直覺手術 (ISRG) 2019 Q4 法說會逐字稿

Ladies and gentlemen, thank you for standing by, and welcome to Intuitive Surgical's Fourth Quarter 2019 Earnings Release. (Operator Instructions) As a reminder, today's conference is being recorded. I'd now like to turn the conference over to Senior Director of Finance, Investor Relations, Calvin Darling. Please go ahead.

女士們，先生們，感謝您的支持，歡迎來到 Intuitive Surgical 2019 年第四季度財報發布。 （操作員說明）提醒一下，今天的會議正在錄製中。我現在想將會議轉交給投資者關係財務高級總監 Calvin Darling。請繼續。

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

謝謝你。下午好，歡迎來到 Intuitive 的第四季度財報電話會議。今天和我在一起的是我們的首席執行官 Gary Guthart；和我們的首席財務官 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 October 18, 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，我想通知您，今天電話會議中提到的評論可能被視為包含前瞻性陳述。由於某些風險和不確定性，實際結果可能與明示或暗示的結果大不相同。這些風險和不確定性在公司提交給證券交易委員會的文件中進行了詳細描述，包括我們最近於 2019 年 2 月 4 日提交的 10-K 表格和 2019 年 10 月 18 日提交的 10-Q。我們的 SEC 文件可通過我們的網站或 SEC 的網站。告誡投資者不要過分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，本次電話會議將在我們的網站上進行音頻重播，網址為：intuitive.com，位於我們投資者關係頁面下的“最新活動”部分。此外，今天的新聞稿和補充財務數據表已發佈到我們的網站。

Today's format will consist of providing you with highlights of our fourth quarter results as described in our press release announced earlier today, followed by a question-and-answer session. Gary will present the quarter's business and operational highlights, Marshall will provide a review of our fourth quarter financial results, then I will discuss procedures and clinical highlights and provide our financial outlook for 2020. And finally, we will host a question-and-answer session.

今天的形式將包括為您提供我們今天早些時候宣布的新聞稿中所述的第四季度業績的亮點，然後是問答環節。 Gary 將介紹本季度的業務和運營亮點，Marshall 將回顧我們第四季度的財務業績，然後我將討論程序和臨床亮點，並提供我們 2020 年的財務展望。最後，我們將主持問答會議。

With that, I will turn it over to Gary.

有了這個，我會把它交給加里。

Thank you for joining us today. At Intuitive, 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 fourth quarter of 2019 was another strong one for Intuitive in pursuit of these aims, capping a good year for the company. Our performance is reflected in healthy total growth and customer use of our systems, new capital installations, sustained quality service of our customers, clinical publications and the launch of new products and services.

感謝您今天加入我們。在 Intuitive，我們通過他們對四重目標產生積極影響的能力來衡量我們的努力：更好的結果、更好的患者體驗、更好的護理團隊體驗和更低的每次患者治療的總成本。 2019 年第四季度是 Intuitive 追求這些目標的又一強勁表現，為公司迎來了豐收的一年。我們的業績反映在健康的總體增長和客戶對我們系統的使用、新的資本安裝、客戶的持續優質服務、臨床出版物以及新產品和服務的推出。

For the quarter, global procedure growth was approximately 19%. Growth was led by general surgery in the United States with positive contributions to the global growth rate from Japan, China, Germany and Korea. Globally, customer utilization of systems increased again in the quarter, indicating greater productivity per installed system. Leasing and alternative placement models have also helped our customers gain access to additional procedure capacity with lower capital outlays.

本季度，全球程序增長約為 19%。增長由美國的普外科引領，日本、中國、德國和韓國對全球增長率做出了積極貢獻。在全球範圍內，客戶對系統的利用率在本季度再次增加，表明每個已安裝系統的生產力更高。租賃和替代安置模式還幫助我們的客戶以較低的資本支出獲得額外的程序能力。

In the United States, year-over-year procedure growth for the quarter was 18%. General surgery accounted for the largest increase, accompanied by stable growth in urology and gynecology. Within general surgery, hernia repair, cholecystectomy, bariatric and colorectal surgery showed strength.

在美國，該季度的程序同比增長為 18%。普外科佔比增幅最大，泌尿科和婦科則保持穩定增長。在普通外科手術中，疝修補術、膽囊切除術、減肥手術和結直腸手術顯示出實力。

Outside the United States, several markets are early in their transition from growth in urology to other surgical categories, including gynecology, thoracic surgery and general surgery, with growth varying by country. Calvin will take you through global procedure dynamics in more detail later in the call.

在美國以外，一些市場正處於從泌尿科增長向其他外科類別（包括婦科、胸外科和普外科）過渡的早期階段，增長因國家而異。 Calvin 將在稍後的電話會議中更詳細地帶您了解全局過程動態。

With regard to our installed base, placement of new systems in the quarter was solid. We placed 336 systems in the quarter, with growth in total placements rising 16% from Q4 of 2018. Net of trade-ins and retirements, our da Vinci installed base grew to approximately 5,582. The mix of system placements this quarter continues to favor our flagship Xi System, and trade-ins were healthy. The proportion of systems placed under operating leases was 38% this quarter compared with 33% 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.

就我們的安裝基礎而言，本季度新系統的放置是穩固的。我們在本季度安裝了 336 個系統，總安裝量比 2018 年第四季度增長了 16%。扣除以舊換新和退役後，我們的達芬奇安裝基數增長到大約 5,582 個。本季度的系統佈局組合繼續有利於我們的旗艦 Xi System，並且以舊換新是健康的。本季度經營租賃的系統比例為 38%，上一季度為 33%。提醒一下，根據租賃或基於使用的安排放置的系統總數和百分比可能每季度都有很大差異。

Over the past several years, we've been working to enable greater access to our products and services. For example, we believe leasing and usage-based models benefit our customers by lowering barriers for them to provide high-quality computer-aided interventions. We anticipate continuing to expand access and lower cost for our customers as our business progresses into different procedures and geographies.

在過去的幾年裡，我們一直在努力讓人們更容易地訪問我們的產品和服務。例如，我們相信租賃和基於使用的模式可以降低客戶提供高質量計算機輔助干預的障礙，從而使他們受益。隨著我們的業務發展到不同的程序和地區，我們預計將繼續為我們的客戶擴大訪問範圍並降低成本。

Turning to expenses. We believe we are still in the early days of computer-aided surgery and acute interventions. As a result, we are investing in building our capability in several important ways, including deepening internationally, launching our new platforms, strengthening our computational capabilities and executing projects that support future scale and provide leverage opportunities as we grow. Our spending for the quarter and for the year was within the upper end of spend guidance we shared with you in 2019. It is supported by solid procedure growth, capital placements and product cost reductions.

轉向開支。我們相信我們仍處於計算機輔助手術和急性干預的早期階段。因此，我們正在以多種重要方式投資建設我們的能力，包括深化國際化、推出我們的新平台、加強我們的計算能力以及執行支持未來規模並在我們成長過程中提供槓桿機會的項目。我們本季度和全年的支出都在我們在 2019 年與您分享的支出指導的上限範圍內。它得到了穩健的程序增長、資本配置和產品成本降低的支持。

Financial highlights of our fourth quarter results are as follows: Procedures grew approximately 19% over the fourth quarter last year. We placed 336 da Vinci Surgical systems, up from 290 in the fourth quarter of 2018. Our installed base grew 12% from a year ago. Revenue for the quarter was approximately $1.3 billion, up 22%. Pro forma gross profit margin was 72.2% compared to 71.8% in the fourth quarter last year. Instrument and accessory revenue increased to $671 million, up 24%. Total recurring revenue in the quarter was $896 million, growing 24% over Q4 of 2018 and representing 70% of total revenue. We generated a pro forma operating profit of $506 million in the quarter, up 23% from the fourth quarter of last year, and pro forma net income was $417 million, up 18%.

我們第四季度業績的財務亮點如下： 程序比去年第四季度增長了約 19%。我們放置了 336 台達芬奇手術系統，高於 2018 年第四季度的 290 台。我們的安裝基數比一年前增長了 12%。本季度收入約為 13 億美元，增長 22%。備考毛利率為 72.2%，而去年第四季度為 71.8%。儀器和配件收入增至 6.71 億美元，增長 24%。本季度總經常性收入為 8.96 億美元，比 2018 年第四季度增長 24%，佔總收入的 70%。我們在本季度產生了 5.06 億美元的備考營業利潤，比去年第四季度增長了 23%，備考淨收入為 4.17 億美元，增長了 18%。

Highlights for the full year 2019 are as follows: Procedures grew approximately 18% over 2018. We placed 1,119 systems in the year, growing the installed base 12% over 2018. Revenue for the year was approximately $4.5 billion, growing 20% over 2018. And pro forma net income was approximately $1.5 billion, up 17% over 2018.

2019 年全年的亮點如下： 程序比 2018 年增長約 18%。我們在這一年放置了 1,119 個系統，安裝基數比 2018 年增長了 12%。全年收入約為 45 億美元，比 2018 年增長 20%。備考淨收入約為 15 億美元，比 2018 年增長 17%。

Turning to progress in our innovation pipeline, I'll start first with systems. We are in our Phase I launch of da Vinci SP, and we are working to expand its clinical clearances and build SP products at scale. In the quarter, we installed 6 systems to bring our installed base of SP to 44. Customer response and early clinical results using SP remain encouraging, with over 50 peer-reviewed clinical articles on SP to date. With regard to additional indications for SP, we've 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 for SP in the U.S. in 2020. While I would like a faster launch of SP, the combination of additional indications for SP and our readiness for deployment at larger scale will pace the speed of our SP commercial expansion.

談到我們創新管道的進展，我將首先從系統開始。我們正處於達芬奇 SP 的第一階段推出，我們正在努力擴大其臨床許可並大規模生產 SP 產品。在本季度，我們安裝了 6 個系統，使我們的 SP 安裝基礎達到 44 個。使用 SP 的客戶反應和早期臨床結果仍然令人鼓舞，迄今為止，在 SP 上發表了超過 50 篇經過同行評審的臨床文章。關於 SP 的其他適應症，我們一直在與 FDA 討論結直腸適應症的數據要求。我們預計這需要包含後續分析的 IDE 試用版。這意味著我們預計 2020 年美國不會出現第三個 SP 跡象。雖然我希望更快地推出 SP，但 SP 的其他跡象和我們準備更大規模部署的結合將加快我們的 SP 商業化速度擴張。

In flexible diagnostics, our Ion platform is focused on the need for accurate and timely biopsies to support definitive early diagnosis of suspicious lesions. As of the end of the quarter, there are approximately 16 systems in the field, some commercial and some clinical trial sites with several hundred procedures performed. To date, the rollout is meeting our expectations, and user feedback during this initial launch period has been strong. We expect several publications reviewing the performance of Ion to be presented during 2020.

在靈活的診斷中，我們的 Ion 平台專注於對準確和及時的活檢的需求，以支持對可疑病變的明確早期診斷。截至本季度末，該領域大約有 16 個系統，一些商業和一些臨床試驗場所進行了數百個程序。迄今為止，此次推出符合我們的預期，並且在最初的發布期間用戶反饋非常強烈。我們預計將在 2020 年發表幾篇審查 Ion 性能的出版物。

Turning to instruments and accessories. Our team has been making great progress in building out our instrument portfolio with high-quality products. Our experience has shown that procedure adoption occurs when holistic -- 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. Our team initiated our first phase launch in the quarter for our SynchroSeal sealing and transection device, along with our first integrated energy controller called the E-100. SynchroSeal provides surgeons with wristed, precise and fast sealing and transection ability often used in general surgery. Early feedback on its performance has been outstanding. SynchroSeal joins our portfolio of advanced instruments, stapling instruments and advanced energy instruments that customers are now adopting in their da Vinci cases.

轉向儀器和配件。我們的團隊在用高質量產品構建我們的儀器組合方面取得了長足的進步。我們的經驗表明，程序採用發生在整體上——當護理團隊的整體需求得到滿足時，當正確的系統和成像產品與正確的儀器和附件相結合時。我們的團隊在本季度啟動了我們的 SynchroSeal 密封和橫切裝置的第一階段發布，以及我們的第一個集成能量控制器 E-100。 SynchroSeal 為外科醫生提供了在普通外科中常用的手腕、精確和快速的密封和橫斷能力。對其性能的早期反饋非常出色。 SynchroSeal 加入了我們的先進儀器、裝訂儀器和先進能源儀器產品組合，客戶現在在他們的達芬奇案例中採用這些儀器。

Turning to imaging and analytics. We're working on imaging, computing and real-time cloud technologies that allowed for capabilities from big data analytics to telementering, to augmented reality. Here alone, Intuitive Surgical simulators have been used for over 17,000 hours by more than 5,800 surgeons. Our IRIS augmented reality system entered clinical use in the fourth quarter of 2019, and we're pleased with our first customer responses. Over the past several years, our analytical capability has increased, and we now routinely engage our customers to help assess the performance of their robotic-assisted surgery programs relative to other surgical modalities. Armed with local comparative analysis of robotic-assisted surgery within their institutions, hospitals with active programs have been building access to da Vinci systems in growing their programs. We expect continued investment and progress in these areas in 2020.

轉向成像和分析。我們正在研究成像、計算和實時雲技術，這些技術支持從大數據分析到遠程監控再到增強現實的各種功能。僅在這裡，Intuitive Surgical 模擬器已被 5,800 多名外科醫生使用超過 17,000 小時。我們的 IRIS 增強現實係統於 2019 年第四季度進入臨床使用，我們對我們的第一批客戶反應感到滿意。在過去幾年中，我們的分析能力有所提高，現在我們定期與客戶合作，幫助評估他們的機器人輔助手術計劃相對於其他手術方式的性能。憑藉對機構內機器人輔助手術的本地比較分析，擁有活躍項目的醫院一直在建立對達芬奇系統的訪問，以發展他們的項目。我們預計 2020 年將在這些領域繼續投資和取得進展。

As we move into 2020, let's step back and review the da Vinci Surgery universe. In the past several years, general surgeons have increased their adoption of our offerings, underpinned by improvements in the quadruple aim and procedures they perform, from hernia repair, cholecystectomy and colorectal surgery to bariatric surgery. These surgical procedures span a broad range of complexity and economics. At the same time, Intuitive continues to deepen our capability in key countries to support the adoption of robotic-assisted surgery in their health care environments. We are flexing 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, I 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 in both technology and business models, and we see a path to do both.

隨著我們進入 2020 年，讓我們退後一步，回顧一下達芬奇手術的世界。在過去的幾年裡，普通外科醫生增加了他們對我們產品的採用，這得益於他們執行的四重目標和程序的改進，從疝氣修復、膽囊切除術和結直腸手術到減肥手術。這些外科手術涵蓋了廣泛的複雜性和經濟性。與此同時，Intuitive 繼續深化我們在主要國家/地區的能力，以支持在其醫療保健環境中採用機器人輔助手術。我們正在通過推出新系統、新儀器和更新我們的軟件，以及改變我們的銷售和支持模式以及定價結構，讓我們的公司更好地為這些客戶服務。鑑於追求四重目標的巨大全球機遇，我相信公司未來幾年將充滿活力。我們將指導公司在廣泛的程序和地域範圍內滿足客戶的臨床和經濟需求。這樣做將涉及對技術和商業模式創新的持續投資，我們看到了兩者兼而有之的途徑。

Moving into 2020, we are focused on the following: first, supporting adoption of da Vinci in general surgery, including hernia repair, colorectal procedures and bariatrics; second, launching our SP Ion imaging instruments and analytics platforms; third, extending our depth in OUS markets, particularly Asia and EU, with growth beyond urology; and finally, supporting additional clinical and economic validation in our focused procedures and countries.

進入 2020 年，我們將重點關注以下方面：首先，支持在普通外科手術中採用達芬奇，包括疝氣修復、結直腸手術和減肥治療；第二，推出我們的 SP 離子成像儀器和分析平台；第三，擴大我們在 OUS 市場的深度，尤其是亞洲和歐盟，並在泌尿外科之外實現增長；最後，支持在我們的重點程序和國家進行額外的臨床和經濟驗證。

Lastly, we are pleased to publish today our inaugural quarter sustainability report which you can find on our website, outlining our multiyear efforts in these areas.

最後，我們很高興今天發布我們的首個季度可持續發展報告，您可以在我們的網站上找到該報告，概述我們在這些領域的多年努力。

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

我現在將電話轉給馬歇爾，他將審查財務亮點。

Good afternoon. I would 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.

下午好。我將在非公認會計原則或備考基礎上描述我們表現的亮點。稍後我還將在準備好的評論中總結我們的 GAAP 表現。我們的備考結果和公認會計原則結果之間的對賬發佈在我們的網站上。

Revenue and procedures are consistent with our preliminary press release of January 9. Key business metrics for the fourth quarter were as follows: Fourth quarter 2019 procedures increased approximately 19% compared with the fourth quarter of 2018 and increased approximately 11% compared with last quarter. Procedure growth continues to be driven by general surgery in the U.S. and urology worldwide. Calvin will review details of procedure growth later in this call.

收入和程序與我們 1 月 9 日的初步新聞稿一致。第四季度的主要業務指標如下： 2019 年第四季度的程序與 2018 年第四季度相比增加了約 19%，與上一季度相比增加了約 11%。手術增長繼續受到美國普外科和全球泌尿外科的推動。 Calvin 將在本次電話會議稍後審查程序增長的詳細信息。

Fourth quarter system placements of 336 systems increased 16% compared with 290 systems last year and increased 22% compared with 275 systems last quarter. We expanded our installed base of da Vinci systems by 12% to approximately 5,582 systems. This growth rate compares with 12% in the last quarter and 13% last year. Utilization of clinical systems in the field, measured by procedures per system, grew approximately 6%, which is the same as the 6% growth last quarter and last year.

與去年的 290 個系統相比，第四季度 336 個系統的系統佈局增加了 16%，與上一季度的 275 個系統相比增加了 22%。我們將達芬奇系統的安裝基礎擴大了 12%，達到約 5,582 個系統。這一增長率與上一季度的 12% 和去年的 13% 相比。以每個系統的程序衡量，該領域臨床系統的利用率增長了約 6%，與上一季度和去年的 6% 增長相同。

Our revenue overview is as follows: Fourth quarter 2019 revenue was $1.3 billion, an increase of 22% compared with $1 billion for the fourth quarter of 2018 and an increase of 13% compared with $1.1 billion last quarter. Instrument and accessory revenue of $671 million increased 24% 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 5% compared with the fourth quarter of 2018 and was consistent with last quarter. Instrument and accessory revenue per procedure has grown in the low single digits over the past couple of years, reflecting increased usage of our advanced instruments, partially offset by higher growth in benign procedures where revenue per procedure is lower than the overall average. While adoption of benign procedures has been a major contributor to the overall I&A revenue, to the extent benign procedures grow faster than complex procedures, I&A per procedure may decline. In addition, over time, as we achieve greater penetration of our advanced instruments in da Vinci procedures, the growth rate for advanced instruments will slow and align with the growth rate of underlying procedures of which advanced instruments are used. Systems revenue for the fourth quarter of 2019 was $416 million, an increase of 22% compared with the fourth quarter of 2018 and an increase of 23% compared with last quarter. Relative to the fourth quarter of 2018, systems revenue reflected higher system placements, higher ASPs and higher lease-related revenue.

我們的收入概覽如下： 2019 年第四季度收入為 13 億美元，比 2018 年第四季度的 10 億美元增長 22%，比上一季度的 11 億美元增長 13%。儀器和配件收入為 6.71 億美元，比去年增長 24%，高於程序增長，主要反映了客戶購買模式和我們先進儀器的使用增加。每個程序實現的儀器和附件收入約為 1,980 美元，與 2018 年第四季度相比增長 5%，與上一季度持平。在過去的幾年裡，每項手術的儀器和附件收入以較低的個位數增長，這反映了我們先進儀器的使用增加，部分被良性手術的較高增長所抵消，其中每項手術的收入低於整體平均水平。雖然採用良性程序一直是整體 I&A 收入的主要貢獻者，但如果良性程序的增長速度快於復雜程序，則每個程序的 I&A 可能會下降。此外，隨著時間的推移，隨著我們在達芬奇程序中更深入地滲透我們的先進儀器，先進儀器的增長率將放緩，並與使用先進儀器的基礎程序的增長率保持一致。 2019年第四季度系統收入為4.16億美元，與2018年第四季度相比增長22%，與上一季度相比增長23%。相對於 2018 年第四季度，系統收入反映了更高的系統佈局、更高的 ASP 和更高的租賃相關收入。

We completed 126 operating lease transactions representing 38% of total placements compared with 84 or 29% of total placements in the fourth quarter of 2018 and 92 or 33% of total placements last quarter. As of December 31, we have 658 operating leases outstanding and realized approximately $34 million from revenues related to these arrangements in the quarter compared with $16 million last year and $27 million last quarter.

我們完成了 126 筆經營租賃交易，佔總配售的 38%，而 2018 年第四季度為 84 筆或占總配售的 29%，上一季度為 92 筆或占總配售的 33%。截至 12 月 31 日，我們有 658 份未完成的經營租賃，本季度與這些安排相關的收入實現了約 3400 萬美元，而去年同期為 1600 萬美元，上一季度為 2700 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 -- operating leases placed in the quarter dampens short-term revenue growth for the quarter in which they're placed.

經營租賃創造了未來的經常性收入來源並減少了系統收入的波動性，而操作系統數量的增加——本季度的經營租賃抑制了它們所在季度的短期收入增長。

Operating leases include usage-based financings that we provided 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.

經營租賃包括我們向某些具有先進機器人技術經驗的醫院提供的基於使用的融資。我們相信，我們的租賃融資替代方案符合客戶目標，並促進了更快的市場採用。相對於在租賃期內購買的系統，我們賺取了反映金錢時間價值的少量溢價，並且在基於使用的安排的情況下，這些系統可能無法達到預期的使用水平的風險。經營租賃和基於使用的安排的比例可能會長期增加，並且會因季度而異。

We recognized $34 million of lease buyout revenue in the fourth quarter compared with $20 million last quarter and $17 million last year. Lease buyout revenue has varied significantly from quarter-to-quarter and will likely continue to do so.

我們在第四季度確認了 3400 萬美元的租賃收購收入，而上一季度為 2000 萬美元，去年為 1700 萬美元。每個季度的租賃收購收入差異很大，而且很可能會繼續如此。

138 or 41% of current quarter system placements involved trade-ins, reflecting customer desire to access or standardize on our fourth-generation technology, contributing to an Xi installed base growth of 39% year-over-year. This is an increase compared with 81 or 28% of system placements in the fourth quarter of 2018 and 116 or 42% last quarter. Trade-in activity can fluctuate and could be difficult to predict. However, given prior product trade-in cycles, we expect the proportion of the installed base traded in, in future quarters to decrease over time.

本季度 138 或 41% 的系統佈局涉及以舊換新，反映了客戶希望訪問或標準化我們的第四代技術，促成 Xi 安裝基數同比增長 39%。與 2018 年第四季度的 81 或 28% 的系統佈局和上一季度的 116 或 42% 相比，這一數字有所增加。以舊換新活動可能會波動，並且可能難以預測。然而，鑑於之前的產品以舊換新周期，我們預計未來幾個季度以舊換新的安裝基數比例將隨著時間的推移而下降。

81% of the systems placed in the quarter were da Vinci Xis and 16% were da Vinci X Systems compared with 79% da Vinci Xis and 17% da Vinci Xs last quarter. 6 of the systems placed in the quarter -- fourth quarter, were SP systems. Our rollout of SP surgical system will continue to be measured, putting systems in the hand of experienced da Vinci users while we optimize training pathways in our supply chain.

本季度放置的系統中有 81% 為 da Vinci Xis，16% 為 da Vinci X Systems，而上一季度為 79% da Vinci Xis 和 17% da Vinci Xs。本季度（第四季度）放置的系統中有 6 個是 SP 系統。我們將繼續衡量我們推出的 SP 手術系統，將系統交到經驗豐富的達芬奇用戶手中，同時我們優化供應鏈中的培訓途徑。

We placed 7 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.

我們在本季度放置了 7 個離子系統。離子系統佈置不包括在我們的整體系統計數中，將單獨報告。與 Ion 相關的程序和其他信息不包括在我們準備好的評論中，當它們變得更加實質性時將單獨報告。

Globally, our average selling price, which excludes the impact of operating lease revenue and lease buyouts, was approximately $1.61 million compared with $1.46 million last year and $1.57 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收購的影響）約為 161 萬美元，而去年為 146 萬美元，上一季度為 157 萬美元。

Our fourth quarter ASPs reflect a favorable geographic mix as we sold 39 systems into China and 26 into Japan where ASPs are higher, given the higher cost of doing business in those geographies. Excluding geographic mix, ASPs for the quarter declined slightly relative to the third quarter, reflecting pricing arrangements associated with a higher mix of multisystem contracts. System ASPs will fluctuate with geographic and system mix and may decline relative to the average total 2019 ASP, reflecting increased multisystem arrangements.

鑑於在這些地區開展業務的成本較高，我們第四季度的 ASP 反映了有利的地理組合，因為我們向中國銷售了 39 個系統，向日本銷售了 26 個系統，因為在這些地區開展業務的成本更高。不包括地域組合，本季度的 ASP 相對於第三季度略有下降，這反映了與更高組合的多系統合同相關的定價安排。系統 ASP 將隨著地理和系統組合而波動，並且可能相對於 2019 年的平均總 ASP 有所下降，這反映了多系統安排的增加。

Outside of the U.S., results were as follows: OUS procedures grew approximately 22% compared with the fourth quarter of 2018 and increased 9% compared with last quarter. Fourth quarter revenue outside of the U.S. of $422 million increased 37% compared with the fourth quarter of 2018 and increased 27% compared with last quarter. The increase compared with the prior year reflects increased instruments and accessories revenue of $47 million or 39% growth and increased systems revenue of $58 million or 42% growth. The increase in instrument and accessory revenue was primarily driven by procedure growth and stocking orders associated with China system sales. The increase in systems revenue is primarily the result of increased placements and increased ASPs reflecting favorable geographic and product mix.

在美國以外，結果如下：與 2018 年第四季度相比，OUS 程序增長了約 22%，與上一季度相比增長了 9%。第四季度在美國以外的收入為 4.22 億美元，與 2018 年第四季度相比增長了 37%，與上一季度相比增長了 27%。與上一年相比的增長反映了儀器和配件收入增加了 4700 萬美元或 39% 的增長，以及系統收入增加了 5800 萬美元或 42% 的增長。儀器和配件收入的增長主要是由與中國系統銷售相關的程序增長和庫存訂單推動的。系統收入的增加主要是由於展示位置增加和 ASP 增加反映了有利的地理和產品組合。

Outside of the U.S., we placed 140 systems in the fourth quarter compared with 115 in the fourth quarter of 2018 and 90 systems last quarter. Current quarter system placements included 54 into Europe, 26 into Japan and 39 into China compared with 55 in Europe, 31 into Japan and 2 into China in the fourth quarter of 2018. 71% of the systems placed in the quarter were da Vinci Xis and 24% were da Vinci X Systems compared with 55% da Vinci Xis and 30% da Vinci Xs last year. 32 of the system placements in the current quarter were operating leases compared with 15 last year and 21 last quarter. The 39 systems into China included customers who had begun their tender processes and we believe expedited their purchase cycles to avoid a tariff increase that was expected on December 15. The proposed tariff was suspended on December 13. We would expect remaining purchases under the quota to be completed consistent with historical time lines, and therefore, we expect placements to be lower in the first quarter and skew more towards the end of 2020 and into 2021. While overall European system placements were relatively flat in the quarter and for 2019, shipments by country fluctuates significantly. Placements into the 4 largest European markets increased 29% in the fourth quarter and 19% for the year. Overall 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 sales into some markets are constrained by government limitations.

在美國以外，我們在第四季度放置了 140 個系統，而 2018 年第四季度為 115 個，上一季度為 90 個。 2018 年第四季度，歐洲有 54 個，日本有 26 個，中國有 39 個，而歐洲有 55 個，日本有 31 個，中國有 2 個。本季度 71% 的系統放置在本季度，其中 71% 是達芬奇和24% 是達芬奇 X 系統，而去年達芬奇 Xs 和達芬奇 Xs 分別為 55% 和 30%。本季度的系統安置中有 32 次是經營租賃，而去年為 15 次，上季度為 21 次。進入中國的 39 個系統包括已經開始招標程序的客戶，我們認為加快了他們的採購週期以避免預計 12 月 15 日關稅上調。擬議關稅於 12 月 13 日暫停。我們預計配額下的剩餘採購將與歷史時間線一致，因此，我們預計第一季度的佈局將較低，並在 2020 年底和 2021 年出現更多傾斜。雖然整個歐洲系統佈局在本季度和 2019 年相對持平，但出貨量國家波動很大。第四季度歐洲四大市場的投放量增加了 29%，全年增加了 19%。由於一些 OUS 市場處於採用的早期階段，美國以外的整體佈局將繼續變化；一些市場是高度季節性的，反映了預算週期或假期模式；某些市場的銷售受到政府限制。

Moving on to gross margin and operating expenses. Pro forma gross margin for the fourth quarter of 2019 was 72.2% compared with 71.8% for the fourth quarter of 2018 and 72% last quarter. The increase compared with the fourth 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, mix of systems and instrument and accessory revenue, system ASPs and our ability to further reduce product costs and improve manufacturing efficiencies.

繼續討論毛利率和運營費用。 2019 年第四季度的備考毛利率為 72.2%，而 2018 年第四季度為 71.8%，上一季度為 72%。與 2018 年第四季度和上一季度相比的增長主要反映了更高的系統 ASP 和產品成本的降低。未來利潤率將根據我們的新產品組合、系統和儀器及配件收入組合、系統平均售價以及我們進一步降低產品成本和提高製造效率的能力而波動。

Pro forma operating expenses increased 23% compared with the fourth quarter of 2018 and increased 19% compared with last quarter. Spending is consistent with our plan. It includes an order of magnitude of increase, costs associated with the expansion of our OUS markets, spending on our imaging and analytics capabilities and investment in our infrastructure in order to scale the business. We believe we have a unique opportunity to expand the benefits of computer-aided surgery and acute interventions around the world and have been and will continue to invest in the business accordingly.

與 2018 年第四季度相比，備考運營費用增加了 23%，與上一季度相比增加了 19%。支出與我們的計劃一致。它包括一個數量級的增長、與我們的 OUS 市場擴展相關的成本、在我們的成像和分析能力上的支出以及對我們基礎設施的投資以擴大業務規模。我們相信我們有一個獨特的機會來擴大全球計算機輔助手術和急性干預的好處，並且已經並將繼續相應地投資於該業務。

Our pro forma tax rate for the quarter was 21.1% compared with our expectations of 19% to 20%, reflecting geographic mix. Our actual tax rate will fluctuate with changes in the geographic mix of income, changes in taxation made by local authorities and with the impact of onetime items. Our fourth quarter 2019 pro forma net income was $417 million or $3.48 per share compared with $353 million or $2.96 per share for the fourth quarter of 2018 and $409 million or $3.43 per share for last quarter.

我們本季度的備考稅率為 21.1%，而我們的預期為 19% 至 20%，反映了地域組合。我們的實際稅率將隨著收入地理組合的變化、地方當局的稅收變化以及一次性項目的影響而波動。我們 2019 年第四季度的備考淨收入為 4.17 億美元或每股 3.48 美元，而 2018 年第四季度為 3.53 億美元或每股 2.96 美元，上一季度為 4.09 億美元或每股 3.43 美元。

I will now summarize our GAAP results. GAAP net income was $358 million or $2.99 per share for the fourth quarter of 2019 compared with GAAP net income of $293 million or $2.45 per share for the fourth quarter of 2018 and GAAP net income of $397 million or $3.33 per share for last quarter.

我現在將總結我們的 GAAP 結果。 2019 年第四季度 GAAP 淨收入為 3.58 億美元或每股 2.99 美元，而 2018 年第四季度 GAAP 淨收入為 2.93 億美元或每股 2.45 美元，上一季度 GAAP 淨收入為 3.97 億美元或每股 3.33 美元。

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 stock-based compensation and IP charges, amortization of intangibles and acquisition-related items and legal settlements.

備考和 GAAP 淨收入之間的調整在我們的網站上進行了概述和量化。它包括與員工股票獎勵、員工股票薪酬和知識產權費用、無形資產攤銷和收購相關項目以及法律和解相關的超額稅收優惠。

We ended the quarter with cash and investments of $5.8 billion compared with $5.4 billion at September 30, 2019. The cash generated from operations was partially offset by investments in working capital and infrastructure during the quarter. Capital expenditures for the quarter and the year are higher than historical averages as we invest in our infrastructure. We expect investments in our infrastructure to continue into 2020.

截至本季度末，我們的現金和投資為 58 億美元，而 2019 年 9 月 30 日為 54 億美元。本季度運營產生的現金部分被營運資本和基礎設施投資所抵消。由於我們投資基礎設施，本季度和年度的資本支出高於歷史平均水平。我們預計對基礎設施的投資將持續到 2020 年。

In the quarter, we grew inventory by approximately $16 million to $596 million, representing approximately 142 days of inventory, which is slightly lower than at the end of the third quarter. We did not repurchase any shares in the quarter and have approximately $1.7 billion remaining under the Board buyback authorization.

本季度，我們的庫存增加了約 1600 萬美元至 5.96 億美元，相當於約 142 天的庫存，略低於第三季度末。我們在本季度沒有回購任何股票，並且在董事會回購授權下剩餘約 17 億美元。

In summary, I want to highlight certain business dynamics that may impact your models. First, as I noted, we will grow operating expenses appropriately as we see the substantial opportunity to expand the benefits of computer-aided surgery and acute interventions. Calvin will provide you with operating expense growth guidance. In addition, as we align to our -- with our customer needs, we believe the percentage of leasing and alternative financing arrangements will increase over time. We also believe the number of trade-in transactions will level off in the short term and then decline over time. System ASPs will fluctuate with geographic and system mix and may decline relative to the average total 2019 ASP, reflecting increased multisystem arrangements. While adoption of benign procedures has been a major contributor to overall I&A revenue, to the extent benign procedures grow faster than complex procedures, I&A per procedure may decline. Lastly, it's likely we will see elongated negotiation time lines and possibly price pressures as competition gets closer to launching their products. We will continue to manage the business for the long term as we believe that the fundamentals of the business are strong.

總之，我想強調可能影響您的模型的某些業務動態。首先，正如我所指出的，我們將適當增加運營費用，因為我們看到了擴大計算機輔助手術和急性干預的好處的巨大機會。 Calvin 將為您提供運營費用增長指導。此外，隨著我們與客戶需求保持一致，我們相信租賃和替代融資安排的百分比將隨著時間的推移而增加。我們還認為，以舊換新交易的數量將在短期內趨於平穩，然後隨著時間的推移而下降。系統 ASP 將隨著地理和系統組合而波動，並且可能相對於 2019 年的平均總 ASP 有所下降，這反映了多系統安排的增加。雖然採用良性程序一直是整體 I&A 收入的主要貢獻者，但如果良性程序的增長速度快於復雜程序，則每個程序的 I&A 可能會下降。最後，隨著競爭越來越接近推出他們的產品，我們可能會看到延長的談判時間線和可能的價格壓力。我們將繼續長期管理業務，因為我們相信業務的基本面強勁。

And with that, I'd like to turn it over to Calvin, who'll go over procedure performance and our outlook for 2020.

有了這個，我想把它交給 Calvin，他將討論程序性能和我們對 2020 年的展望。

Thank you, Marshall. Our overall fourth quarter procedure growth was approximately 19% compared to 19% during the fourth quarter of 2018 and nearly 20% last quarter. Our Q4 procedure growth was driven by 18% growth in U.S. procedures and 22% growth in OUS markets. Overall procedure growth for the full year 2019 was approximately 18%, equal to 18% in 2018, comprised of 17% growth in the U.S. and 21% growth in OUS markets. In the U.S., Q4 procedure growth was consistent with recent trends and was largely driven by continued strength in general surgery, with substantive contributions from gynecologic and urologic procedures.

謝謝你，馬歇爾。與 2018 年第四季度的 19% 和上一季度的近 20% 相比，我們第四季度的整體程序增長約為 19%。我們的第四季度程序增長受到美國程序增長 18% 和 OUS 市場增長 22% 的推動。 2019 年全年的整體程序增長約為 18%，相當於 2018 年的 18%，其中美國市場增長 17%，OUS 市場增長 21%。在美國，第四季度的手術增長與最近的趨勢一致，主要是由普外科的持續強勢推動，婦科和泌尿科手術做出了實質性貢獻。

In U.S. general surgery, fourth quarter growth in leading procedures, hernia repair and colorectal remains solid at rates consistent with last quarter. Cholecystectomy growth continued to accelerate in the fourth quarter and now represents a significant driver of incremental procedures. While da Vinci cholecystectomy adoption has been robust given the high level of lab penetration, it is difficult for us to predict the extent and pace of future chole adoption. Bariatric procedures also showed continued solid growth in Q4 and will become an increasing area of field focus for us in 2020. For the full year 2019, approximately 421,000 U.S. general surgery procedures were performed, up 29% from 2018, representing approximately 48% of overall U.S. da Vinci procedures. Q4 U.S. gynecology procedure growth was largely consistent with the first 3 quarters of 2019. For the full year 2019, approximately 282,000 U.S. gynecologic surgery procedures were performed, up 6% from 2018, representing approximately 32% of overall U.S. procedures.

在美國普外科，第四季度主要手術、疝修補和結直腸手術的增長保持穩定，與上一季度一致。膽囊切除術的增長在第四季度繼續加速，現在是增量手術的重要推動力。雖然鑑於實驗室滲透率高，達芬奇膽囊切除術的採用一直很強勁，但我們很難預測未來膽囊採用的程度和速度。減肥手術在第四季度也顯示出持續穩健增長，並將在 2020 年成為我們越來越關注的領域。2019 年全年，美國進行了約 421,000 例普通外科手術，比 2018 年增長 29%，約佔整體的 48%美國達芬奇程序。第四季度美國婦科手術增長與 2019 年前 3 個季度基本一致。2019 年全年，美國進行了約 282,000 例婦科手術，比 2018 年增長 6%，約占美國整體手術的 32%。

In U.S. urology, fourth quarter dVP growth rates continued to exceed our expectations, although growth did moderate from Q3. For the full year 2019, approximately 138,000 U.S. urologic procedures were performed, up just under 10% from 2018, representing approximately 16% of overall U.S. da Vinci procedures. As a highly penetrated procedure category, we believe that our U.S. prostatectomy volumes should track to the broader prostate surgery market and will likely grow more modestly in 2020.

在美國泌尿科，第四季度的 dVP 增長率繼續超出我們的預期，儘管從第三季度開始增長放緩。 2019 年全年，美國進行了約 138,000 例泌尿外科手術，比 2018 年增加了不到 10%，約占美國達芬奇手術總量的 16%。作為一個高度滲透的手術類別，我們認為我們的美國前列腺切除術數量應該會跟上更廣泛的前列腺手術市場，並且在 2020 年可能會適度增長。

Fourth quarter OUS procedure volume grew approximately 22% compared with 24% for the fourth quarter of 2018 and 23% last quarter. Fourth quarter 2019 OUS procedure growth was driven by continued growth in urology procedures and earlier-stage growth in general, gynecologic and thoracic surgery.

與 2018 年第四季度的 24% 和上一季度的 23% 相比，第四季度 OUS 手術量增長了約 22%。 2019 年第四季度 OUS 手術增長是由泌尿外科手術的持續增長和一般婦科和胸外科的早期增長推動的。

In China, as in Q3, procedure growth accelerated modestly as new systems installed under the latest system quota began to provide capacity for incremental growth. In Q4, the China procedure growth rate slightly exceeded the overall OUS metric. As Marshall mentioned, 39 systems were shipped into China in Q4. Note that 35 of these 39 systems went to new hospitals. Teams in these hospitals will need to move through training pathways and established da Vinci procedure processes before these new systems contribute meaningfully to procedure growth in China.

在中國，與第三季度一樣，隨著在最新系統配額下安裝的新系統開始為增量增長提供能力，程序增長溫和加速。第四季度，中國程序增長率略高於整體 OUS 指標。正如馬歇爾所說，第四季度有 39 套系統運往中國。請注意，這 39 個系統中有 35 個用於新醫院。這些醫院的團隊需要通過培訓途徑和建立達芬奇程序流程，然後這些新系統才能為中國的程序增長做出有意義的貢獻。

In Japan, procedure growth was again strong at just over 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，手術增長再次強勁，略高於 40%，這反映了 2018 年 4 月獲得報銷資格的手術的增長以及泌尿外科手術的後期持續增長。我們在日本的重點仍然是外科醫生和團隊培訓以及建立監考網絡。

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. lagged.

總體而言，歐洲程序的增長與前期基本一致，但因國家/地區而異。德國的結果特別強勁，而英國的結果則落後。

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. A recent article by Drs. Wexner and Emile et al in the journal of Techniques in Coloproctology provided results from a systemic review and meta-analysis of intracorporeal versus extracorporeal anastomosis in minimally invasive right colectomy. This study analyzed data from 25 studies and 4,450 patients. Intracorporeal anastomosis was associated with significantly shorter-length extraction site incisions, earlier bowel recovery, fewer complications and lower rates of conversion, anastomotic leaks, surgical site infections and incisional hernia as compared to extracorporeal anastomosis. This study highlighted the many clinical outcome advantages associated with intracorporeal anastomosis, da Vinci systems, instruments and smart stapling technology, enabling performing anastomosis of the bowel inside the body. And it is our hope that more patients can benefit from intracorporeal anastomosis with continued adoption of our technology. Intuitive investment in a prospective multicenter intracorporeal versus extracorporeal anastomosis study comparing robotic versus laparoscopic approaches called the ANCOR study is timely. And the enrollment for this study is expected to be completed this year, with results expected in 2021. The details of the ANCOR study are available online at clinicaltrials.gov.

現在轉向我們業務的臨床方面。在這些電話會議的每個季度，我們都會重點介紹我們認為值得注意的某些最近發表的研究。但是，為了更全面地了解證據主體，我們鼓勵所有利益相關者徹底審查多年來發表的科學研究的廣泛細節。 Drs 最近的一篇文章。 Wexner 和 Emile 等人在《結直腸技術》雜誌上提供了對微創右結腸切除術中體內與體外吻合的系統回顧和薈萃分析的結果。本研究分析了 25 項研究和 4,450 名患者的數據。與體外吻合術相比，體內吻合術與提取部位切口的長度顯著縮短、腸道恢復更早、並發症更少、轉化率更低、吻合口漏、手術部位感染和切口疝相關。這項研究強調了與體內吻合、達芬奇系統、儀器和智能吻合技術相關的許多臨床結果優勢，從而能夠在體內進行腸道吻合。我們希望隨著我們技術的繼續採用，更多的患者可以從體內吻合術中受益。對一項前瞻性多中心體內與體外吻合研究比較機器人與腹腔鏡方法（稱為 ANCOR 研究）的直觀投資是及時的。這項研究的註冊預計將於今年完成，預計將於 2021 年取得結果。ANCOR 研究的詳細信息可在臨床試驗網站上在線獲取。

I will now turn to our financial outlook for 2020. Starting with procedures. As described in our announcement earlier this month, total 2019 da Vinci procedures grew approximately 18% to roughly 1,229,000 procedures performed worldwide. As communicated previously, during 2020, we anticipate full year procedure growth within a range of 13% to 16%. We expect 2020 procedure growth to continue to be driven by U.S. general surgery and procedures outside the United States where we are at earlier stages of adoption. We expect similar seasonal timing of procedures in 2019, as we have experienced in previous years, with Q1 being the seasonally weakest quarter as patient deductibles are reset. Q1 and full year 2020 will benefit from 1 extra working day attributable to leap year.

我現在將轉向我們對 2020 年的財務展望。從程序開始。正如我們在本月早些時候的公告中所述，2019 年達芬奇手術總數增長了約 18%，達到全球約 1,229,000 例手術。如前所述，在 2020 年，我們預計全年手術增長將在 13% 至 16% 之間。我們預計 2020 年的手術增長將繼續受到美國普通外科手術和美國以外的手術的推動，我們正處於早期採用階段。我們預計 2019 年的程序的季節性時間安排與前幾年類似，第一季度是季節性最弱的季度，因為患者免賠額被重置。 2020 年第一季度和全年將受益於閏年帶來的額外 1 個工作日。

With respect to revenue, as we have mentioned previously, capital sales are ultimately driven by procedure demand, catalyzing hospitals to establish or expand robotic system capacity. Capital sales can vary substantially from period-to-period based upon many factors, including U.S. health care policy, hospital capital spending cycles, reimbursement and government quotas, product cycles, economic cycles and competitive factors. Within this framework, we'd expect 2020 capital placement seasonality to generally follow historical patterns by quarter.

關於收入，正如我們之前提到的，資本銷售最終是由程序需求驅動的，促使醫院建立或擴大機器人系統能力。基於許多因素，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、經濟周期和競爭因素，資本銷售在不同時期可能會有很大差異。在此框架內，我們預計 2020 年的資本配置季節性將按季度大致遵循歷史模式。

During the fourth quarter of 2019, 126 of the 336 systems shipped or 38% were under operating leases. We expect the proportion of systems placed via operating leases will vary from quarter-to-quarter and could trend up in the future. During Q3 and Q4, 42% and 41%, respectively, of systems placements were upgrades to our Gen 4 platform. As we mentioned last quarter, we expect the proportion of trade-in transactions to generally trend downwards in 2020.

在 2019 年第四季度，出貨的 336 個系統中有 126 個或 38% 處於經營租賃狀態。我們預計通過經營租賃放置的系統比例將因季度而異，並可能在未來呈上升趨勢。在第三季度和第四季度，分別有 42% 和 41% 的系統部署是升級到我們的第 4 代平台。正如我們上個季度提到的，我們預計 2020 年以舊換新交易的比例總體呈下降趨勢。

Turning to gross profit. Our full year 2019 pro forma gross profit margin was 71.7%. In 2020, we expect our pro forma gross profit margin to be within a range of between 70% and 71% of net revenue. The slightly lower gross profit margin anticipated in 2020 reflects higher sales of newer products and infrastructure investments. 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.

轉向毛利。我們 2019 年全年的備考毛利率為 71.7%。 2020年，我們預計我們的備考毛利率將在淨收入的70%至71%之間。預計 2020 年毛利率略低，反映了新產品和基礎設施投資的銷售額增加。我們的實際毛利率將隨季度變化，主要取決於產品、區域和以舊換新組合以及新產品推出的影響。

Turning to operating expenses. In 2019, our pro forma operating expenses grew 27%. In 2020, we expect pro forma operating expenses to grow between 15% and 20%. We expect our noncash stock compensation expense to range between $400 million and $440 million in 2020 compared to $336 million in 2019. We expect other income, which is comprised mostly of interest income, to total between $100 million and $115 million in 2020. With regard to income tax, in 2019, our pro forma income tax rate was 19.5%. As we look forward, we estimate our 2020 pro forma tax rate to be between 20% and 21% of pretax income, with the increase primarily reflecting the anticipated geographic mix of pretax income.

轉向運營費用。 2019 年，我們的備考運營費用增長了 27%。 2020 年，我們預計備考運營費用將增長 15% 至 20%。我們預計 2020 年我們的非現金股票補償費用將在 4 億美元至 4.4 億美元之間，而 2019 年為 3.36 億美元。我們預計其他收入（主要包括利息收入）在 2020 年將在 1 億美元至 1.15 億美元之間。關於所得稅方面，2019年，我們的備考所得稅率為19.5%。展望未來，我們估計 2020 年的備考稅率將在稅前收入的 20% 至 21% 之間，增長主要反映了稅前收入的預期地域組合。

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

我們準備好的評論到此結束。我們現在將打開您的問題的電話。

(Operator Instructions) Our first question will come 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 David Lewis。

Just 2 questions for me. Gary, I want to start with you first on chole. It's probably your largest procedure set in terms of volume, 2 sequential quarters of acceleration within chole, obviously, still very low penetration. Historically, that was tied to sort of trainings. Physicians would use chole as a way of training on broader general surgery procedures. But can you just talk about the last 2 quarters' acceleration in procedure? Do you think that's simply training, a leading indicator of general surgery? Or do you think something is going on, distinct from that within broader chole? And a quick follow-up.

對我來說只有2個問題。加里，我想先從你開始。就體積而言，這可能是您最大的程序集，在 chole 內連續 2 個季度加速，顯然，滲透率仍然很低。從歷史上看，這與某種培訓有關。醫生將使用膽汁作為更廣泛的普通外科手術的培訓方式。但是你能談談最近兩個季度的程序加速嗎？你認為這只是訓練，是普通外科的領先指標嗎？或者你認為有什麼事情正在發生，不同於更廣泛的膽汁？并快速跟進。

Okay. On the first one, just I'm going to put a posted note on the assumption of its size relative to everything else. I'll let Calvin come back and put it in context size-wise in terms of current run rate. But the underlying question of what are we seeing in cholecystectomy, we think there's a segment there where we're bringing differentiated clinical value, could be underlying clinical elements like obesity, comorbidities, state of disease of the gallbladder. So while it's a large category as a whole, generally well served by minimally invasive surgery today, there are segments in it that are difficult and for which we think current product sets do really well. There's also a set of training or people deepening their experience as they go through it. So there's a mix of those 2. We think there is a durable component segmenting out how big that is over time. We're still working through where we think those end points are. We have seen it both grow in the last few quarters and appear to be sticky, not to have be a transient.

好的。在第一個上，我將在假設其大小相對於其他所有內容的情況下貼上一張便條。我會讓 Calvin 回來並根據當前的運行速度將其放在上下文大小方面。但我們在膽囊切除術中看到的潛在問題是，我們認為那裡有一部分我們帶來了不同的臨床價值，可能是潛在的臨床因素，如肥胖、合併症、膽囊疾病狀態。因此，雖然它作為一個整體來說是一個很大的類別，如今通常通過微創手術得到很好的服務，但其中有一些部分是困難的，我們認為目前的產品集在這方面做得很好。還有一組培訓或人們在經歷過程中加深他們的經驗。所以有這兩者的混合體。我們認為有一個持久的組成部分可以分割出隨著時間的推移有多大。我們仍在研究我們認為這些終點在哪裡。我們已經看到它在過去幾個季度都在增長並且看起來很粘，而不是暫時的。

Calvin, in terms of kind setting in context relative to other procedures.

卡爾文，在相對於其他程序的上下文中的親切設置方面。

No. I mean the size of the market, you can tell from our commentary, it's gotten to the point where general surgery is a meaningful enough category. It's a more and more significant contributor to growth within the general surgery category that's growing overall. Again, as we mentioned in the commentary, it's hard for us to gauge given the high lab penetration there to what extent and what pace it may ultimately adopt.

不，我的意思是市場規模，你可以從我們的評論中看出，它已經到了普外科是一個足夠有意義的類別的地步。它對整體增長的普通外科手術類別的增長做出了越來越重要的貢獻。同樣，正如我們在評論中提到的，鑑於那裡的高實驗室滲透率，我們很難衡量它最終可能採用的程度和速度。

Okay. And then just curious, second question for me is just on the capital environment. Your fourth quarter U.S. net placement growth was a little lower, and Europe in 2019 was a little lower on a net placement basis. Maybe just comment on underlying demand for systems in the U.S. and the European markets. And also curious if has -- in any respect, has competitors introducing new systems or talking about their new systems more publicly? Has it, in any way, impacted demand or changed the conversation you're having with large IDNs in the U.S. or European customers?

好的。然後只是好奇，對我來說第二個問題只是關於資本環境。您的第四季度美國淨配售增長率略低，而 2019 年歐洲的淨配售增長率略低。也許只是評論美國和歐洲市場對系統的潛在需求。並且好奇是否——在任何方面，競爭對手是否引入了新系統或更公開地談論他們的新系統？它是否以任何方式影響了需求或改變了您與美國或歐洲客戶的大型 IDN 之間的對話？

On the outline of the first question, you just sort of think about what the installed base growth was. So if you think about capital demand underneath, there's what's happening to installed base, so opening additional capacity in various places or trade-ins of older-generation systems. I'll let Marshall speak to the quantitative nature of your question with regard to the U.S. and in Europe. But I'd say there is -- it's something -- there's some trade-in dynamics that I think the team has been discussing with you the last couple of quarters. In general, I think we're feeling like it's reasonably stable.

在第一個問題的概要中，您只需考慮一下安裝基數的增長是多少。因此，如果您考慮底層的資本需求，就會發現已安裝的基礎正在發生變化，因此在各個地方開放額外的容量或以舊換新系統。我會讓馬歇爾談談你關於美國和歐洲的問題的數量性質。但我想說的是——這是一些事情——我認為團隊在過去幾個季度一直在與你討論一些以舊換新的動態。總的來說，我認為我們感覺它相當穩定。

On the second piece of what will competitive advertising and conversation do, from time to time, we see delay deals. We definitely see increasing conversations as they get closer to market with what they want to do, where other companies are starting to get some clearances in other regions. In general, our teams have handled that pretty well. But I think the noise level will increase. I think that customers are interested in listening to other pitches. I think we're pretty well positioned to have a conversation about that. But I do see delay from time to time. It kind of comes in waves, and then it'll settle as the world figures out kind of what they're offering.

在競爭性廣告和對話的第二個方面，我們不時看到延遲交易。隨著他們想要做的事情越來越接近市場，我們肯定會看到越來越多的對話，其他公司也開始在其他地區獲得一些許可。總的來說，我們的團隊處理得很好。但我認為噪音水平會增加。我認為客戶有興趣聽其他音調。我認為我們已經做好了就此進行對話的準備。但我確實不時看到延遲。它有點像一波又一波，然後隨著世界弄清楚他們提供的東西，它就會安定下來。

But Marshall, maybe a little bit on -- a little more quantitative answer than that.

但是馬歇爾，也許有點——比這更定量的答案。

Yes. First, the capital environment has been approximately the same. There haven't been much in terms of change in motives and so forth over the last several quarters. The number of systems that we placed in the U.S., which is disclosed in the web -- website is what is healthy in our view. In fact, what you -- the other way we measure how healthy we're -- how well we're doing is the utilization of systems. And utilization of systems growth, as I said, was 6%, which is consistent with where it's been.

是的。首先，資本環境大致相同。在過去幾個季度中，動機等方面的變化不大。我們在美國放置的系統數量，在網絡上披露——我們認為網站是健康的。事實上，你——我們衡量我們有多健康的另一種方式——我們做得有多好是系統的利用率。正如我所說，系統利用率增長了 6%，這與以前的情況一致。

And in Europe, we saw, as I said, maybe flattish number of systems placed both in the quarter as well as compared to the previous year in total. And just be aware of averages. And it's going to be lumpy. When you're in earlier stages of adoption in less mature markets, you're going to see a lumpiness to placements of capital. When we look at the 4 largest markets, we saw nice growth, which, again, as Calvin commented, procedure growth in Germany was strong, and we saw nice placements in Germany, for example. That help?

正如我所說，在歐洲，我們看到本季度以及與上一年相比，安裝的系統數量可能持平。只需注意平均值。而且會很粗糙。當您在不太成熟的市場中處於採用的早期階段時，您會看到資本配置的混亂。當我們查看 4 個最大的市場時，我們看到了不錯的增長，正如 Calvin 所說，德國的程序增長強勁，例如，我們在德國看到了不錯的安置。這種幫助？

Our next question will come from the line of Tycho Peterson with JPMorgan.

我們的下一個問題將來自摩根大通的 Tycho Peterson。

I'll start with SP. Just curious, following your discussions with FDA, any color you can provide on just when the trial is going to start, the size and what's expected for follow-up analysis? And then outside the U.S., you're obviously generating data on SP and thoracic and OSA in Korea. Can you just talk about some of the data generations outside the U.S. as well?

我將從SP開始。只是好奇，在您與 FDA 討論之後，您可以在試驗開始時提供任何顏色、大小以及後續分析的預期內容？然後在美國之外，您顯然正在生成韓國的 SP 和胸椎和 OSA 數據。您能否也談談美國以外的一些數據生成？

Sure. On the first one, I think we're settling in on what the trial will look like, and I'm not ready yet to answer that, but I think we're getting close. So in future quarters, we should be able to answer that question.

當然。在第一個問題上，我認為我們正在確定審判的樣子，我還沒有準備好回答這個問題，但我認為我們已經接近了。因此，在未來幾個季度，我們應該能夠回答這個問題。

With regard to what we're seeing elsewhere, we're starting to see, in terms of Korea, where we have more regulatory room and clinical indications, we'll start seeing a whole series of publications coming out talking about where there's opportunity. And it's, I think, going to be quite interesting and shows real potential for us. It's the thing that drives our underlying commitment and excitement. I don't have them at the tip of my fingers. I do know that in future quarters, we will start describing to you what the substance of some of these publications are as they start to release.

關於我們在其他地方看到的情況，我們開始看到，在韓國，我們有更多的監管空間和臨床適應症，我們將開始看到一系列出版物談論哪裡有機會。我認為，這將非常有趣，並為我們展示出真正的潛力。這是驅動我們潛在的承諾和興奮的東西。我沒有他們在我的指尖。我確實知道，在未來幾個季度，我們將開始向您描述其中一些出版物開始發佈時的內容。

And then just sticking with the pipeline for a minute. Can you just comment on IRIS, where we are in the rollout? It's obviously early days. And then also, if you could just comment separately on the Schölly endoscope acquisition. And have you worked the supply chain headwinds there?

然後只是堅持管道一分鐘。您能否評論一下 IRIS，我們在哪裡推出？這顯然是早期的。然後，如果您可以單獨評論 Schölly 內窺鏡採集。你有沒有在那裡應對供應鏈的逆風？

Great. I will do so. IRIS, first couple of accounts up and running. We expect more this quarter. It's really testing the whole order-to-delivery pipeline. Think of that as a digital pipeline that has to go through. Feedback is really encouraging. So this early part -- it's one of these things that's easy to describe, but to do well is hard, making sure all your cloud connections are right, making sure you have all your security protocols done, getting the turnaround times right, getting all your machine learning algorithms right. Feedback has been really good about its ability to help surgeons visualize pre-case, which is fantastic, use in other kinds of ways in terms of patient consultation and then access during the case. So the kind of the core idea, I think, is being vetted nicely. We have said before, we don't think it's a significant revenue driver in 2020. I think I would encourage people to think about this as baseline core technology, the kinds of things that as you develop systems like this in the future, that customers will come to expect, a little bit like our Firefly product. It is additive in the way that it's -- the system itself becomes greater than the sum of its parts. So IRIS, I think, looks quite strong.

偉大的。我會照辦的。 IRIS，前幾個帳戶啟動並運行。我們預計本季度會更多。它實際上是在測試整個訂單到交付的管道。將其視為必須通過的數字管道。反饋確實令人鼓舞。所以這個早期部分——這是很容易描述的事情之一，但要做好是很難的，確保你所有的雲連接都是正確的，確保你已經完成了所有的安全協議，得到正確的周轉時間，得到所有你的機器學習算法是對的。關於它幫助外科醫生可視化病例前的能力的反饋非常好，這太棒了，在患者諮詢方面以其他方式使用，然後在病例期間訪問。因此，我認為，這種核心理念正在得到很好的審查。我們之前說過，我們不認為它是 2020 年的重要收入驅動因素。我想我會鼓勵人們將其視為基準核心技術，當你在未來開發這樣的系統時，客戶會來期待，有點像我們的螢火蟲產品。它的方式是相加的——系統本身變得大於其各部分的總和。所以 IRIS，我認為，看起來很強大。

On the Schölly acquisition, the team's doing a really nice job. We were right to bring it in. We were right to bring it in when we did. That is doing a couple of things for us. It's giving us a little more alignment around next-gen products, which is exciting for us. It's helping us double down on some investments in terms of capacity and efficiency that goes with that capacity. And it will, in the medium term, start releasing some profitability and financing with regard to the way we produce our endoscopes that can be turned around and reinvested in the business.

在收購 Schölly 時，團隊做得非常好。我們把它帶進來是對的。我們把它帶進來是對的。這為我們做了幾件事。它讓我們對下一代產品有了更多的了解，這對我們來說是令人興奮的。它幫助我們在與該容量相關的容量和效率方面加倍投資。從中期來看，它將開始釋放一些關於我們生產內窺鏡方式的盈利能力和融資，這些內窺鏡可以扭轉並再投資於業務。

So, so far, so good. It is real work. They are a very good team. I think we knew what we were bringing in and acquiring. I'm really pleased with the leadership of the group and our team members that have joined us in Germany and in Boston or in Massachusetts. It's not to say there isn't work to be done, but so far, so good.

所以，到目前為止，一切都很好。這是真正的工作。他們是一個非常好的團隊。我想我們知道我們引進和獲得了什麼。我對團隊的領導以及我們在德國、波士頓或馬薩諸塞州加入我們的團隊成員感到非常滿意。這並不是說沒有工作要做，但到目前為止，一切都很好。

Okay. And then one just last clarification for Marshall. You called out a China pull-forward dynamic around the tariff. Can you just -- in the context of the 39 systems, are you able to quantify how much of that was tied to the tariff?

好的。然後是馬歇爾的最後一個澄清。你提出了圍繞關稅的中國前行動態。您能否 - 在 39 個系統的背景下，您能否量化其中有多少與關稅有關？

Well, not -- I can't quantify specifically. I would just tell you that there were a number of systems that the customers decided to expedite the process, and we were the beneficiary of that, obviously.

嗯，不是——我無法具體量化。我只想告訴你，有許多系統是客戶決定加快流程的，顯然我們是其中的受益者。

Our next question will come from the line of Bob Hopkins with Bank of America.

我們的下一個問題將來自美國銀行的 Bob Hopkins。

Just a first quick question on the I&A revenue per case. You highlighted some (inaudible) tailwind, potential headwinds that called out that revenue per case could decline next year.

只是關於每個案例的 I&A 收入的第一個快速問題。你強調了一些（聽不清）順風，潛在的逆風，表明每件案件的收入可能會在明年下降。

Bob, we heard -- you got kind of broken -- yes, kind of broken up on the call. So could you reask the question?

Bob，我們聽說——你有點崩潰——是的，在通話中有點崩潰。那你能再問一下嗎？

Sorry about that. Just on Instrument (inaudible). I just want to make sure I hear the messaging because there's some positives in this. I probably thought it could decline. (inaudible) stapling. I just want to sure the messaging on the I&A line for the next 12 months.

對於那個很抱歉。只是在儀器上（聽不清）。我只是想確保我聽到了消息，因為這有一些積極的一面。我可能認為它可能會下降。 （聽不清）裝訂。我只想確定未來 12 個月 I&A 線上的消息傳遞。

Yes. So what I said, Bob, was we've really seen good contribution to I&A revenue overall from benign procedures. But as we've described before, the increase in the I&A per procedure is really a reflection of additional advanced instrument revenue and then a per procedure offset by benign procedure growth. So all I'm calling out is if we're successful in growing benign procedures much faster than complex procedures, then you will see -- then it will win the tug-of-war, and therefore, your I&A per procedure might decline.

是的。所以我說的是，鮑勃，我們真的看到良性程序對整體 I&A 收入的貢獻很大。但正如我們之前所描述的，每個程序 I&A 的增加實際上反映了額外的先進儀器收入，然後每個程序被良性程序增長所抵消。所以我要說的是，如果我們成功地發展良性程序比複雜程序快得多，那麼你會看到——然後它將贏得拔河比賽，因此，你每個程序的 I&A 可能會下降。

On the advanced instruments, we've enjoyed further penetration into the procedures in which advanced instruments are used. And as that has occurred, then our revenue associated with procedures, our revenue per procedure has grown disproportionately to the number of procedures. Over time, as you penetrate that, then you will revert to your advanced technology growth, will be consistent with the number of additional procedures you add versus adding also incremental procedures that were previously not including it. So all we're saying is that there's the potential that the growth rate will decline. We still expect growth, just a lower rate.

在先進儀器上，我們對使用先進儀器的程序進行了進一步的滲透。當這種情況發生時，我們與程序相關的收入，我們每個程序的收入與程序數量不成比例地增長。隨著時間的推移，當您深入了解這一點時，您將恢復到您的先進技術增長，將與您添加的額外程序的數量保持一致，而不是添加以前不包括它的增量程序。所以我們要說的是，增長率有可能下降。我們仍然預計增長，只是較低的速度。

Okay. And then a quick question on U.S. capital. Over the last couple of years, the growth in procedures per average system has been remarkably consistent at about 5%, especially in the U.S. Is there a reason in your view why that number might change meaningfully in 2020? Or is that trend line expected to continue?

好的。然後是關於美國資本的快速問題。在過去的幾年裡，每個平均係統的程序增長非常穩定，約為 5%，尤其是在美國。您認為這個數字在 2020 年可能會發生有意義的變化有什麼原因嗎？還是該趨勢線有望繼續？

No. I think, directionally, continued growth in procedures per system is something we would expect. It's something that we're actively working with customers, sharing analytics and data to help them -- to make their practices programs as efficient as they can be. So I think the trend -- I don't know if it's going to continue in exactly the same rates, but increasing utilization is something we would expect.

不。我認為，從方向上講，每個系統的程序持續增長是我們所期望的。我們正在積極與客戶合作，共享分析和數據以幫助他們——使他們的實踐計劃盡可能高效。所以我認為這種趨勢——我不知道它是否會以完全相同的速度繼續下去，但增加利用率是我們所期望的。

Our next question will come from the line of Larry Biegelsen with Wells Fargo.

我們的下一個問題將來自富國銀行的拉里·比格爾森。

Hopefully, you guys can hear me okay. Just one on Ion and then one on the P&L. How should we think about the ramp of Ion in 2020? Is it still going to be a controlled launch? Should we just expect a steady increase in placements? And I had one follow-up.

希望你們能聽到我的聲音。只有一個在 Ion 上，然後一個在 P&L 上。我們應該如何看待 2020 年的 Ion 斜坡？它仍將是受控發射嗎？我們是否應該期望展示位置穩步增加？我有一個跟進。

As we've said in our prepared remarks, Ion is in the early stages of a measured launch. And so you should expect that it will grow slowly over time, slowly through 2020 and then more rapidly thereafter.

正如我們在準備好的評論中所說，Ion 正處於測量發射的早期階段。因此，您應該期望它會隨著時間的推移緩慢增長，到 2020 年緩慢增長，然後再快速增長。

I got it. And gross margins came in better than 2019 versus your original guidance. What are the puts and takes on the gross margin in 2020? And separately, Gary, R&D as a percent of sales has been increasing. Steadily, it's almost 10% of sales in 2019. Where do you see that going over time?

我得到了它。與您最初的指導相比，毛利率優於 2019 年。 2020年的毛利率是多少？另外，加里，研發佔銷售額的百分比一直在增加。穩定地，它幾乎佔 2019 年銷售額的 10%。你認為隨著時間的推移會發生什麼變化？

Sure. So for gross margins, the gives and takes are, as I outlined in my prepared remarks, pricing on systems, reductions in cost, manufacturing efficiency and mix, mix of both customers and types of product. And I think that what we're messaging for next year is that gross margins will decline slightly, reflecting primarily product mix and a shift -- the effect of new product and investments in the infrastructure.

當然。因此，對於毛利率，正如我在準備好的評論中概述的那樣，給予和索取是系統定價、成本降低、製造效率和組合、客戶和產品類型的組合。我認為我們明年要傳達的信息是毛利率將略有下降，主要反映產品組合和轉變——新產品和基礎設施投資的影響。

And R&D, Marshall, as a percent of sales? Maybe I'm just curious if you expect that to continue to increase. Sorry, Gary?

研發，馬歇爾，佔銷售額的百分比？也許我只是好奇你是否期望它繼續增加。對不起，加里？

Yes. No, I can jump in and take that one. I think about we have grown R&D as a percentage of sales pretty consistently over the last 3 years. And our messaging to you has been we're going to bring a couple of new platforms to market in parallel with some of our multiport efforts, SP and Ion being those two, that we think that next-gen imaging and nonoptical imaging is important, nonwhite light imaging is important, and we've been investing in that domain. We have been investing for scale. We've talked about the fact that I think there's a virtuous cycle here, which is as utilization goes up and volumes go up, it allows us to start taking advantage of automation opportunities and changing the way we manufacture that has taken the company to be a little more capital-intensive than in years past. But some of the things you were just talking about, the linkage to your prior question on gross margin, are enabled by these capital investments on multiyear time lines that allow us to get production scale advantages. And that allows us to share some of that cost savings with our customer and be able to be into lower complexity procedures at good economics and good economics for the company as well as the customer. So we've been doing that as well. And then lastly, it's been building in digital infrastructure.

是的。不，我可以跳進去拿走那個。我認為在過去 3 年中，我們的研發佔銷售額的百分比一直在增長。我們向您傳達的信息是，我們將在我們的一些多端口工作的同時將幾個新平台推向市場，SP 和 Ion 就是這兩個，我們認為下一代成像和非光學成像很重要，非白光成像很重要，我們一直在該領域進行投資。我們一直在投資規模。我們已經談到了這樣一個事實，即我認為這裡存在一個良性循環，即隨著利用率的提高和產量的增加，它使我們能夠開始利用自動化機會並改變我們的製造方式，這使公司成為與過去幾年相比，資本密集程度更高。但是你剛才談到的一些事情，與你之前關於毛利率的問題的聯繫，是由這些多年時間線上的資本投資實現的，這使我們能夠獲得生產規模優勢。這使我們能夠與我們的客戶分享一些節省的成本，並能夠以良好的經濟性和對公司以及客戶的良好經濟性進入較低複雜性的程序。所以我們也一直在這樣做。最後，它一直在建設數字基礎設施。

So those are the major buckets that have been taking the R&D spend side. I think we are not thinking that, that number will leap going forward, but we also think we're still in the early innings of a baseball game here that have real opportunity long term for growth of the market. And we think that we can position ourselves really well by making sure that those 4 buckets are adequately staffed.

因此，這些是一直在研發支出方面的主要部分。我認為我們不認為這個數字會向前飛躍，但我們也認為我們仍處於棒球比賽的早期階段，從長遠來看，市場增長的真正機會。我們認為，通過確保這 4 個桶配備充足的人員，我們可以很好地定位自己。

Our next question will come from the line of Rick Wise with Stifel.

我們的下一個問題將來自 Rick Wise 和 Stifel。

You talked -- Marshall mentioned it, I think Calvin mentioned that system trade-ins may slow, may trend down. I just want to make sure that I'm understanding the reasons why. Is it the lack of a major new next-gen system launch and so you've seen the trade-ins, "the easy trade-ins?" And maybe just as part of that, Gary, just reflecting back on R&D and innovation. Obviously, you're launching a lot of new products and innovation. But should we be thinking that you don't need to launch a next-gen big iron? Or how do we think about that, those 2 aspects of trade-ins and the pipeline?

你談到了——Marshall 提到了它，我認為 Calvin 提到系統以舊換新可能會放緩，可能會趨於下降。我只是想確保我理解其中的原因。是因為缺少一個重要的新的下一代系統發布，所以你已經看到了以舊換新，“簡單的以舊換新”？加里，也許只是其中的一部分，只是回顧了研發和創新。顯然，您正在推出許多新產品和創新。但是我們是否應該認為您不需要推出下一代大鐵桿？或者我們如何看待以舊換新和管道的這兩個方面？

So trade-ins, we've been in the middle of a fairly strong cycle of trade-ins, and you've seen it go up quarter-over-quarter, last 2 quarters kind of flattening out. And what we commented on at the end of the third quarter, Rick, was that the total population of Sis that are out there that can be traded in, obviously, is decreasing as customers trade in their systems. And so the population is decreasing. And when we look back at historical patterns for previous-generation products, we think that we're at the peak of how much of that remaining base will be traded in, in any particular quarter. And so the 2 of those things lead us to the conclusion that you'll see a decrease in the number of trade-ins as we go forward.

所以以舊換新，我們一直處於一個相當強勁的以舊換新周期的中間，你已經看到它環比增長，最後兩個季度趨於平緩。瑞克，我們在第三季度末評論的是，隨著客戶在他們的系統中進行交易，可以交易的 Sis 總人數顯然正在減少。所以人口在減少。當我們回顧上一代產品的歷史模式時，我們認為我們正處於任何特定季度剩餘基礎交易量的頂峰。因此，其中兩件事使我們得出結論，隨著我們的前進，您會看到以舊換新的數量減少。

The second half of the question, I might quibble with the description is big iron, so I'm not going to own that. But I will talk to innovation in multiport. We're not done innovating in multiport. We're often asked, are you -- I see SP, I see Ion. Is that it? And the answer is categorically no. We think there's room for additional innovation beyond our Gen 4 multiport products, and we're working on those things.

問題的後半部分，我可能會懷疑它的描述是大鐵，所以我不打算擁有它。但我會談談多端口的創新。我們還沒有完成多端口的創新。我們經常被問到，你是不是——我看到了 SP，我看到了 Ion。是這樣嗎？答案絕對是否定的。我們認為除了我們的第 4 代多端口產品之外，還有更多創新空間，我們正在努力解決這些問題。

And just 2 other quick ones. I'd be curious to hear more about sales force productivity. You highlighted, Gary, the improved productivity in the third quarter. It seems like that's part -- has to be part of the equation, I'm guessing, in the fourth quarter. How do we think about that factor as a driver in 2020?

還有另外兩個快速的。我很想知道更多關於銷售人員生產力的信息。加里，您強調了第三季度生產力的提高。這似乎是一部分 - 我猜，在第四季度必須成為等式的一部分。作為 2020 年的驅動因素，我們如何看待這個因素？

I'll just ask my second one. Your competitors -- or potential robotic competitors are talking about digital surgery. And we've talked about this before, but I just wonder if you have competitors marketing something called digital surgery. How do we imagine Intuitive answering that kind of a functional or marketing push?

我只會問我的第二個。您的競爭對手——或潛在的機器人競爭對手正在談論數字手術。我們之前已經討論過這個問題，但我只是想知道你是否有競爭對手在推銷一種叫做數字手術的東西。我們如何想像 Intuitive 回答這種功能或營銷推動？

Okay. On the first question, the sales force productivity, we saw a move in the right direction in the fourth quarter. Some of the underlying dynamics in terms of rapid procedure growth or healthy procedure growth driving the need for new territories still exists. So I credit our sales leadership team is doing a really nice job, both managing growth and helping the organization become more productive while thinking through territory opportunities as well as efficiency opportunities. That's a long way of saying we made a step in the right direction. I think they have opportunity to keep moving in the right direction in terms of productivity. So far, so good.

好的。關於第一個問題，銷售人員的生產力，我們看到第四季度朝著正確的方向發展。在快速程序增長或健康程序增長方面推動對新領域的需求的一些潛在動力仍然存在。因此，我認為我們的銷售領導團隊做得非常好，既管理增長，又幫助組織提高生產力，同時考慮區域機會和效率機會。可以說我們朝著正確的方向邁出了一大步。我認為他們有機會在生產力方面繼續朝著正確的方向前進。到現在為止還挺好。

With regard to some of the commentary around digital surgery, the short answer is welcome to the party. I think that we've been working these issues for more than a decade. As I said before, my initial response is it's a valuable thing to be working on, and that's why we've been doing it. We've been the Internet of Things in surgical robots for a decade, cloud-enabled for a decade. We are quite deep.

關於數字手術的一些評論，歡迎簡短回答。我認為我們已經處理這些問題十多年了。正如我之前所說，我最初的反應是，這是一件很有價值的事情，這就是我們一直在做的原因。十年來，我們一直是手術機器人中的物聯網，十年來支持雲。我們很深。

As you go out and talk a little more than the tagline, you talk about what taglines are, what's the substance? So dig down a little bit, and the substance comes down to, I think, 4 opportunities. One opportunity is in the use of big data for analytic power. And that says that as you look across large sets of customers doing various things, can you help establish benchmarks that people can improve upon? And we have done that. It's been something we've been working on. So I think we're becoming quite skilled and will become more so. That's 1 category.

當你走出去多談一些標語時，你會談論標語是什麼，內容是什麼？所以深入挖掘一下，我認為實質內容可以歸結為 4 個機會。一個機會是利用大數據進行分析。這就是說，當您查看做各種事情的大量客戶時，您能否幫助建立人們可以改進的基準？我們已經做到了。這是我們一直在努力的事情。所以我認為我們正在變得非常熟練，並且會變得更加熟練。那是1類。

Another category is the use of computing power in real time to aid the surgeon or interventionalist during a case to get a better outcome. And absolutely interesting, there are many, many companies in the world that are thinking about that and making progress, and we are one of them. Ion is fundamentally powered by computing to help you make good decisions. IRIS is fundamentally a real-time computing capability in addition to big data. So that's one.

另一類是實時使用計算能力來幫助外科醫生或介入醫生在病例中獲得更好的結果。絕對有趣的是，世界上有很多很多公司正在考慮這一點並取得進展，我們就是其中之一。 Ion 從根本上由計算提供支持，以幫助您做出正確的決定。 IRIS本質上是大數據之外的實時計算能力。所以這是一個。

The next bucket is around education and the reduction of variation team to team. We know that care team variation in any acute intervention, be it surgery, robotic surgery, laparoscopy, is highly variable. And the use of computing and analytics to help that process is clear. And I talked to you a little bit about how much we have in simulation, 200,000 simulated tasks done by surgeons this last year, 17,000 hours of simulation capability. These are things that we can help turn into better learning environments and reduction in care team variation.

下一個桶是圍繞教育和減少團隊之間的差異。我們知道，任何急性干預（無論是手術、機器人手術、腹腔鏡檢查）中的護理團隊變化都是高度可變的。使用計算和分析來幫助這個過程是很清楚的。我和你談了一點，我們在模擬方面有多少，去年外科醫生完成了 200,000 個模擬任務，17,000 小時的模擬能力。這些是我們可以幫助轉變為更好的學習環境和減少護理團隊差異的事情。

And the last bucket is efficiency improvement. The use of computing technologies and networking to help hospitals become more productive and to help our company become more productive, and we're leveraging those opportunities on both to help our customers and otherwise.

最後一個桶是效率提升。使用計算技術和網絡來幫助醫院提高生產力並幫助我們的公司提高生產力，我們正在利用這些機會來幫助我們的客戶和其他方面。

So I look forward to the conversation. I think it will win. The winner won't be the tagline. I think the winner will be those who deliver real value that's validated against those 4 categories.

所以我很期待談話。我認為它會贏。贏家不會是標語。我認為贏家將是那些提供經過這 4 個類別驗證的真正價值的人。

We'll take 1 more question, operator.

我們再回答 1 個問題，接線員。

Okay. The final question, one moment here. That final question will come from the line of Richard Newitter with SVB.

好的。最後一個問題，在這裡稍等片刻。最後一個問題將來自 SVB 的 Richard Newitter。

Just 2 quick ones. The first, I'll ask them both just right upfront. The first one, the comments on cholecystectomy as a training procedure and kind of what you're seeing there as a spillover to, again, [comfortable about] the general surgery. Are you seeing that same dynamic increase in the usage or the utilization within hernia as kind of like a training ground for other types of general surgeries? Or is hernia kind of also equally as sticky?

只有2個快速的。首先，我會提前問他們兩個。第一個，關於膽囊切除術作為一種培訓程序的評論，以及你所看到的那種對普通手術的溢出效應。您是否將疝氣的使用或利用的動態增加視為其他類型普通手術的訓練場？還是疝氣也同樣粘稠？

And then the second question, just Marshall, on the I&A per case. If the benign growth does accelerate relative to the advanced type cases, what's the impact to gross margin there?

然後是關於每個案例的 I&A 的第二個問題，只有 Marshall。如果良性增長確實相對於先進型案例加速，那麼對那裡的毛利率有什麼影響？

I'll take the first one. I'll let Marshall take the second one. One thing I would -- just to be clear, on general surgery is general surgery is quite a diverse set of procedures with quite a diverse set of practice patterns amongst general surgeon practitioners or practices. First of all, I think they choose procedures to do not simply to be trained because -- but because they think they and the patient can be benefited by that procedure. So I don't think they run off and train for the sake of training. I think they decide that there's some value here. They will sequence their way into a practice, and that would make sense, both by patient selection and by the type of procedure they do.

我會拿第一個。我會讓馬歇爾拿第二個。我想說的一件事是——明確地說，在普通外科手術中，普通外科手術是一套非常多樣化的程序，在普通外科醫生或實踐中具有非常多樣化的實踐模式。首先，我認為他們選擇的程序不僅僅是為了接受培訓，而是因為他們認為他們和患者可以從該程序中受益。所以我不認為他們為了訓練而跑去訓練。我認為他們認為這裡有一些價值。他們將按順序進入實踐，這將是有意義的，無論是根據患者選擇還是根據他們所做的程序類型。

You had asked, does the same kind of effect of, well, let's start with the right patient population for cholecystectomy also apply to something like hernia? The answer to that is yes. Some surgeons will elect to go into a hernia set first. Then if they find value in the product, find value in the process, they may like to move from there to a different procedure. Interestingly, we found that there's not a one-size-fits-all way that a practice adopts. They may choose a different entry point, depending on their interest and experiences.

你問過，好吧，讓我們從合適的膽囊切除術患者人群開始，同樣的效果是否也適用於疝氣等疾病？答案是肯定的。一些外科醫生會選擇先進入疝氣組。然後，如果他們在產品中發現價值，在過程中發現價值，他們可能希望從那裡轉移到不同的程序。有趣的是，我們發現實踐中沒有一種萬能的方法。他們可能會根據自己的興趣和經驗選擇不同的切入點。

Second question, Marshall?

第二個問題，馬歇爾？

I&A per case, if benign procedures were to grow faster than more complex procedures, it's a very slight improvement in gross margin. The advanced instruments have just a slightly lower gross margin than our other instruments.

每個案例的 I&A，如果良性程序比更複雜的程序增長得更快，那麼毛利率會有非常輕微的改善。先進儀器的毛利率略低於我們的其他儀器。

Okay. 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 our customers have termed their quadruple aim: better, more predictable patient outcomes, better patient experiences, better experiences for care teams and, ultimately, a lower total cost of care per patient episode. 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 the environment in which they operate.

好的。那是我們的最後一個問題。最後，我們相信從根本上改善手術和急性干預是一個巨大而持久的機會。我們的團隊繼續與醫院、醫生和護理團隊密切合作，以追求我們的客戶所稱的四重目標：更好、更可預測的患者結果、更好的患者體驗、更好的護理團隊體驗以及最終降低總護理成本每個患者發作。我們相信，手術和急症護理的價值創造從根本上說是人性化的。它源於對患者和護理團隊、他們的需求以及他們所處的運營環境的尊重和理解。

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

感謝您對這次非凡旅程的支持。我們期待在 3 個月後再次與您交談。

Okay, ladies and gentlemen, that does conclude today's conference. I want to thank you for your participation. You may now disconnect.

好的，女士們，先生們，今天的會議到此結束。我要感謝您的參與。您現在可以斷開連接。