。還有一些產品——以及一些產品的銷售——受到政府限制。

Moving on to gross margin and operating expenses. Pro forma gross margin for the third quarter was 72% compared with 71.5% for the third quarter of 2018 and 71.3% last quarter. The increase compared with the third quarter of 2018 and last quarter primarily reflects higher system ASPs and product cost reductions. 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. We expect the return of the medical device tax in 2020, which will reduce our gross margin by approximately 70 to 100 basis points.

接下來分析毛利率和營運費用。第三季的備考毛利率為 72%，而 2018 年第三季為 71.5%，上一季為 71.3%。與 2018 年第三季和上一季相比，成長主要反映了系統平均售價的提高和產品成本的降低。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。我們預計醫療器材稅將於 2020 年恢復徵收，這將使我們的毛利率下降約 70 至 100 個基點。

Pro forma operating expenses increased 31% compared with the third quarter of 2018 and increased 7% compared with last quarter. Spending is consistent with our plan and includes, in order of magnitude of increase, costs associated with expansion of our OUS markets, spending on our informatics capabilities and investment in our infrastructure in order to scale the business. We believe we have a unique opportunity to expand the benefits of minimally invasive surgery around the world and have been -- and will continue to invest in the business accordingly.

與 2018 年第三季相比，以備考計算的營運費用成長了 31%，與上一季相比成長了 7%。支出與我們的計劃一致，按成長幅度排序，包括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的投資。我們相信我們擁有一個獨特的機會，可以向全世界推廣微創手術的益處，並且我們已經並將繼續相應地投資於這項業務。

Our pro forma effective tax rate for the third quarter was 16.8%, reflecting $8 million of reserves -- of reserve releases primarily associated with the expiration of statutes of limitation in certain jurisdictions. While we expect our tax rate to be between 19% and 20% in the fourth quarter, our actual tax rate 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.

第三季的預期有效稅率為 16.8%，反映了 800 萬美元的儲備金——這些儲備金的釋放主要與某些司法管轄區的訴訟時效到期有關。雖然我們預計第四季度的稅率將在 19% 到 20% 之間，但實際稅率會隨著美國和美國境外收入組成的變化、地方當局的稅收變化以及一次性項目的影響而波動。

Our third quarter 2019 pro forma net income was $409 million or $3.43 per share compared with $337 million or $2.83 per share for the third quarter of 2018 and $388 million or $3.25 per share for last quarter.

2019 年第三季度，我們的備考淨收入為 4.09 億美元，即每股 3.43 美元，而 2018 年第三季度為 3.37 億美元，即每股 2.83 美元，上一季為 3.88 億美元，即每股 3.25 美元。

I will now summarize our GAAP results. GAAP net income was $397 million or $3.33 per share for the third quarter of 2019 compared with GAAP net income of $293 million or $2.45 per share for the third quarter of 2018 and GAAP net income of $318 million or $2.67 per share for last quarter. 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, amortization of intangibles and acquisition-related items and legal settlements.

現在我將總結一下我們的GAAP業績。2019 年第三季 GAAP 淨利為 3.97 億美元，即每股 3.33 美元，而 2018 年第三季 GAAP 淨利為 2.93 億美元，即每股 2.45 美元，上一季 GAAP 淨利為 3.18 億美元，即每股 2.67 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相關的超額稅收優惠、無形資產攤銷、收購相關項目和法律和解。

We ended the quarter with cash and investments of $5.4 billion compared with $5.1 billion at June 30, 2019. The cash generated from operations was offset by stock repurchases, acquisition of Schölly Fiberoptic's 3D robotic endoscope business and investments in working capital and infrastructure during the quarter. We repurchased approximately 141,000 shares for $70 million at an average price of $493 per share.

截至本季末，我們的現金和投資為 54 億美元，而 2019 年 6 月 30 日為 51 億美元。本季營運活動產生的現金流被股票回購、收購 Schölly Fiberoptic 的 3D 機器人內視鏡業務以及對營運資金和基礎設施的投資所抵銷。我們以每股 493 美元的平均價格回購了約 141,000 股股票，總計 7,000 萬美元。

In the quarter, we grew inventory by approximately 67 million to 580 million, representing approximately 150 days of inventory. We continue to build inventory to address the growth of the business as well as mitigate risks of disruption that could arise from trade supply or other matters.

本季度，我們的庫存增加了約 6,700 萬，達到 5.8 億，相當於約 150 天的庫存量。我們持續增加庫存，以滿足業務成長的需求，並降低因貿易供應或其他因素而可能造成的中斷風險​​。

In summary, our results for the quarter were solid. While we will provide you with detailed 2020 guidance in January, I want to highlight certain business dynamics that may impact your models. As I noted earlier, we will continue to invest in the business, growing operating expenses as we see it, the substantial opportunity to expand the benefits of minimally invasive surgery. We also believe the percentage of leasing and alternative financing arrangements will increase over time. In addition, we believe the number of trade-in transactions will level off in the short term and then decline over time. It is also likely we will see increased price negotiations and elongated negotiation time lines as competition get closer to launching new products. These dynamics could result in profit fluctuation. However, we will continue to manage the business for the long term as we believe that the fundamentals of the business are strong.

總而言之，我們本季的業績表現穩健。雖然我們將在 1 月向您提供詳細的 2020 年指導，但我想重點介紹一些可能會影響您商業模式的因素。正如我之前提到的，我們將繼續投資這項業務，增加營運支出，因為我們認為這是擴大微創手術益處的巨大機會。我們也認為，租賃和替代融資安排的比例會隨著時間的推移而增加。此外，我們認為短期內以舊換新交易的數量將趨於穩定，然後隨著時間的推移而下降。隨著競爭對手越來越接近推出新產品，我們很可能會看到價格談判增加和談判時間延長。這些因素可能會導致利潤波動。但是，我們將繼續著眼於長期經營，因為我們相信該業務的基本面很強勁。

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，我將把發言權交給卡爾文，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 third quarter procedure growth was nearly 20% compared to 20% during the third quarter of 2018 and 17% last quarter. Our Q3 procedure growth was driven by 18% growth in U.S. procedures and 23% growth in OUS markets. Third quarter 2019 procedure growth benefited from 1 additional working day compared to last year. Through 3 quarters, working days are now roughly consistent between this year and last. Our Q3 2019 year-to-date procedure growth was 18%, equal to 18% growth through 3 quarters of last year.

謝謝你，馬歇爾。與 2018 年第三季的 20% 和上一季的 17% 相比，我們第三季的整體手術量增加了近 20%。第三季手術量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 23%。2019 年第三季手術量的成長得益於比去年多出的 1 個工作天。前三個季度，工作日數與今年和去年基本持平。2019 年第三季至今，我們的手術量成長了 18%，與去年同期前三個季度的成長率相同，均為 18%。

In the U.S., Q3 procedure growth was largely driven by continued strength in general surgery, with substantive contributions from gynecologic and urologic procedures. In U.S. general surgery, third quarter growth in leading procedures, hernia repair and colorectal, remains solid at days adjusted growth rates consistent with last quarter. Cholecystectomy growth continued to accelerate in the third quarter and now represents a significant driver of incremental procedures. While we remain cautious regarding the size of the addressable chole market for robotics, our recent data is encouraging. Growth in cholecystectomy represents a healthy mix of new and continuing surgeons, shows very little churn and sees increasing Firefly utilization. Bariatric procedures, while still not an area of broad emphasis, again accelerated modestly in Q3.

在美國，第三季手術量的成長主要得益於一般外科手術的持續強勁成長，婦科和泌尿外科手術也做出了實質貢獻。在美國一般外科領域，第三季主要手術（疝氣修補術和結直腸手術）的成長依然穩健，經天數調整後的成長率與上一季保持一致。膽囊切除術的成長在第三季度持續加速，現在已成為手術量成長的重要驅動因素。儘管我們對機器人技術可觸及的膽固醇市場規模仍持謹慎態度，但我們最近的數據令人鼓舞。膽囊切除術的成長體現了新外科醫生和老外科醫生之間的健康組合，人員流動率很低，並且 Firefly 的使用率不斷提高。減重手術雖然仍不是重點領域，但在第三季再次小幅加速成長。

Q3 U.S. gynecology procedure growth was largely consistent with the first half of 2019 and last year in the mid-single-digit range, with hysterectomy for cancer volumes accelerating modestly in the quarter. We had surprisingly strong growth in U.S. urology and dVP procedures in the third quarter. dVP growth was just over 10% for the quarter after having moderated to low single digits in Q2. As a highly penetrated mature procedure category, we believe that our U.S. prostatectomy volume should track to the broader prostate surgery market.

第三季度美國婦科手術量的增長與 2019 年上半年和去年基本持平，保持在個位數中段水平，其中子宮癌切除術的數量在本季度略有加速增長。第三季度，我們在美國泌尿外科和dVP手術方面取得了出乎意料的強勁成長。本季 dVP 成長率略高於 10%，而第二季則放緩至個位數。作為一個高度成熟的手術類別，我們認為，我們在美國前列腺切除術的數量應該與更廣泛的前列腺手術市場保持一致。

Third quarter OUS procedure volume grew approximately 23% compared with 23% for the third quarter of 2018 and 20% last quarter. Third 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.

第三季 OUS 手術量成長約 23%，與 2018 年第三季的 23% 和上一季的 20% 相比有所成長。2019 年第三季 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。

In China, as in Q2, procedure growth accelerated modestly as new systems installed under the latest system quota began to provide additional capacity for incremental growth. The Q3 China procedure growth rate remained below the overall OUS metric.

在中國，與第二季度一樣，隨著根據最新系統配額安裝的新系統開始提供額外的容量以促進增量增長，手術量的增長略有加快。中國第三季手術量成長率仍低於美國整體水準。

In Japan, procedure growth was again strong at roughly 40%, reflecting growth in procedures granted reimbursement status in April 2018 and continued later-stage growth in urology procedures. Our emphasis in Japan remains on surgeon and team training and building proctoring networks.

在日本，手術量再次強勁增長，增幅約為 40%，這反映了 2018 年 4 月獲得報銷資格的手術量的增長，以及泌尿外科手術後期階段的持續增長。我們在日本的工作重點仍然是外科醫生和團隊培訓以及建立指導網絡。

Overall European procedure growth was largely consistent with prior periods with variation by country. German results were particularly strong, while results in the U.K. were below our plans.

歐洲整體手術量成長與過去時期基本一致，但各國之間存在差異。德國的成績尤其出色，而英國的成績則低於我們的預期。

Now turning to the clinical side of our business. 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.

現在我們來談談我們業務的臨床方面。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。

Adoption of Intuitive systems for surgery is fundamentally based upon the clinical utility they provide for surgeons and positive procedure outcomes they enable for patients. We are now in the early stages of introducing the da Vinci SP to the market, and over 50 clinical articles have been published involving the SP thus far. Last month, some of the first clinical research related to da Vinci SP usage in transoral surgery was published by JAMA Otolaryngology - Head & Neck Surgery section. The research titled A Next-Generation Single-Port Robotic Surgical System for Transoral Robotic Surgery results from prospective nonrandomized clinical trials was authored by Dr. F. Christopher Holsinger from Stanford, et al. The objective of the study was to evaluate the da Vinci SP in head and neck surgery prospectively through concurrent nonrandomized clinical trials.

手術中採用直覺系統的根本原因在於它們為外科醫生提供的臨床實用性以及為患者帶來的積極手術效果。我們現在正處於將達文西 SP 推向市場的早期階段，迄今為止，已有超過 50 篇與 SP 相關的臨床文章發表。上個月，《美國醫學會耳鼻喉頭頸外科雜誌》發表了一些關於達文西 SP 手術系統在經口手術中應用的首批臨床研究。史丹佛大學的 F. Christopher Holsinger 博士等人撰寫了題為《下一代單孔經口機器人手術系統：前瞻性非隨機臨床試驗結果》的研究報告。研究的目的是透過同期進行的非隨機臨床試驗，對達文西SP在頭頸外科手術中的應用進行前瞻性評估。

The study included a total of 47 patients across 4 institutions: 3 in the U.S. and 1 in Hong Kong. All 47 patients had tumors of the oral pharynx and underwent surgery with the da Vinci SP. 40 patients had malignant tumors while 7 were benign. All 47 patients, 8 women and 39 men with a mean age of 61, safely underwent transoral resection with the da Vinci SP without conversion to open surgery, laser surgery or multi-port robotic surgery. There were no intraoperative complications or device-related serious adverse events. Mean estimated intraoperative blood loss per procedure was 15.4 milliliters, with no patients received a transfusion.

研究共納入 4 個機構的 47 名患者：3 個在美國，1 個在香港。所有 47 名患者均患有口咽腫瘤，並接受了達文西 SP 手術。40 名患者患有惡性腫瘤，7 名患者患有良性腫瘤。所有 47 名患者（8 名女性和 39 名男性，平均年齡 61 歲）均安全地接受了達文西 SP 經口切除術，無需轉為開放性手術、雷射手術或多孔機器人手術。術中未發生併發症或與器械相關的嚴重不良事件。平均估計術中每例手術失血量為 15.4 毫升，沒有病人接受輸血。

Within 30 days, 45 of the 47 patients were eating by mouth and without the need for percutaneous endoscopic gastrostomy tube. The authors concluded, "The use of the device appears to be feasible, safe and effective for transoral robotic surgery of oropharyngeal tumors."

30 天內，47 名患者中有 45 名能夠經口進食，無需經皮內視鏡胃造瘻管。作者總結道：“該設備用於經口機器人手術治療口咽腫瘤似乎是可行、安全且有效的。”

I will now turn to our financial outlook for 2019, starting with procedures. Last quarter, we forecast 2019 procedure growth of 16% to 17%. We are now increasing our forecast and expect full year 2019 procedure growth of 17% to 18%.

接下來，我將談談我們對 2019 年的財務展望，首先從流程說起。上個季度，我們預測 2019 年手術量將增加 16% 至 17%。我們現在提高了預測值，預計 2019 年全年手術量將增加 17% 至 18%。

Turning to gross profit. On our last call, we forecast our 2019 full year pro forma gross profit margin to be within 70% and 71% of net revenue. We are now slightly increasing our forecast and expect full year gross profit margin to be between 71% and 71.5% of net revenue. Our actual gross profit margin will vary quarter-to-quarter depending largely on product, regional and trade-in mix and the impact of new product introductions.

接下來討論毛利。在上一次電話會議上，我們預測 2019 年全年預計毛利率將達到淨收入的 70% 至 71%。我們現在略微上調了預測，預計全年毛利率將佔淨收入的 71% 至 71.5%。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. On our last call, we forecast to grow full year pro forma 2019 operating expenses between 24% and 28% above 2018 levels. We are now retiring the top end of the range and expect our full year pro forma operating expense growth to be between 24% and 27%. On our last call, we forecast our noncash stock compensation expense to range between $320 million and $340 million in 2019. We are now refining this estimate to the top half of the range between $330 million and $340 million.

接下來談談營運費用。在上次電話會議上，我們預測 2019 年全年備考營運費用將比 2018 年水準成長 24% 至 28%。我們現在將停產高端產品，預計全年備考營運費用成長率將在 24% 至 27% 之間。在上一次電話會議上，我們預測 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。我們現在將這項估算值修正為 3.3 億美元至 3.4 億美元區間的上半部。

We expect other income, which is comprised mostly of interest income, to total between $125 million and $130 million in 2019 compared to $130 million to $135 million forecast on our last call. With regard to income tax, apart from certain nondiscrete items impacting Q3, we have a consistent view of our tax rate. We estimate our Q4 pro forma tax rate to be between 19% and 20% of pretax income. That concludes our prepared comments.

我們預計 2019 年其他收入（主要包括利息收入）總額將在 1.25 億美元至 1.3 億美元之間，而上次電話會議預測的總額為 1.3 億美元至 1.35 億美元。關於所得稅，除了影響第三季的某些非離散項目外，我們對稅率有一致的看法。我們預計第四季的預計稅率為稅前收入的 19% 至 20%。我們的發言到此結束。

We will now open the call to your questions.

現在開始回答各位的問題。

(Operator Instructions) And our first question comes from the line of David Lewis with 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。

Just a couple of questions for me. Gary, just starting off on procedure acceleration. Even adjusting for [telling] that there's still couple hundred basis points, maybe 200 to 300 basis points of momentum acceleration to the third quarter, I wonder if you could talk about some of the drivers there. You talked about the gen surg capacity issues last quarter. It sounds that they've been resolved. But was that the principal driver of the momentum improvement? Or could you just kind of point out other factors that drove this relative momentum acceleration to the third quarter? And then I had a quick follow-up.

我還有幾個問題想問。Gary，剛開始學習程式加速。即使考慮到第三季仍有幾百個基點（也許 200 到 300 個基點）的成長勢頭加速，我想知道您能否談談其中的一些驅動因素。你上個季度談到了一般外科手術能力問題。聽起來問題已經解決了。但這真的是推動勢頭改善的主要因素嗎？或者您能否指出推動第三季相對成長動能加速的其他因素？然後我又快速地跟進了一次。

General surgery was positive for us. I would not say that we have resolved all of the constrained issues that we have been -- we had talked about last quarter. We moved in the right direction. So I think productivity for the U.S. sales force was something we talked about last quarter. I think we took a modest step in the right way. We'll keep working on that, likewise, convenient access to systems. So general surgery was strong for us, but I think there's more opportunity there over the long term. We had -- and Calvin touched on it, we're positively surprised in the urology part of the business. And we're digging in a little bit to figure out where that positive surprises come from. Calvin, I don't know if you want to add to that.

普通外科手術對我們來說是積極的。我不會說我們已經解決了所有我們上個季度討論過的受限問題。我們朝著正確的方向前進了。所以我覺得，提高美國銷售團隊的生產力是我們上個季度討論過的議題。我認為我們朝著正確的方向邁出了一小步。我們將繼續努力，同樣地，也希望方便使用者存取系統。所以，普通外科對我們來說很強勢，但我認為從長遠來看，那裡還有更大的發展機會。我們有——卡爾文也提到過——我們在泌尿科業務方面感到非常驚訝。我們正在深入研究，以找出這些驚喜的來源。卡爾文，我不知道你是否想補充什麼。

No. I'd say -- I mean you saw us kind of settle in the low single digits last quarter and just over 10% this quarter, and we are working with our field team and customers to better understand the dynamics behind that.

不。我想說——我的意思是，你們也看到了，上個季度我們的成長率穩定在個位數，而本季度略高於 10%，我們正在與我們的現場團隊和客戶合作，以更好地了解其背後的動態。

Okay. Very helpful. Then maybe just a quick 2-part question on broader CapEx. And Gary, the gross system placements this quarter, I know trade-ins and retirements looked heavier, but gross system placements in the U.S. looked a little lighter. Is there anything you've seen from a change in the capital environment in the U.S. that you're willing to call out?

好的。很有幫助。那麼，或許可以問一個關於更廣泛的資本支出問題的簡短兩部分的問題。蓋瑞，本季系統總配置量，我知道以舊換新和退休看起來比較重，但美國的系統總配置量看起來略輕。您認為美國資本環境的變化有哪些值得特別指出的？

And then related to that, Marshall, your commentary on next year competitive dynamics, maybe could you share with us what you've seen from some of these new systems that have now been displayed in the U.S. and Europe, any comments you're willing to provide there and how your commercial strategy may change next year as you learn more about these systems?

關於這一點，馬歇爾，您對明年的競爭格局有何看法？您能否與我們分享您從目前在美國和歐洲展示的一些新系統中觀察到的情況？您願意就此發表什麼評論？隨著您對這些系統了解的加深，您的商業策略明年可能會發生哪些變化？

On the first front, I don't know that we're a perfect read on the CapEx environment more broadly. We do think that procedure growth is in the U.S., the dominant driver of additional systems over time, system capability but also clinical installed base access. So I think we saw in this quarter, met our expectations. I think the second question around spending looking into next year, I'll let Marshall take.

首先，我不認為我們對更廣泛的資本支出環境有完美的掌握。我們認為，在美國，手術量的成長是隨著時間的推移，系統容量和臨床安裝基礎的增加，這是推動系統數量成長的主要因素。所以我覺得本季我們達到預期了。關於明年支出方面的第二個問題，我認為還是讓馬歇爾來回答。

Yes. So U.S. and specifically about dynamics around potential competitors and my comment about the impacts that might have in terms of elongated negotiations or negotiations with customers, we know that when the competitors' products comes out, that will be an impact. When it comes out or when it will have an impact is less certain. And so we're just trying to make sure that you understand that as those dynamics occur, that you're not surprised.

是的。所以，就美國而言，特別是關於潛在競爭對手的動態，以及我關於這可能會對延長談判或與客戶的談判產生的影響的評論，我們知道，當競爭對手的產品上市時，這將產生影響。它何時發布或何時產生影響尚不確定。所以，我們只是想確保您明白，當這些動態發生時，您不會感到驚訝。

And next, we turn to the line of Larry Biegelsen with Wells Fargo.

接下來，我們來看看拉里·比格爾森在富國銀行的業績。

Just maybe 1 follow-up for you, Marshall, on the operating margin and the OpEx spending that you talked about for next year. I mean in the past, you've talked about not expecting constant deleveraging over time, but how should we think about margins, margin pressure in 2020 relative to 2019 as you invest for top line growth and you potentially have new competition coming in? I have one follow-up.

馬歇爾，關於你提到的明年的營業利潤率和營運支出，我可能還有一個後續問題。我的意思是，過去您曾說過不指望隨著時間的推移不斷去槓桿化，但是當您投資以實現營收成長並可能面臨新的競爭對手時，我們應該如何看待2020年相對於2019年的利潤率和利潤率壓力？我還有一個後續問題。

Yes. I think you -- what you've heard from us and you've heard from others is that there's a substantial opportunity in front of us in terms of the minimally invasive market. And so we think about those opportunities, we think about the technology, that they're necessary to take advantage of those to improve patient outcomes and we think about global expansion. And so that's where we're spending our money. We'll give you more precise guidance on what spending will do when we get to the January call. So I'm not going to really comment at this point about magnitude of leverage or deleverage or whatever. But we will continue to spend on expansion.

是的。我認為，你從我們這裡以及其他人那裡聽到的都是，在微創市場方面，我們面前存在著巨大的機會。因此，我們會考慮這些機會，我們會考慮這些技術，認為它們是利用這些機會改善患者預後的必要條件，我們也會考慮全球擴張。所以，這就是我們花錢的地方。我們將在1月份的電話會議上為您提供更準確的支出預期指導。所以，我現在不打算對槓桿率、去槓桿率或其他任何相關問題發表評論。但我們會繼續加大擴張投入。

That's helpful. And then (inaudible) 2020 theme, Calvin, on the guidance, the implied Q4 is about -- that's somewhere about 15% at the midpoint for procedure growth. Should we be thinking about more of the high end here, Calvin? And maybe if you could talk about the puts and takes for next year. You have some good growth drivers from general surgery and international. Should we be thinking about kind of stability in procedure growth?

那很有幫助。然後（聽不清楚）2020 年的主題，卡爾文，關於指導，隱含的第四季度大約是——手術量增長的中點大約是 15%。卡爾文，我們是不是應該多考慮高端產品？或許您可以談談明年的投注和投注策略。你們在普通外科和國際市場方面有一些不錯的成長動力。我們是否應該考慮程式成長的穩定性？

Yes. I think as you look at Q4, then further out into 2020, the growth drivers, as you say, are general surgery in the United States as well as growth outside the United States, and I think that's likely to continue to be the drivers.

是的。我認為，展望第四季度以及更遠的 2020 年，正如你所說，成長動力來自美國的普通外科手術以及美國以外的成長，我認為這很可能會繼續成為成長動力。

At the high end of the guidance range, I think we're seeing consistency with where we are in a year-to-date basis. But again, in the third quarter, we saw benefit from some of the mature categories. So I think at the lower end, you can contemplate some moderation there.

我認為，在預期範圍的高端，我們與今年迄今的業績保持了一致性。但第三季度，我們再次從一些成熟品類中受益。所以我認為，在較低水平上，可以考慮採取一些適度的措施。

And next, we turn to the line of Bob Hopkins with Bank of America.

接下來，我們來看看鮑伯霍普金斯在美洲銀行的業績。

I just want to ask a couple of quick questions on the comments you guys made on SP in prepared remarks. It sounds like the regulatory pathway is moving around a little bit. Gary, is that a function of something specific with your process? Or is it just a tougher regulatory environment generally with the FDA with these newer product platforms?

我只想就你們在準備好的發言稿中對SP的評論問幾個簡單的問題。聽起來監管路徑似乎有所變動。Gary，這是你流程中某些特定因素導致的嗎？或者只是因為FDA對這些新產品平台的監管環境更加嚴格？

Yes. I think it's probably the latter. As you look at both our products that are moving into new clinical domains and also a little more broadly across the med device industry, it looks like the environment is becoming a more data-centric or the data requirements are increasing.

是的。我覺得很可能是後者。當你觀察我們正進入新的臨床領域的產品，以及更廣泛地觀察整個醫療器材產業時，你會發現環境正變得越來越以數據為中心，或者說數據需求正在增加。

And just -- also just wondering if you could characterize kind of the demand for SP generally and what your comments imply about kind of next year's growth opportunity in SP. Should we be thinking it's fairly limited until you get colorectal? Or do you see enough underlying demand that 2020 could be some nice sales of that product?

另外，我還想問一下，您能否概括一下SP的整體需求，以及您的評論對SP明年的成長機會有何暗示。我們是否應該認為，在罹患大腸直腸癌之前，它的影響範圍相當有限？或者您認為該產品的潛在需求夠大，2020 年的銷售量可能會不錯？

We won't forecast it for you on this call. I think in general, there's an opportunity for the indications that we have, and more indications are better. The clinical data that we're seeing, and that's building in the database, reinforces my support for the product line long term. And I think there's also a set of indications beyond the colorectal that will be interesting to us. That said, we'll work with regulatory bodies to meet the requirements, and that may take some time. That will pace us. So near term, as we get closer to 2020 and get into it, we'll talk a little more about it.

本次電話會議我們不會為您做出預測。我認為總的來說，我們目前掌握的跡像是有利的，而且跡象越多越好。我們看到的臨床數據，以及資料庫中不斷累積的數據，都進一步增強了我對該產品線的長期支持。我認為除了大腸直腸癌之外，還有一些其他的適應症也值得我們關注。也就是說，我們會與監管機構合作以滿足相關要求，但這可能需要一些時間。這將控制我們的節奏。所以，近期內，隨著我們越來越接近 2020 年並進入 2020 年，我們會更多地談論這個問題。

And we have a question from the line of Tycho Peterson with JPMorgan.

我們也收到來自摩根大通的泰科彼得森提出的問題。

I want to go back to some of the procedure commentary. The cholecystectomy recovery, can you comment on what you think might be driving that? And then to your comments on the dVP step-up, any early view on what might be behind that? Is that patients dropping out of watchful waiting? Or is there another dynamic there?

我想回顧一下之前的一些程序性評論。關於膽囊切除術後的恢復，您認為可能影響恢復的因素有哪些？那麼，關於dVP升級，您有什麼初步看法，認為背後可能有什麼原因嗎？那是患者退出觀察等待治療的情況嗎？或者，這裡面還有其他因素在運作？

Yes. On the chole side, Tycho, talked about acceleration being driven by a healthy mix of the new surgeons and existing surgeons, there's not a lot of churn and increasing FireFly utilization. So that feels a lot different than, say, our earlier experience with Single-Site set of tools or was more of a cosmesis-oriented value proposition.

是的。在膽囊切除術方面，泰科談到，手術速度的提升得益於新外科醫生和現有外科醫生的健康組合，人員流動不大，而且 FireFly 的使用率也在不斷提高。所以這感覺和我們之前使用 Single-Site 工具集的經驗大不相同，或者說，它更側重於表面效果，價值主張也更注重實際應用。

And what's interesting is while in the past, chole may have been a popular training procedure, and it still can be that, now it's not necessarily the first procedure. It's a lot more often that it's, say, a hernia repair that's the first procedure. And as general surgeons are applying robotics across their practices, chole is obviously a big part of what they do.

有趣的是，雖然過去膽囊切除術可能是一種流行的訓練程序，而且現在仍然可能是一種訓練程序，但現在它不一定是第一個程序。通常情況下，比如說，疝氣修補術是第一個需要進行的手術。隨著普通外科醫生將機器人技術應用於他們的診療實踐中，膽囊切除術顯然是他們工作的重要組成部分。

So the reasons for optimism, given what we see in the data, but we continue to monitor and analyze the growth trends closely and remain conservative about the overall opportunity.

因此，鑑於我們從數據中看到的情況，我們有理由保持樂觀，但我們將繼續密切監測和分析成長趨勢，並對整體機會保持謹慎態度。

Prostatectomy.

前列腺切除術。

Yes. Prostatectomy, I think we pretty much stated on that, we were surprised and were kind of digging into what the (inaudible) may be.

是的。前列腺切除術，我想我們基本上就是從那裡開始的，我們感到驚訝，並且正在深入研究（聽不清楚）可能是什麼原因造成的。

Okay. And then on SP, it sounds like you worked through the endoscope issues in relatively short order. Should we think about any sort of catch-up effect in the fourth quarter in terms of installations? And then any comment you're willing to make on the IDE trial, how big you think that might have to be?

好的。至於SP，聽起來你很快就解決了內視鏡的問題。我們是否應該考慮第四季度安裝量方面會出現某種追趕效應？那麼，你願意對 IDE 審判發表的任何評論，你認為它需要有多重要？

Well, on the SP endoscope, we have released supply and -- but we still have some work to do, and we will work through it really for SP endoscopy at scale. So we can support the scale we're at today. But as we get bigger and what our long-term plans are, I want to see improvements in that product line. So we will see.

嗯，關於 SP 內視鏡，我們已經放出了供應，但是我們還有一些工作要做，我們會努力實現 SP 內視鏡的大規模應用。所以我們可以維持目前的規模。但隨著我們規模的擴大以及我們長期計劃的製定，我希望看到該產品線得到改進。我們拭目以待。

We're not ready to describe what the outline for the trial yet are. Indeed, it finalizes an IDE that will get published in a public database, and you'll be able to look it up and we'll point you to it.

我們目前還不方便透露審判的具體方案。實際上，它最終確定了一個 IDE，該 IDE 將發佈到公共資料庫中，您可以查找它，我們將為您指明方向。

Right. And then lastly, any comments you can make on ASPs? I think last quarter, there was a view that they would maybe step down, but obviously, they didn't. So just curious how we should be thinking about system ASPs going forward.

正確的。最後，您對ASP有什麼看法嗎？我認為上個季度有一種觀點認為他們可能會辭職，但顯然他們並沒有。所以，我很好奇我們今後應該如何看待系統應用服務提供者（ASP）。

Yes. I think specific in my remarks actually, for ASPs this quarter, we just saw a really favorable mix just like last quarter in terms of Xis versus Xs and Sis. We also saw a really favorable mix in terms of distributor -- lower distributor and higher direct sales. As far as what you should expect going forward, I think what I said was for the remainder of this year, you should look at ASPs more similar to the mix between Q1 and Q2, and that's where we see it coming out. And that will reflect higher mix of distribution sales in Q4, which is typical if you go back and look at our history.

是的。我覺得我剛才的發言比較具體，就本季 ASP 而言，我們看到了一個非常有利的組合，就像上個季度一樣，Xis 與 Xs 和 Sis 的比例比較理想。我們也看到分銷商組成非常有利－分銷商數量減少，直接銷售額增加。至於未來應該如何預期，我認為我之前說過，今年剩下的時間裡，平均售價應該更接近第一季和第二季之間的水平，而我們也看到了這樣的趨勢。這將反映出第四季度分銷通路銷售佔比更高，回顧我們的歷史，這很正常。

And next, we turn to the line of JP McKim with Piper Jaffray.

接下來，我們來看看 JP McKim 和 Piper Jaffray 的合作。

I just wanted to touch on just the uplift in instrument ASPs. Can you talk about, a, the sustainability there and just what's really driving it? Is it more advanced procedures or just more advanced instruments with the staplers and vessel sealers?

我只想簡單談談樂器平均售價的提升。您能談談，a，那裡的可持續性，以及真正推動其發展的因素是什麼嗎？是操作流程更複雜，還是只是使用了更先進的器械，例如縫合器和血管封閉器？

Yes. JP, it's Calvin. Yes, we saw this. In this quarter, revenue per procedure was approximately $1,980, and that's the highest we've seen in quite some time. Marshall mentioned in his comments that we did see a benefit relative to the last quarter just due to timing of orders, but obviously, a higher usage of the advanced stapling and vessel sealing has also contributed to the growth. Going forward, clearly, the favorable timing of the orders should offset, but there's a number of factors that are going to kind of impact the trend going in different directions, including the anticipated continued growth in the advanced instrument usage, offset by an increasing proportion of lower complexity cases like cholecystectomy that we've talked about. So I&A revenue per procedure is going to have variability quarter-to-quarter, and I don't have a long-term direction to give you.

是的。JP，我是卡爾文。是的，我們看到了。本季度，每例手術的收入約為 1980 美元，這是我們一段時間以來看到的最高收入。馬歇爾在評論中提到，由於訂單時間安排，我們確實看到了相對於上一季的收益，但顯然，先進的縫合和血管密封技術的更高使用率也促進了成長。展望未來，顯然，訂單的有利時機應該會起到抵消作用，但有很多因素會朝著不同的方向影響這一趨勢，包括預計先進儀器的使用將持續增長，但同時也會被我們討論過的膽囊切除術等低複雜度病例比例的增加所抵消。因此，每項手術的 I&A 收入會逐季度波動，我無法給出長期方向。

Okay. That's helpful. And then maybe just on -- you've got the CHEST conference coming up this weekend. Maybe what can we or should we expect from you guys in terms of Ion, any Single-Site data and then maybe what investors should be looking for in terms of the right way to sort of compare systems or what really is going to drive adoption if there's an interest?

好的。那很有幫助。然後，也許就只有一件事——你這週末還有 CHEST 會議要參加。就 Ion 而言，我們可以或應該期待你們提供哪些資訊？任何單站點資料？投資人應該關注哪些方面，才能找到比較不同系統的正確方法？如果市場對 Ion 感興趣，有什麼因素才能真正推動其普及？

Yes. So the conference, I think what you're going to see is a lot of what we've talked on this call. We're going to talk about just qualitatively, I think, some of the early experiences in the field. We'll be doing a lot of test drives and talking about the system and its capabilities. I don't think -- there's no new data that I think is going to be groundbreaking at the event.

是的。所以，我認為在這次會議上，你們將會看到我們這次電話會議上討論的很多內容。我認為，我們將主要定性地討論該領域的一些早期經驗。我們將進行多次試駕，並討論該系統及其功能。我不認為——我認為這次活動不會公佈任何具有突破性的新數據。

In general, I think you'll see from both sides relatively early data. I think the larger market in Ion and in the robotic-assisted bronchoscopy will be data-oriented, in broader settings, looking at safety and efficacy. And as that develops, I think we're feeling pretty good. There have been systems in the market in the past, as you know, and I think a fair number of accounts will wait to see what the data says. So there's the feature-benefit kind of conversations that happened in the early market. I think a lot of the market will wait to see what that expresses like in clinical use.

總的來說，我認為你會從雙方看到相對較早的數據。我認為 Ion 和機器人輔助支氣管鏡的更大市場將是數據導向的，在更廣泛的範圍內，專注於安全性和有效性。隨著事態發展，我覺得我們感覺相當不錯。如您所知，過去市場上也出現過類似的系統，我認為相當一部分帳戶會等待數據結果出來後再做決定。所以，早期市場上就出現了關於產品特性和優勢的討論。我認為市場上的許多人會觀望，看看它在臨床應用上的表現如何。

And our next question comes from the line of Richard Newitter with SVB Leerink.

我們的下一個問題來自 SVB Leerink 的 Richard Newitter。

Wanted to just follow up on chole. So I know that I believe chole is a faster procedure relative to some of the more complex areas where the robot gets used. So I'm just curious the extent to which you think acceleration (inaudible) staying power could that help alleviate some of the capacity and training issues that you've outlined in the past with respect to the mix or the types of procedures getting done.

想跟進一下膽固醇的狀況。所以我知道，與一些更複雜的手術（例如機器人輔助手術）相比，膽囊切除術的手術速度要快得多。所以我很好奇，您認為加速（聽不清楚）持續能力在多大程度上可以幫助緩解您過去概述的關於手術組合或手術類型的一些能力和培訓問題。

I think it can change the -- certainly, utilization rate for systems in the field, it's still -- it can still create access challenges as different people buy for time, but as you just described, if they're faster through it. With regard to training, I think that high-volume procedures allow surgeons to move through their early experiences more quickly, and that has a generally positive note effect.

我認為它可以改變——當然，現場系統的利用率，它仍然——它仍然會造成訪問挑戰，因為不同的人購買時間，但正如你剛才所描述的，如果他們能更快地完成操作。就培訓而言，我認為大批量手術可以讓外科醫生更快地累積早期經驗，這通常會產生積極的影響。

Great. And I was hoping -- thanks for the color on the China procedure growth metrics relative to the overall U.S. Just curious, as you have more systems getting placed each quarter, how many quarters you think it might take to get approaching the international average? And I think it would be helpful just to know, where was the growth rate trending in the last 2 quarters relative to this quarter?

偉大的。我很想知道——感謝您提供的關於中國相對於美國整體手術量增長指標的詳細數據。我很好奇，隨著每季植入的系統越來越多，您認為需要多少個季度才能接近國際平均？我認為，了解過去兩個季度與本季相比的成長率趨勢會很有幫助。

Right. So the overall OUS growth rate is roughly 23%. And in the last 2 quarters, we've seen some modest acceleration. We're probably approaching that right now, so successful scenario, in the next quarter or 2, we may cross over.

正確的。因此，OUS 的整體成長率約為 23%。在過去的兩個季度裡，我們看到了一些小幅加速成長。我們現在可能正接近這個目標，所以如果一切順利，在接下來的一個或兩個季度內，我們可能會實現這一目標。

And next, we turn to the line of Imron Zafar with Deutsche Bank.

接下來，我們來看看伊姆龍·紮法爾在德意志銀行的業績。

Gary, you highlighted in your prepared remarks the stapling franchise. Can you talk a little bit more about, I guess, the 60-millimeter in particular and the impact you're seeing in terms of specific procedures, where you're just seeing the uptake? Is it colorectal versus gastric sleeve? And then also, how much cannibalization are you seeing in the 45-millimeter in cases like bowel resection, et cetera?

加里，你在事先準備好的演講稿中重點提到了訂書機連鎖店。您能否再詳細談談，特別是 60 毫米規格，以及您在具體手術中看到的影響，例如您觀察到的接受度提升情況？是直腸切除術還是袖狀胃切除術？另外，在腸切除等病例中，45 毫米內徑的內徑有多少被腸段吞噬？

60 is mostly used in the lower abdomen, so you definitely have stomach and in colorectal. There's modest exchange for the 45s where a 60 will do. [It's fewer fires]. But in general, I think that mix and surgeon selection in that space is pretty well understood from prior experience with laparoscopy, and we're not overly stressed about it.

60主要用於下腹部，所以你肯定有胃部和結直腸的問題。45 盎司的鈔票可以適度兌換，而 60 盎司的鈔票就可以。[火災數量減少了]。但總的來說，我認為根據以往的腹腔鏡手術經驗，該領域的手術方式和外科醫生選擇已經相當明確，我們對此並不太擔心。

Okay. And then in Japan, I know last quarter, you've talked about some sequential slowdown. But the metrics you gave today, the 40%-plus procedure growth and healthy placements, I think 27, can you just talk about the contributors to procedure growth there? Is it still urology, non-dVP urology or general surgery mostly? And then are we expecting more procedure reimbursement approvals in April 2020?

好的。然後在日本，我知道上個季度您也談到了經濟成長環比放緩的情況。但您今天給出的指標，40%以上的手術量增長和健康的植入數量（我認為是27），您能否談談促成手術量增長的因素？還是主要從事泌尿科、非dVP泌尿科還是普通外科？那麼，我們是否可以預期在 2020 年 4 月會有更多手術報銷獲得批准？

Yes. So as we mentioned on the call, the growth -- it moved back to 40% where we had been prior to last quarter. Last quarter, I think we largely felt the effect of a number of holidays or fewer workdays in the quarter than this quarter where that recovered. So that was the main thing. We're seeing increasing numbers of the 12 procedures that were granted reimbursement status in April of 2018 as well as continuing to see adoption of the urology procedures.

是的。正如我們在電話會議上提到的，成長率已經回升至 40%，也就是上個季度之前的水平。我認為上個季度我們主要受到了假期較多或工作日較少的影響，而本季度這種情況有所改善。所以，這就是最重要的事。我們看到，2018 年 4 月獲得報銷資格的 12 項手術的數量不斷增加，泌尿外科手術也繼續被採用。

We don't think that the -- of the 12, that they'll adopt it equal rate, and we'll see some start to break out from the pack, whether it's in colorectal or thoracic relative to some of the others. With regard to reimbursement opportunities going forward, it's something we track and we discuss with surgical societies for their support as needed. We'll see. Nothing to communicate with you at this time.

我們認為這 12 家醫院不會以相同的速度採用這項技術，我們會看到一些醫院開始脫穎而出，無論是在結直腸還是胸腔外科領域，相對於其他一些醫院而言。關於未來的報銷機會，我們會持續關注，並在需要時與外科協會討論，爭取他們的支持。我們拭目以待。目前沒有什麼需要和您溝通的。

Next, we turn to the line of Craig Bijou with Cantor Fitzgerald.

接下來，讓我們來看看 Craig Bijou 與 Cantor Fitzgerald 的合作。

Just a couple of quick follow-ups. Gary, on SP, I think you mentioned that you might be looking at other indications. So I guess I just wanted to get a sense for given the IDE that will be required for colorectal, could we see another indication come in before seeing colorectal?

還有一些後續問題。Gary，關於SP，我想你提到你可能還會注意其他指標。所以我想了解一下，考慮到結直腸癌需要獲得IDE批准，我們是否有可能在結直腸癌獲得批准之前看到其他適應症的出現？

I can give you no reason to be optimistic for that.

我無法給你任何理由對此抱持樂觀態度。

Okay. Fair enough. And then, Marshall, just your comments on the med device tax, I just wanted to -- you said that you expect it to come in, and I just wanted to get -- is that just you being conservative or assuming that it'll come in, in 2020? Or is there anything else behind that comment?

好的。很公平。然後，馬歇爾，關於醫療器材稅，我想問一下——你說你預計它會出台，我只是想確認一下——你只是比較保守，還是假設它會在 2020 年出台？或者，這句話背後有其他意義？

At this point, that is what is supposed to happen. I know there's lobbying efforts to try to change that, but we're just telling you the way it is.

這時，就應該發生這種情況。我知道有人在遊說試圖改變這一點，但我們只是如實告訴你們事實情況。

Also fair enough.

這話說得也對。

And we have a question from the line of Jason Mills with Canaccord Genuity.

我們收到來自 Canaccord Genuity 的 Jason Mills 的提問。

I wanted to follow up, Calvin, on the revenue per procedure. You've given us that data fairly consistently. So (inaudible) things would have to change quite significantly across several different procedures for that trend line to change over, let's say, the next 3 years. So it's been on a nice, fairly decent upward slope. What would you say, I guess, over the longer term with respect to that trend line, given you have so much data, but it is a dynamic business, it would seem like it could continue to trend upward with some volatility quarter-to-quarter but upward over a longer period of time. Can you tell me what I'm missing if that's incorrect?

卡爾文，我想跟進一下每次手術的收入狀況。您一直以來都會向我們提供這類數據。所以（聽不清楚）要讓這條趨勢線在未來三年內發生變化，幾個不同的流程都必須發生相當大的變化。所以它一直處於相當不錯的上升趨勢。我想，從長遠來看，鑑於您掌握了大量數據，您會如何看待這條趨勢線？但這是一個動態的行業，它似乎可能會繼續呈上升趨勢，儘管每個季度之間會有一些波動，但從長遠來看，它會繼續上升。如果我的理解有誤，請告訴我哪裡出了問題？

No, it has been increasing in low single digits the last couple of years anyway. And I tried to mention that we do expect to see a contribute -- continued contribution from the advanced instruments as a tailwind to the metric, but that's being offset by a number of factors. I mentioned increasing proportion of lower complexity cases. And fact is, people are just becoming all the more efficient as time goes on as well, wasting less, doing less with more. And we help them to do that with some of the analytics we provide. So those are the offsets. And so you have the gives and the takes. So at this point, I'm not ready to say whether the trend is going to continue up or be flat or trend down.

不，近幾年來它一直以個位數低位成長。我曾試圖提及，我們確實預期先進儀器將繼續為該指標帶來助力，但這被許多因素抵消了。我提到低複雜度病例比例的增加。事實上，隨著時間的推移，人們的效率也越來越高，浪費更少，用更多的資源做更少的事情。我們透過提供的一些分析工具來幫助他們做到這一點。這些就是偏移量。所以，凡事都有得有失。所以目前我還無法斷定這個趨勢會繼續上漲、維持平穩還是下跌。

Okay. It's fair enough. And obviously, the bigger view of one of the competitors, we saw -- well, the number that they continue to harp on was 2% robotic surgery relative to procedures done, whether it be general endoscopic. I was wondering if you could perhaps, Gary, comment on that number from your perspective, obviously, it being much more broad. If you could comment on that number or just give any general commentary as it relates to robotic surgery penetration. I know you talked qualitatively about it being early innings, but just specifics of that quantitative figure, I'd like your thoughts. And then specifically to Japan, as it relates to the penetration of robotic surgery, it would seem to be lower than that. I'd like your commentary with respect to that geography specifically if you don't mind.

好的。這很合理。顯然，我們看到其中一位競爭對手的更大視角——他們一直強調的手術機器人手術佔 2%，無論手術類型是普通內視鏡手術還是其他手術。加里，我想問你是否可以從你的角度對這個數字發表一下看法，畢竟你的角度要寬泛得多。如果您能就這個數字發表評論，或者就機器人手術普及程度發表一些一般性意見，那就太好了。我知道你之前定性地談到這只是比賽初期，但我想聽聽你對具體量化數據的看法。具體到日本，就機器人手術的普及程度而言，似乎低於這個水準。如果您不介意的話，我想聽聽您對那部分地理環境的看法。

Well, let's zoom out for a second and then we can zoom back in. I think the opportunity for computer-aided and robotically assisted surgery and acute intervention more broadly is clearly substantial and clearly durable. And that's going to draw new entrants, which is (inaudible). I think those new entrants will help accelerate broader adoption more generally. And customers will appreciate that choice, and I think they'll look at that.

好，我們先把鏡頭拉遠一點，然後再拉近一點。我認為電腦輔助和機器人輔助手術以及更廣泛的急診幹預的機會顯然是巨大的，而且顯然是持久的。這將吸引新的參與者，這（聽不清楚）。我認為這些新進入者將有助於加速更廣泛的普及。顧客會欣賞這種選擇，我認為他們會考慮的。

Our strategy over this period has really been to understand our customers deeply and understand the quadruple aim. It's really hard to do the total accounting of what the total available market will be. And what I'd ask you to look at is, over time, what does it look like in the next couple of years? What does it look like in the next 4? Or what does it look like in the next 10? I think some of our competitors, as they speak about these opportunities, are looking out pretty far.

在此期間，我們的策略是真正深入了解我們的客戶，並理解四重目標。要全面估算整個可用市場規模，真的很難。我想請大家觀察的是，隨著時間的推移，未來幾年它會變成什麼樣子？接下來的4個月會是什麼樣子？或者說，未來10年會是什麼樣子？我認為我們的一些競爭對手在談論這些機會時，目光投向了非常長遠的地方。

And okay, that's a forecast, hard to have an exact crystal ball. But clearly, even speaking with our most candid critics, the idea that computer aids and robotics are going to make an impact more broadly in surgery is pretty well accepted. So I think we're early innings.

好吧，這只是個預測，很難擁有一個精準的水晶球。但顯然，即使是最坦率的批評者也普遍接受電腦輔助和機器人技術將在外科手術中產生更廣泛的影響這一觀點。所以我覺得我們現在還處於比賽初期。

Japan, I think likewise. We're a little bit different health care system. The single payer system that runs through MHLW or the predominantly single-payer system means that their requirements and negotiations using data with the government early are much more important and getting those right open to market over time, and that's what we've been working on. So clearly, that's an early set of opportunities for us as well.

日本方面，我的看法也是一樣。我們的醫療保健系統有點不一樣。透過厚生勞動省實施的單一支付方制度或以單一支付方為主的製度意味著，他們及早利用數據與政府進行要求和談判更為重要，隨著時間的推移，將這些要求和談判正確化並向市場開放，而這正是我們一直在努力的方向。所以很明顯，這對我們來說也是一系列早期機會。

Our methodology when we think about total available market is to be conservative in the early days, show that we can bring real value and then revise as we see greater depth. Other companies take a different statistical approach to that.

我們在考慮整個可用市場時的方法是在初期採取保守策略，證明我們能夠帶來真正的價值，然後隨著我們看到更深入的市場情況而進行調整。其他公司則採用不同的統計方法。

And next, we turn to the line of Vijay Kumar with Evercore ISI.

接下來，讓我們來看看 Vijay Kumar 與 Evercore ISI 的合作。

Maybe just tacking on the last question, Gary, if you just look at the medium-term outlook, right, just given where we are in the CapEx cycle, given the amount of product cycles that you guys have on a number of different platforms, where -- I know historically, you looked at utilization rates as being -- on the system utilization rates -- the growth in system utilization as being a leading indicator for systems. Is this now -- given the acceleration we're seeing in procedures, is that a leading indicator for our systems? Like can you just give us a sense for what drives that systems next year? Because, obviously, you have competition. I'm just curious given -- why we're seeing base procedures accelerating. Is that an indicator for how we should be modeling systems?

加里，或許可以補充最後一個問題，如果你只看中期前景，對吧，考慮到我們目前所處的資本支出週期，考慮到你們在許多不同平台上擁有的產品週期數量，我知道從歷史上看，你們一直將利用率視為系統利用率，系統利用率的增長是系統的領先指標。鑑於我們目前看到的流程加速，這是否可以作為我們系統的領先指標？您能否簡要介紹明年推動該系統發展的因素？因為很顯然，你面臨競爭。我只是好奇——為什麼我們看到基礎程式正在加速推進。這是否能為我們如何建構系統模型提供一些啟示？

Well, I'll just draw a broader picture and let Calvin speak to a little bit of the modeling. In the broader sense, we know that in a mature market that has experience with robotic surgery, that procedure demand will drive the underlying system demand. And there's 2 ways that they go about it. One is capacity, and they can get additional capacity by more efficient utilization of their systems. We have designed our systems with that in mind. We work closely with them in various arrangements to help them get improved efficiency. They don't have to buy an x system if they don't want to. The other thing is feature content. Does the product have the feature content that's required to do the procedures they want to do? And so we work with them on those things.

好吧，我先概括一下情況，然後讓卡爾文談談建模方面的問題。從更廣義的角度來看，我們知道，在一個擁有機器人手術經驗的成熟市場中，手術需求將帶動系統本身的需求。他們採取了兩種方法。一是產能，他們可以透過更有效地利用系統來獲得額外的產能。我們在設計系統時就考慮到了這一點。我們透過各種合作安排與他們密切合作，幫助他們提高效率。如果他們不想買，就不用買。另一點是特色內容。該產品是否具備他們想要執行的操作所需的功能內容？因此，我們會和他們一起處理這些事情。

Clearly, competitors will enter the market and make claims. And I guess what I would say for both customers and for shareholders, due diligence is really important. It's really easy to make claims on trade show floors, and it's pretty hard to back them up in real life. And our experience in the world has been that there's a lot of noise in the beginning as those claims are made. And then it takes a couple or 3 years in the actual clinical market and clinical use to see what the broad market thinks about that. That will have an impact for us in the next few years. I don't know if it's next year or the year after. And I think that's what Marshall's commentary was signaling is that customers will evaluate and will take their time, and that may change capital acquisition cycle time lines or otherwise and may change the nature of negotiations for us. But we're planning and thinking for the long term and we're focused on enablement of the quadruple aim and we'll be here for our customers as we go through that. Calvin, anything you want to help with modeling?

顯然，競爭對手會進入市場並提出各種主張。我想說的是，對於客戶和股東而言，盡職調查真的非常重要。在展會現場很容易做出各種聲明，但在現實生活中卻很難證實這些聲明。我們在世界上的經驗是，在提出這些主張之初，往往會有很多喧囂。然後還需要兩到三年的時間在實際的臨床市場和臨床應用中，才能了解整個市場對此有何看法。這將對我們未來幾年產生影響。我不知道是明年還是後年。我認為馬歇爾的評論所暗示的就是，客戶會進行評估，並且會花時間考慮，這可能會改變資本獲取週期的時間線或其他方面，也可能改變我們談判的性質。但我們正在進行長遠規劃和思考，我們專注於實現四重目標，我們將在過程中始終與我們的客戶站在一起。卡爾文，你想在建模上幫什麼忙嗎？

No. I mean clearly, procedures are the catalyst for driving the demand for systems. When we look at our models, we would expect to see a continuation of the trend of increasing utilization over time.

不。我的意思是，很明顯，流程是推動系統需求的催化劑。從我們的模型來看，我們預期隨著時間的推移，利用率會持續呈上升趨勢。

Vijay, if you have a short follow-up, this is your chance. One last one.

Vijay，如果你有一個簡短的後續報道，這就是你的機會。最後一個。

Just 1 quick follow-up, Gary. I mean headcount is up 30%, up from 5,000. We've crossed 7,000. I mean that's an impressive phenomenal number. I'm just curious where that is going.

加里，還有一個後續問題。我的意思是，員工人數增加了 30%，從 5000 人增加了 30%。我們已經突破了7000。我的意思是，這真是一個令人印象深刻的驚人數字。我只是好奇這件事會如何發展。

Yes. We try to balance our growth in our investments by both the opportunity, and we think the opportunity is enormous and durable. And then we balance it by what we think we can achieve and do well, and that really is what caps our growth and our spend. Absorbing, training, selecting, developing staff, doing rapid growth is really a challenge, and that's what we are focused on.

是的。我們努力在投資成長方面取得平衡，既要把握機遇，又要把握機遇，我們認為機會龐大且持久。然後，我們會根據我們認為自己能夠取得的成就和能夠做好的事情來平衡，而這才是真正限制我們成長和支出的因素。吸收、培訓、選拔、發展員工，實現快速成長，這確實是一個挑戰，而這正是我們關注的重點。

As we get into 2020, 2021, and we'll share with you in future quarters what our plans are, but we try to balance those 2 things: being agile on pursuing the opportunity; at the same time, making sure we're not overextended and losing our ability to execute and be efficient.

隨著我們進入 2020 年和 2021 年，我們將在未來的幾個季度與大家分享我們的計劃，但我們會努力平衡這兩件事：靈活地抓住機會；同時，確保我們不會過度擴張，從而失去執行和提高效率的能力。

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

所以，謝謝你。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存在著巨大而持久的機會。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、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，以及最終更低的治療總成本。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。

Thank you for your support on this extraordinary journey to improve surgery. We look forward to talking with you again in 3 months.

感謝您在這段非凡的外科手術改進之旅中給予的支持。我們期待三個月後再次與您交談。

Ladies and gentlemen, that does conclude our conference for today. Thank you for your participation and for using AT&T Executive Teleconference Service. You may now disconnect.

女士們、先生們，我們今天的會議到此結束。感謝您的參與以及使用AT&T高階主管電話會議服務。您現在可以斷開連線了。