直覺手術 (ISRG) 2021 Q3 法說會逐字稿

Ladies and gentlemen, thank you for standing by. Welcome to the Intuitive Q3 2021 Earnings Release Conference Call. (Operator Instructions) And as a reminder, this conference call is being recorded.

女士們，先生們，謝謝你們的支持。歡迎來到直觀的 2021 年第三季度收益發布電話會議。 （操作員說明）作為提醒，本次電話會議正在錄音中。

I would now like to turn the call over to your host, Senior Vice President of Finance, Jamie Samath. Please go ahead, sir.

我現在想將電話轉給您的主持人，財務高級副總裁 Jamie Samath。請繼續，先生。

Good afternoon, and welcome to Intuitive's third quarter earnings conference call. With me today, we have Gary Guthart, our CEO; Marshall Mohr, our CFO; and Brian King, our Treasurer.

下午好，歡迎參加 Intuitive 第三季度財報電話會議。今天和我在一起的是我們的首席執行官 Gary Guthart；我們的首席財務官 Marshall Mohr；和我們的財務主管布賴恩·金。

Before we begin, I would like to let you know that Philip Kim, our Head of Investor Relations for the last couple of years, has moved on to pursue his next opportunity. We appreciate his contributions and wish him well in his next endeavor. Joining us on the call today is Brian King, who has been our Treasurer for the last 7 years. Brian will be expanding his responsibilities to include the role of Head of Investor Relations.

在我們開始之前，我想讓您知道，過去幾年我們的投資者關係主管菲利普·金（Philip Kim）已經開始尋求他的下一個機會。我們感謝他的貢獻，並祝愿他在接下來的努力中一切順利。今天加入我們的電話會議是布萊恩·金，他在過去 7 年裡一直是我們的財務主管。布賴恩將擴大他的職責，包括投資者關係主管的角色。

Moving on, 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 our Securities and Exchange Commission filings, including our most recent Form 10-K filed on February 10, 2021 and Form 10-Q filed on July 21, 2021. 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.

接下來，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我們的證券交易委員會文件中有詳細描述，包括我們於 2021 年 2 月 10 日提交的最新 10-K 表格和 2021 年 7 月 21 日提交的 10-Q 表格。我們的 SEC 文件可通過我們的網站或 SEC 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. 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。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 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 financial results. I will discuss procedure and clinical highlights and provide an update of our financial outlook. 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三季度業績的亮點，然後是問答環節。 Gary 將介紹本季度的業務和運營亮點。 Marshall 將對我們的財務業績進行審查。我將討論程序和臨床亮點，並提供我們財務前景的更新。最後，我們將舉辦問答環節。

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. Our team performed well in the third quarter in the face of pandemic-related headwinds. The rise of the Delta variant and stresses in some hospitals pressured the demand for surgery. Global supply chain disruption has yet to abate, necessitating redirection of internal resources to continue to meet our customers' demand. Despite these challenges, growth in the use of our products continued in the quarter and capital demand remained robust. Our new platforms advanced in their commercialization, in their innovation and in their clinical programs.

感謝您今天加入我們。面對與大流行相關的不利因素，我們的團隊在第三季度表現良好。 Delta變體的興起和一些醫院的壓力對手術的需求造成壓力。全球供應鏈中斷尚未減弱，需要重新調整內部資源以繼續滿足客戶的需求。儘管存在這些挑戰，我們產品的使用在本季度繼續增長，資本需求依然強勁。我們的新平台在商業化、創新和臨床項目方面取得了進展。

Turning first to procedures. The increased COVID burden tempered the recovery we saw in the second quarter, particularly in the month of August. The impact of the Delta variant drove procedures in the United States below our expectations at the start of the quarter with run rate stabilizing the last couple of weeks of September.

先談程序。增加的 COVID 負擔緩和了我們在第二季度看到的複蘇，特別是在 8 月份。 Delta 變體的影響使美國的程序在本季度初低於我們的預期，運行率在 9 月的最後幾週穩定下來。

Adoption continues in the United States driven particularly by benign general surgery procedures, including bariatric surgery, cholecystectomy and hernia repair. Trends in malignant procedures remain solid, including prostatectomy, hysterectomy, lobectomy and colon resection.

美國繼續採用這種手術，尤其是在良性普通外科手術的推動下，包括減肥手術、膽囊切除術和疝修補術。惡性手術的趨勢依然穩固，包括前列腺切除術、子宮切除術、肺葉切除術和結腸切除術。

Two trends that have emerged over the past few years are the increased use of da Vinci in benign procedures and rising use of our advanced instrumentation in targeted procedures. Both are the result of focusing on our customers' needs and delivering product and economic solutions to match.

過去幾年出現的兩個趨勢是達芬奇在良性手術中的使用增加，以及我們的先進儀器在靶向手術中的使用增加。兩者都是關注客戶需求並提供匹配的產品和經濟解決方案的結果。

Outside the United States, procedure performance varied as a function of regional pandemic impact. In China, growth in the quarter was strong and spanned multiple specialties, reflecting continued adoption. In Japan and Korea, our procedure business remains healthy with slight sequential procedure growth Q2 to Q3 despite COVID-related surgery disruption. Germany, the U.K. and France had reasonable year-over-year procedure growth, and our customers are having success in diversifying procedure categories beyond urology.

在美國以外，程序性能隨地區大流行影響而變化。在中國，本季度增長強勁，跨越多個專業，反映了持續採用。在日本和韓國，儘管與 COVID 相關的手術中斷，我們的手術業務仍然保持健康，第二季度至第三季度的手術略有連續增長。德國、英國和法國的程序同比增長合理，我們的客戶在泌尿外科以外的程序類別多樣化方面取得了成功。

Regarding the capital environment, new system placements continue to be robust. The United States had an outstanding capital quarter with a balanced mix of hospitals new to da Vinci as well as healthy incremental placements for existing customers and trade-ins of older technology. This performance has been driven by collaboration with U.S. integrated delivery networks as they thoughtfully manage and expand the capacity of their da Vinci fleets. Elsewhere, China, Japan and Europe had solid placements in the quarter, and our placements in Brazil showed strength.

在資本環境方面，新系統配置繼續強勁。美國的資本季度表現出色，達芬奇的新醫院均衡組合，現有客戶的健康增量安置和舊技術的以舊換新。這一業績得益於與美國綜合交付網絡的合作，因為他們精心管理和擴大其達芬奇車隊的容量。在其他地方，中國、日本和歐洲在本季度的表現穩健，我們在巴西的表現也很強勁。

Turning to our newer platforms. Our single port system, da Vinci SP, had a solid quarter as we pursue additional indications. Placements of our flexible bronchoscopy platform, Ion, grew nicely sequentially Q2 to Q3, powered by continued strong customer experiences in the field.

轉向我們的新平台。我們的單端口系統 da Vinci SP 在我們追求更多適應症時表現穩健。在該領域持續強勁的客戶體驗的推動下，我們的柔性支氣管鏡檢查平台 Ion 在第二季度至第三季度連續增長良好。

Our finances were strong again this quarter, though they followed an unusual path. System strength and favorable system sales mix drove strong system revenue. Procedures grew at the low end of our expectations as a result of the Delta variant. Instrument and accessory revenue per procedure moved down modestly as benign procedures continue to make up more of the procedure mix and our extended use instrument program reaches equilibrium in the field.

本季度我們的財務狀況再次強勁，儘管它們走的是一條不同尋常的道路。系統實力和有利的系統銷售組合推動了強勁的系統收入。由於 Delta 變體，程序的增長低於我們的預期。隨著良性程序繼續構成更多程序組合併且我們的擴展使用儀器計劃在該領域達到平衡，每個程序的儀器和附件收入小幅下降。

Our spending grew sequentially and year-over-year as we continue to invest in expanding our new platforms and digital programs as well as build our go-to-market capabilities globally. Our expense growth was again modestly lower than planned, driven by some increase in time to fill open positions in a tight labor market, lower travel-related spending given the pandemic and some underspending in prototypes. We will continue to invest in programs that fulfill the mission and build the company.

隨著我們繼續投資於擴展我們的新平台和數字計劃以及在全球建立我們的上市能力，我們的支出環比和同比增長。我們的費用增長再次略低於計劃，原因是在勞動力市場緊張的情況下填補空缺職位的時間有所增加，由於大流行而導致與旅行相關的支出減少以及原型中的一些支出不足。我們將繼續投資於完成使命和建設公司的項目。

Turning to our innovation efforts. We develop and deploy technology-enabled solutions to support our customers' pursuit of the quadruple aim: better outcomes, better patient experiences, better care team experiences and lower total cost to treat per patient episode.

轉向我們的創新努力。我們開發和部署技術支持的解決方案，以支持我們的客戶追求四重目標：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總成本。

I'd like to take a moment to overview the clinical status of our programs. For our da Vinci system, there are now over 9.7 million lifetime procedures performed with over 28,000 peer-reviewed clinical publications. Da Vinci X and Xi now have over 70 representative clinical uses, allowing broad use across multiple clinical specialties, from urology, to gynecology, thoracic surgery, general surgery and transoral surgery.

我想花點時間來概述一下我們項目的臨床狀態。對於我們的達芬奇系統，現在有超過 970 萬次終生手術，超過 28,000 篇經過同行評審的臨床出版物。 Da Vinci X 和 Xi 現在有超過 70 種具有代表性的臨床用途，可廣泛用於多個臨床專科，從泌尿科到婦科、胸外科、普外科和經口外科。

Tens of thousands of surgeons routinely use our multiport systems. We continue to invest in our multiport products, instruments and services to further expand their capabilities and indications. Leading surgeons continue to work with us to pursue new learning with several prospective studies ongoing.

成千上萬的外科醫生經常使用我們的多端口系統。我們繼續投資於我們的多端口產品、儀器和服務，以進一步擴大其能力和適應症。領先的外科醫生繼續與我們合作，通過正在進行的幾項前瞻性研究來追求新的學習。

Our flexible bronchoscopy system, Ion, continues to build momentum clinically and commercially with several presentations and manuscripts updating Ion clinical progress at the 2021 CHEST conference this weekend. As described in yesterday's press release, early clinical trial results point to outstanding capability, allowing for definitive diagnosis of hard-to-reach lung lesions. Our teams are hard at work building our manufacturing and supply capabilities to meet rising demand.

我們的柔性支氣管鏡檢查系統 Ion 在本週末的 2021 CHEST 會議上通過幾份報告和手稿更新了 Ion 臨床進展，繼續在臨床和商業上建立勢頭。正如昨天的新聞稿中所述，早期臨床試驗結果表明其具有出色的能力，可以對難以觸及的肺部病變進行明確診斷。我們的團隊正在努力建設我們的製造和供應能力，以滿足不斷增長的需求。

Our single port system, SP, has a clinical database of 28 peer-reviewed clinical publications. There are currently several ongoing prospective studies for SP in Korea and the United States, including our IDE trial for colorectal indications. This quarter, we received FDA approval of our uniportal thoracic IDE. Broad SP adoption will be paced by additional regional and clinical clearances, which remain our focus for the SP program.

我們的單端口系統 SP 擁有一個包含 28 篇經過同行評審的臨床出版物的臨床數據庫。目前在韓國和美國正在進行幾項針對 SP 的前瞻性研究，包括我們針對結直腸適應症的 IDE 試驗。本季度，我們的單孔胸腔 IDE 獲得了 FDA 的批准。廣泛的 SP 採用將通過額外的區域和臨床許可來加快步伐，這仍然是我們對 SP 計劃的關注。

Our digital solutions provide data-driven insights to surgeons, operative services and hospital administration. From virtual reality training, to efficiency insights, to custom comparative outcomes analysis, these tools are now routinely employed by our customers and our teams to improve programs. Our analytics program supported thousands of customers in the quarter.

我們的數字解決方案為外科醫生、手術服務和醫院管理提供數據驅動的見解。從虛擬現實培訓到效率洞察，再到定制比較結果分析，我們的客戶和我們的團隊現在經常使用這些工具來改進項目。我們的分析計劃在本季度支持了數千名客戶。

Turning to machine learning. Our teams are at the leading edge of ML-based clinical science for surgery through our collaborations with leading academic centers, informing algorithmic and scientific discovery. Taken together, these programs allow our customers to quantify our collective impact on the quadruple aim, core to our mission.

轉向機器學習。通過與領先的學術中心合作，我們的團隊處於基於 ML 的外科臨床科學的前沿，為算法和科學發現提供信息。總之，這些計劃使我們的客戶能夠量化我們對四重目標的集體影響，這是我們使命的核心。

Before turning the time over to Marshall, today, we announced some changes in responsibilities of our senior executive team. These changes are the result of a structured process over the past few years, and they are driven by our need to support growth in our product lines, commercial reach, operations capabilities and business infrastructure as we scale to meet the global opportunity to advance minimally invasive care.

在將時間交給馬歇爾之前，今天，我們宣布了我們高級管理團隊職責的一些變化。這些變化是過去幾年結構化過程的結果，它們是由我們需要支持我們的產品線、商業範圍、運營能力和業務基礎設施的增長而推動的，因為我們要擴大規模以滿足推進微創技術的全球機遇關心。

Starting January 1, 2022, our Executive Vice President and Chief Business Officer, Dave Rosa, will take on an important new role of Executive Vice President and Chief Strategy and Growth Officer, leading our efforts to identify and realize long-term business opportunities, continuing to build the value of our integrated product offerings and ensuring our customers clearly understand the value of our ecosystem in creating successful minimally invasive programs.

從 2022 年 1 月 1 日起，我們的執行副總裁兼首席商務官 Dave Rosa 將擔任執行副總裁兼首席戰略與增長官這一重要的新角色，領導我們努力識別和實現長期業務機會，繼續建立我們集成產品的價值，並確保我們的客戶清楚地了解我們的生態系統在創建成功的微創程序方面的價值。

Henry Charlton, currently General Manager of the U.S. and Europe, will succeed Dave as Chief Commercial Officer, overseeing global commercial sales, regional marketing and commercial enablement. Also, Marshall Mohr will take on an important new position as Executive Vice President, Global Business Services, leading Intuitive's continued growth in information technology, enterprise process, data and systems and global facilities. Jamie Samath will succeed Marshall as Chief Financial Officer.

現任美國和歐洲總經理的 Henry Charlton 將接替 Dave 擔任首席商務官，負責監督全球商業銷售、區域營銷和商業支持。此外，Marshall Mohr 將擔任全球商業服務執行副總裁，領導 Intuitive 在信息技術、企業流程、數據和系統以及全球設施方面的持續增長。 Jamie Samath 將接替 Marshall 擔任首席財務官。

They are each outstanding proven leaders and will report to me. We expect them to spearhead our efforts to achieve our mission and continue to position Intuitive as first choice of our customers in a growing marketplace.

他們都是經過驗證的傑出領導者，將向我匯報。我們希望他們帶頭努力實現我們的使命，並繼續將 Intuitive 定位為我們客戶在不斷增長的市場中的首選。

I'll now turn the call over to Marshall, who will take you through our financial highlights in greater detail.

我現在將把電話轉給馬歇爾，他將帶您更詳細地了解我們的財務亮點。

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. The information in our earnings release and within our prepared remarks reflects the 3-for-1 stock split completed earlier in October.

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。我們的收益發布和我們準備好的評論中的信息反映了 10 月初完成的 3 比 1 股票分割。

Overall, third quarter procedures grew 20% year-over-year and reflected the impact of Delta variant resurgence. COVID also impacted third quarter 2020 procedures, making year-over-year comparisons complicated. In the U.S., procedures grew 16%, reflecting the impact the COVID resurgence had on hospital resources regionally.

總體而言，第三季度的程序同比增長 20%，反映了 Delta 變體復甦的影響。 COVID 還影響了 2020 年第三季度的程序，使同比比較變得複雜。在美國，手術量增長了 16%，反映了 COVID 死灰復燃對地區醫院資源的影響。

The impact of the resurgence was most pronounced in August and early September, and regionally, in the South and Southeast. Later in the quarter, as COVID cases began to slow, procedures began to recover. However, it is difficult to estimate the extent to which this resurgence or future resurgences will impact da Vinci procedures.

復甦的影響在 8 月和 9 月初以及在南部和東南部地區最為明顯。在本季度晚些時候，隨著 COVID 病例開始放緩，程序開始恢復。然而，很難估計這種死灰復燃或未來死灰復燃對達芬奇手術的影響程度。

Year-over-year OUS procedures grew 30%, with the impact of COVID varying regionally. In Europe, COVID had a greater impact in Italy and France and less in U.K. and Germany. While there continued to be COVID hotspots within some of our Asia Pacific markets, overall procedures in the region performed well. China growth in the third quarter continued to be far higher than other regions, primarily reflecting system installation growth over the past year.

OUS 程序同比增長 30%，COVID 的影響因地區而異。在歐洲，COVID 在意大利和法國的影響更大，而在英國和德國的影響較小。雖然我們的一些亞太市場繼續存在 COVID 熱點，但該地區的整體程序表現良好。中國第三季度的增長繼續遠高於其他地區，主要反映了過去一年的系統安裝增長。

Relative to the beginning of the pandemic, many hospitals are able to better manage increased COVID patient hospitalization. However, staffing shortages and hospital supply chain issues are challenging some hospital capacities and could impact deferrable procedures, including da Vinci procedures going forward. Jamie will provide additional procedure commentary later in this call.

相對於大流行的開始，許多醫院能夠更好地管理增加的 COVID 患者住院治療。然而，人員短缺和醫院供應鏈問題正在挑戰一些醫院的能力，並可能影響可延期的程序，包括未來的達芬奇程序。 Jamie 將在本次電話會議稍後提供額外的程序評論。

Key business metrics for the third quarter were as follows: third quarter 2021 procedures increased approximately 20% compared with third quarter 2020 and decreased approximately 3% compared with last quarter, compound annual growth between the second quarters of 2019 and 2021 was 13.5%, third quarter system placements of 336 systems increased 72% compared with 195 systems for the third quarter of 2020 and increased 2% compared with 328 systems last quarter. We expanded our installed base of da Vinci systems over the last year by 11% to approximately 6,525 systems. This growth rate compares with 8% last year and 10% last quarter.

第三季度的主要業務指標如下：2021年第三季度程序與2020年第三季度相比增加約20%，與上季度相比減少約3%，2019年第二季度至2021年第二季度的複合年增長率為13.5%，第三季度與 2020 年第三季度的 195 個系統相比，336 個系統的季度系統佈局增加了 72%，與上一季度的 328 個系統相比增加了 2%。去年，我們將達芬奇系統的安裝基礎擴大了 11%，達到約 6,525 個系統。這一增長率與去年的 8% 和上一季度的 10% 相比。

Utilization of clinical systems in the field, measured by procedures per system, increased approximately 9% compared with last year and decreased 6% compared with last quarter. The compounded annual utilization growth rate between the third quarters of 2019 and 2021 was 3%.

以每個系統的程序衡量，該領域臨床系統的利用率與去年相比增加了約 9%，與上一季度相比下降了 6%。 2019 年第三季度至 2021 年第三季度的複合年利用率增長率為 3%。

Moving on to capital placement. System placements in the quarter reflected a continued trend of IDN multisystem purchases and were driven by procedure growth and hospitals upgrading in order to access or standardize on fourth-generation capabilities. Looking forward, we see the following capital revenue dynamics. Procedure growth drives capital purchases in many of our markets. To the extent that COVID impacts procedures, it will also impact capital purchases.

繼續進行資本配置。本季度的系統佈局反映了 IDN 多系統購買的持續趨勢，並受到程序增長和醫院升級的推動，以訪問或標準化第四代功能。展望未來，我們將看到以下資本收入動態。程序增長推動了我們許多市場的資本購買。就 COVID 影響程序而言，它也會影響資本購買。

The trade-in cycle has been a tailwind to system placements. However, as the installed base of older generation product declines, the number of trade-ins will decline over time. Leasing and alternative financing arrangements enable customer access to our systems. While the percentage of systems placed under operating leases fluctuates quarter-to-quarter, we believe leasing will increase as a percentage of sales over time, which will result in the deferral of otherwise current revenue into future periods. Macroeconomic conditions created by COVID could regionally impact hospital capital spending. And as competition progresses in various markets, we will likely experience longer selling cycles and price pressures.

以舊換新周期一直是系統佈局的順風車。然而，隨著老一代產品安裝基數的下降，以舊換新的數量將隨著時間的推移而下降。租賃和替代融資安排使客戶能夠訪問我們的系統。雖然根據經營租賃放置的系統的百分比逐季波動，但我們認為隨著時間的推移，租賃佔銷售額的百分比將增加，這將導致當前收入推遲到未來期間。 COVID 創造的宏觀經濟條件可能會在區域內影響醫院的資本支出。隨著各個市場競爭的加劇，我們可能會經歷更長的銷售週期和價格壓力。

Additional revenue statistics and trends are as follows: Third quarter revenue was $1.4 billion, representing a 30% increase from last year and a 4% decrease from the last quarter. The compound annual revenue growth rate between the third quarters of 2019 and 2021 was 12%. The year-over-year revenue increase reflected growth in both procedures and system placements. The decrease relative to the second quarter of 2021 reflects lower instrument and accessory revenue associated with lower procedures and increased leasing as a percentage of placements.

其他收入統計和趨勢如下： 第三季度收入為 14 億美元，比去年增長 30%，比上一季度下降 4%。 2019年第三季度至2021年第三季度的年收入複合增長率為12%。收入同比增長反映了程序和系統佈局的增長。相對於 2021 年第二季度的減少反映了與減少程序相關的儀器和配件收入減少以及租賃佔安置百分比的增加。

Leasing represented 41% of current quarter placements compared with 35% last year and 33% last quarter. Leasing as a percentage of total sales has and will continue to fluctuate with customer and geographic mix. However, we anticipate more customers will seek leasing or alternative financing arrangements than reflected in historical run rates.

租賃佔當前季度安置的 41%，而去年為 35%，上季度為 33%。租賃佔總銷售額的百分比已經並將繼續隨著客戶和地域組合而波動。然而，我們預計更多的客戶將尋求租賃或替代融資安排，而不是歷史運行率所反映的。

40% of systems placed in the third quarter involved trade-ins, which is consistent with the 40% last year and higher than the 38% last quarter. As customers continue to upgrade to fourth-generation capabilities, the population of installed Sis is decreasing, particularly in U.S., where 97 trade-ins were completed in the third quarter, leaving an installed base of Sis of approximately 425 systems. As a result, we expect lower trade-out transactions over time. Trade-in activity can fluctuate and be difficult to predict.

第三季度放置的系統中有 40% 涉及以舊換新，這與去年的 40% 一致，高於上一季度的 38%。隨著客戶繼續升級到第四代功能，已安裝 Sis 的數量正在減少，特別是在美國，第三季度完成了 97 次以舊換新，留下大約 425 個系統的安裝基數。因此，我們預計隨著時間的推移，交易量減少。以舊換新活動可能會波動且難以預測。

Third quarter average selling prices increased to $1.57 million from $1.55 million for both the third quarter of 2020 and the second quarter of 2021. Average selling prices will fluctuate with geographic and product mix. Consistent with historical patterns, we expect a higher mix of systems sold to distributors in the fourth quarter which carry lower prices.

第三季度平均售價從 2020 年第三季度和 2021 年第二季度的 155 萬美元增加到 157 萬美元。平均售價將隨地域和產品組合而波動。與歷史模式一致，我們預計第四季度銷售給分銷商的系統組合會更高，價格更低。

We recognized $25 million of lease buyout revenue in the third quarter compared with $17 million last year and $26 million last quarter. Lease buyout revenue has varied significantly quarter-to-quarter and will likely continue to do so. Instrument and accessory revenue per procedure of $1,900 decreased slightly compared with $1,910 per procedure for the third quarter of last year and decreased compared with $1,940 per procedure in the second quarter. The year-over-year change reflects increased usage of extended use instruments, mostly offset by increased usage of our advanced instruments. The decrease from the previous quarter reflects customers continuing to adjust their instrument buying patterns to reflect the additional uses per instrument included in extended use instruments.

我們在第三季度確認了 2500 萬美元的租賃收購收入，而去年同期為 1700 萬美元，上一季度為 2600 萬美元。租賃收購收入在每個季度之間變化很大，並且可能會繼續如此。每項手術的儀器和附件收入為 1,900 美元，與去年第三季度每項程序的 1,910 美元相比略有下降，與第二季度的每項程序 1,940 美元相比有所下降。同比變化反映了延長使用儀器的使用增加，大部分被我們先進儀器的使用增加所抵消。與上一季度相比的下降反映了客戶繼續調整他們的儀器購買模式，以反映擴展使用儀器中包含的每台儀器的額外用途。

10 of the systems placed in the third quarter were SP systems. Our installed base of SP systems is now 89, 10 in Korea and 79 in the U.S. We continue our measured rollout of SP as we work on gathering clinical data to gain additional procedure clearances in the U.S.

第三季度放置的系統中有 10 個是 SP 系統。我們的 SP 系統安裝基礎現在是 89 個，韓國有 10 個，美國有 79 個。我們繼續有計劃地推出 SP，因為我們致力於收集臨床數據以在美國獲得額外的程序許可。

We placed 28 Ion systems in the quarter, bringing the installed base to 98 systems. There were approximately 2,000 Ion procedures completed in the third quarter. Ion system placements and procedures are excluded from our overall da Vinci system and procedure counts. Our rollout of Ion is progressing well.

我們在本季度安裝了 28 個 Ion 系統，使安裝基礎達到 98 個系統。第三季度完成了大約 2,000 次 Ion 程序。離子系統放置和程序不包括在我們的整體達芬奇系統和程序計數中。我們對 Ion 的推出進展順利。

Outside the U.S., we placed 109 systems in the third quarter compared with 79 in the third quarter of 2020 and 115 systems last quarter. Current quarter system placements included 47 into Europe, 20 into Japan and 17 into China compared with 39 into Europe, 15 into Japan and 12 into China in the third quarter of 2020. We also placed 9 systems in Brazil in the third quarter and now have placed 23 systems in Brazil over the past 4 quarters.

在美國以外，我們在第三季度放置了 109 個系統，而 2020 年第三季度為 79 個，上一季度為 115 個。當前季度的系統佈局包括 47 個進入歐洲、20 個進入日本和 17 個進入中國，而 2020 年第三季度有 39 個進入歐洲、15 個進入日本和 12 個進入中國。我們還在第三季度在巴西放置了 9 個系統，現在有過去 4 個季度在巴西安裝了 23 個系統。

Moving on to gross margin and operating expenses. Pro forma gross margin for the third quarter of 2021 was 71.3% compared with 70.2% for the third quarter of 2020 and 71.7% last quarter. The third quarter of 2020 included $23 million of service credits issued in conjunction with our Customer Relief Program, higher period costs associated with lower production levels and higher excess and obsolete inventory charges.

繼續討論毛利率和運營費用。 2021 年第三季度的備考毛利率為 71.3%，而 2020 年第三季度為 70.2%，上一季度為 71.7%。 2020 年第三季度包括與我們的客戶救濟計劃一起發放的 2300 萬美元的服務信貸、與較低生產水平相關的較高期間成本以及較高的過剩和過時庫存費用。

The decline in gross margin relative to the second quarter primarily reflects product mix. Product and customer mix fluctuate quarter-to-quarter, which can cause fluctuations in gross margins.

毛利率相對第二季度的下降主要反映了產品組合。產品和客戶組合按季度波動，這可能導致毛利率波動。

COVID has impacted global supplies of semiconductors and other materials used in our products. While to date, we've been able to secure supply necessary to ensure fulfillment of customer demand, our teams are expending significant time and effort to bridge future supply with demand. To date, we have experienced immaterial component cost increases and freight expedition fees. However, global shortages could result in future supply disruption as well as delayed development and regulatory activities. We also expect supply issues to result in higher production costs.

COVID 影響了我們產品中使用的半導體和其他材料的全球供應。雖然迄今為止，我們已經能夠確保滿足客戶需求所需的供應，但我們的團隊正在花費大量時間和精力來彌合未來的供應與需求。迄今為止，我們經歷了無形的部件成本增加和貨運遠征費。然而，全球短缺可能導致未來供應中斷以及開發和監管活動延遲。我們還預計供應問題將導致更高的生產成本。

Pro forma operating expenses increased 21% compared with the third quarter of 2020 and increased 2% compared with last quarter. The increase compared to the prior year reflects costs associated with higher headcount, increased variable compensation and increased spending in areas impacted by COVID. Third quarter spending was below our expectations due to delays in headcount hiring and lower spending on activities restricted by COVID, including clinical development, marketing events and travel costs.

與 2020 年第三季度相比，備考運營費用增加了 21%，與上一季度相比增加了 2%。與上一年相比的增長反映了與員工人數增加、可變薪酬增加以及受 COVID 影響的地區支出增加相關的成本。第三季度的支出低於我們的預期，原因是員工招聘延遲以及 COVID 限制活動的支出減少，包括臨床開發、營銷活動和差旅費用。

In addition, COVID delayed some R&D work resulting in underspend on prototypes. We expect spending on activities restricted by COVID to increase as the impacts of the pandemic decline. We also expect spending to increase as a percentage of revenue as investments in headcount, infrastructure and other support areas catch up to the growth of the business. Finally, we expect to continue to invest in expanding and accelerating our ecosystem of products and capabilities. Jamie will provide spend guidance later in this call.

此外，COVID 推遲了一些研發工作，導致原型支出不足。我們預計，隨著大流行的影響下降，在受 COVID 限制的活動上的支出將會增加。我們還預計，隨著對員工人數、基礎設施和其他支持領域的投資趕上業務增長，支出佔收入的百分比將增加。最後，我們希望繼續投資於擴大和加速我們的產品和能力生態系統。 Jamie 將在本次電話會議稍後提供支出指導。

Our pro forma effective tax rate for the third quarter was approximately 24%. We recorded expense of $11 million associated with periods prior to 2020 related to guidance recently provided by the IRS associated with stock-based compensation. We expect our pro forma tax rate for the fourth quarter to be approximately 21.5%. Our actual tax rate will fluctuate with changes in geographic mix of income, changes in taxation made by local authorities and with the impact of onetime items.

我們第三季度的備考有效稅率約為 24%。我們記錄了與 2020 年之前的時期相關的 1100 萬美元的費用，這些費用與美國國稅局最近提供的與股票薪酬相關的指導有關。我們預計第四季度的備考稅率約為 21.5%。我們的實際稅率將隨著收入地域組合的變化、地方當局的稅收變化以及一次性項目的影響而波動。

Our third quarter pro forma net income was $435 million or $1.19 per share compared with $334 million or $0.92 per share for the third quarter of 2020 and $477 million or $1.31 per share for the last quarter. Third quarter 2021 and 2020 included pretax gains of approximately $8 million and $62 million associated with investments in companies that resulted from development agreements entered into in prior years.

我們第三季度的備考淨收入為 4.35 億美元或每股 1.19 美元，而 2020 年第三季度為 3.34 億美元或每股 0.92 美元，上一季度為 4.77 億美元或每股 1.31 美元。 2021 年和 2020 年第三季度包括約 800 萬美元和 6200 萬美元的稅前收益，這些收益與前幾年簽訂的開發協議所產生的對公司的投資相關。

I will now summarize our GAAP results. GAAP net income was $381 million or $1.04 per share for the third quarter of 2021 compared with GAAP net income of $314 million or $0.87 per share for the third quarter of 2020, and GAAP net income of $517 million or $1.42 per share for last quarter.

我現在將總結我們的 GAAP 結果。 2021 年第三季度 GAAP 淨收入為 3.81 億美元或每股 1.04 美元，而 2020 年第三季度 GAAP 淨收入為 3.14 億美元或每股 0.87 美元，上一季度 GAAP 淨收入為 5.17 億美元或每股 1.42 美元。

We ended the quarter with cash and investments of $8.2 billion compared with $7.7 billion last quarter. The increase in cash in the third quarter primarily reflected cash from operations and stock exercises. We did not repurchase any shares in the quarter.

我們在本季度末的現金和投資為 82 億美元，而上一季度為 77 億美元。第三季度現金的增加主要反映了來自運營和股票行權的現金。我們在本季度沒有回購任何股票。

And with that, I'd like to turn it over to Jamie.

有了這個，我想把它交給傑米。

Thank you, Marshall.

謝謝你，馬歇爾。

Our overall third quarter procedure growth was approximately 20% compared to growth of 7% during the third quarter of 2020. Q3 procedure growth reflected 16% growth in U.S. procedures and 30% growth in OUS markets. In the U.S., procedures in Q3 were adversely impacted by an increase in COVID-related hospitalizations due to the Delta variant. Procedures were particularly impacted in those states with relatively lower vaccination rates.

我們第三季度的整體程序增長約為 20%，而 2020 年第三季度的增長率為 7%。第三季度的程序增長反映了美國程序增長 16% 和 OUS 市場增長 30%。在美國，由於 Delta 變體，與 COVID 相關的住院人數增加，對第三季度的程序產生了不利影響。在疫苗接種率相對較低的州，程序尤其受到影響。

As the number of COVID-related hospitalizations peaked and began to improve in September, we saw U.S. procedures start to recover. Q3 growth reflected relative strength in bariatrics procedures, cholecystectomy and hernia repair. In the more mature procedure categories, year-over-year growth in prostatectomy was strong relative to historical averages and benign hysterectomy grew in the low single-digit range.

隨著與 COVID 相關的住院人數在 9 月達到頂峰並開始改善，我們看到美國的手術開始恢復。第三季度的增長反映了減肥手術、膽囊切除術和疝修補術的相對強度。在更成熟的手術類別中，相對於歷史平均水平，前列腺切除術的同比增長強勁，而良性子宮切除術在低個位數範圍內增長。

Third quarter OUS procedure volume grew approximately 30% compared with 9% growth for the third quarter of 2020. Third quarter 2021 OUS procedures were driven by growth in prostatectomy and earlier stage growth in general surgery, gynecology, kidney cancer procedures and thoracic surgery. China procedure growth remained strong and broad-based as a result of continued expansion of the installed base under the current quota and the addition and training of surgeons new to the da Vinci platform.

與 2020 年第三季度的 9% 增長相比，第三季度 OUS 手術量增長了約 30%。2021 年第三季度 OUS 手術受到前列腺切除術的增長以及普通外科、婦科、腎癌手術和胸外科的早期增長的推動。由於在當前配額下安裝基礎的持續擴大以及對達芬奇平台的新外科醫生的增加和培訓，中國的手術增長保持強勁和廣泛的基礎。

Growth in Japan was solid but was impacted by localized lockdowns stemming from ongoing efforts to prevent resurgences of COVID. Growth in Korea was also solid, primarily driven by gynecology, urology and head and neck procedures. A little more than half of the procedures in these 3 key Asian markets are outside of urology.

日本的增長穩健，但受到持續努力防止 COVID 死灰復燃的局部封鎖的影響。韓國的增長也很穩健，主要受婦科、泌尿科和頭頸部手術的推動。在這 3 個主要亞洲市場中，有一半以上的手術不在泌尿科範圍內。

In Europe, procedure growth varied by country based on the relative impact of the Delta variant and the impact of COVID-related mitigation measures. Growth in the U.K. and Germany was solid with procedure growth in France and Italy impacted by reduced capacity for surgery as hospitals reserved resources for potential increases in COVID patients.

在歐洲，根據 Delta 變體的相對影響和 COVID 相關緩解措施的影響，程序增長因國家/地區而異。英國和德國的增長穩健，法國和意大利的手術增長受到手術能力下降的影響，因為醫院為 COVID 患者的潛在增加預留了資源。

During Q3, customers in the U.S. and Europe effectively consumed their remaining inventory of 10-life instruments following the launch of extended use instruments in those regions in Q4 of last year. With this full adoption in the U.S., customers are benefiting from I&A per procedure costs that are reduced by approximately 10% in lower acuity procedures such as cholecystectomy and hernia repair. In Europe, customers are benefiting from an even larger reduction in I&A costs for targeted procedures.

在第三季度，美國和歐洲的客戶在去年第四季度在這些地區推出延長使用儀器後，有效地消耗了他們剩餘的 10 壽命儀器庫存。隨著在美國的全面採用，客戶受益於每次手術的 I&A 成本，在膽囊切除術和疝修補術等低敏銳度手術中降低了約 10%。在歐洲，客戶正在受益於目標程序的 I&A 成本的更大降低。

While recent procedure trends are confounded by the various waves of the pandemic, we believe, based on customer feedback, the adoption of extended use instruments is having a positive impact on targeted procedures. In our new platform, Ion procedures increased almost fourfold as compared to Q3 of 2020, driven by a significant expansion of the number of systems at customers and an increase in usage in the existing installed base. Our single port platform, which is gated by additional regional and clinical clearances showed solid performance with almost 50% year-over-year procedure growth.

儘管最近的程序趨勢受到各種流行病浪潮的影響，但我們認為，根據客戶的反饋，採用擴展使用工具正在對目標程序產生積極影響。在我們的新平台中，與 2020 年第三季度相比，Ion 程序增加了近四倍，這得益於客戶系統數量的顯著增加和現有安裝基礎的使用量增加。我們的單端口平台受到額外的區域和臨床許可的限制，表現出穩健的表現，同比增長近 50%。

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。

During the quarter, Dr. Michael Kent from Beth Israel Deaconess Center, Harvard Medical School in Boston, Massachusetts, published results from a landmark multicenter pulmonary open, robotic and thoracoscopic lobectomy or PORTaL study in the Annals of Surgery. This retrospective study sponsored by Intuitive compared lobectomy outcomes associated with open VATS and robotic-assisted da Vinci surgery with over 6,000 cases included in this analysis.

在本季度，馬薩諸塞州波士頓哈佛醫學院貝斯以色列女執事中心的 Michael Kent 博士在《外科年鑑》上發表了一項具有里程碑意義的多中心肺開放、機器人和胸腔鏡肺葉切除術或 PORTaL 研究的結果。這項由 Intuitive 贊助的回顧性研究比較了與開放式 VATS 和機器人輔助達芬奇手術相關的肺葉切除術結果，該分析包括了 6,000 多例病例。

After one-to-one propensity score matching, a comparison of open and da Vinci lobectomies with approximately 800 patients in each group showed a 2-day shorter length of stay and a 9.5% lower rate of prolonged hospital stay associated with da Vinci lobectomies. The da Vinci cohort also had an approximately 8-minute shorter mean OR time for cases without a concomitant procedure. Postoperative complications were approximately 9% lower with the da Vinci robotic approach. With regards to the propensity score match comparison of minimally invasive approaches with over 1,700 patients in each group, the da Vinci approach evidenced a 1.1-day shorter mean length of stay and a 6.1% low rate of conversion to thoracotomy when compared to VATS, with the differences in conversion rates reported for each tumor stage in the analysis.

在一對一的傾向評分匹配後，開放式和達芬奇肺葉切除術與每組約 800 名患者的比較顯示，與達芬奇肺葉切除術相關的住院時間縮短了 2 天，住院時間延長了 9.5%。對於沒有伴隨手術的病例，達芬奇隊列的平均 OR 時間也縮短了大約 8 分鐘。使用達芬奇機器人方法，術後並發症大約降低了 9%。關於微創方法與每組 1,700 多名患者的傾向評分匹配比較，與 VATS 相比，達芬奇方法的平均住院時間縮短 1.1 天，開胸手術的中轉率低 6.1%，分析中報告的每個腫瘤階段的轉化率差異。

The authors concluded in part, "In this retrospective multi-institutional data analysis, both robotic-assisted and VATS lobectomy were associated with improved perioperative outcomes compared to open lobectomy. Robotic-assisted lobectomy was associated with additional differences compared to VATS such as a reduced length of stay and conversion rate."

作者部分總結道：“在這項回顧性多機構數據分析中，與開放式肺葉切除術相比，機器人輔助和 VATS 肺葉切除術與圍手術期結局改善有關。與 VATS 相比，機器人輔助肺葉切除術與其他差異有關，例如減少停留時間和轉化率。”

In August of this year, Professor Umberto Bracale from the University of Naples Federico II in Naples, Italy, published a systematic review with meta-analysis of transversus abdominis release or TAR for ventral hernia repair, assessing short-term outcomes of the open and robotic-assisted approaches. The meta-analysis combined 6 studies containing over 800 patients, of which just over 200 patients underwent robotic-assisted da Vinci surgery and just under 600 patients who underwent the open approach. Results of this meta-analysis found that the robotic-assisted approach was associated with a 4.4-day shorter length of stay, 64% lower risk of postoperative complications and 79% lower risk of developing systemic complications. Readmission and reoperations were comparable between both groups.

今年 8 月，意大利那不勒斯費德里科二世大學 (University of Naples Federico II) 的 Umberto Bracale 教授發表了一篇對腹橫肌鬆解或 TAR 進行腹疝修復的薈萃分析的系統評價，評估了開放式和機器人手術的短期結果輔助方法。薈萃分析結合了 6 項研究，包含 800 多名患者，其中 200 多名患者接受了機器人輔助達芬奇手術，近 600 名患者接受了開放式手術。這項薈萃分析的結果發現，機器人輔助方法的住院時間縮短了 4.4 天，術後並發症的風險降低了 64%，發生全身並發症的風險降低了 79%。再入院和再次手術在兩組之間具有可比性。

The authors concluded in part, "Based on the data from the meta-analysis, the robotic approach for TAR seems safe and feasible even in more difficult cases. Robotic-assisted TAR shows the common advantages of minimally invasive procedures that improve short-term outcomes with significant benefits in the early postoperative period."

作者部分總結道：“基於薈萃分析的數據，即使在更困難的情況下，TAR 的機器人方法似乎也是安全可行的。機器人輔助 TAR 顯示了改善短期結果的微創手術的共同優勢在術後早期有顯著的益處。”

Lastly, as noted in yesterday's press release, preliminary results from the PRECIsE study evaluating outcomes associated with the Ion endoluminal system were presented at the annual CHEST conference. This preliminary analysis of 69 subjects showed a diagnostic yield of 83% with a sensitivity of malignancy of 84% to 88% from the biopsy of peripheral pulmonary nodules with a mean size of 17 millimeters. These initial outcomes regarding the performance of the Ion system are encouraging, and we look forward to the full study being published in the second half of 2022.

最後，正如昨天的新聞稿中所述，PRECISE 研究評估與 Ion 腔內系統相關的結果的初步結果已在年度 CHEST 會議上公佈。這項對 69 名受試者的初步分析顯示，平均大小為 17 毫米的外周肺結節活檢的診斷率為 83%，對惡性腫瘤的敏感性為 84% 至 88%。這些關於 Ion 系統性能的初步結果令人鼓舞，我們期待在 2022 年下半年發表完整的研究報告。

I will now turn to our financial outlook for 2021. During Q3, we experienced a more challenging supply chain environment with a deterioration in on-time delivery performance from our suppliers. We also saw increased supply chain costs. While this did not have a material impact to our operating results in Q3, the outlook we are providing does not reflect any potential significant disruption or additional costs related to supply constraints.

我現在將談談我們對 2021 年的財務展望。在第三季度，我們經歷了更具挑戰性的供應鏈環境，供應商的準時交貨表現惡化。我們還看到供應鏈成本增加。雖然這對我們第三季度的經營業績沒有重大影響，但我們提供的前景並未反映任何潛在的重大中斷或與供應限制相關的額外成本。

Starting with procedures. Last quarter, we forecast 2021 procedure growth of 27% to 30%. Given Q3 results and the impact of the Delta variant, we are now narrowing our forecast and expect full year 2021 procedure growth of 27% to 29%. This procedure outlook does not reflect a significant impact from OR staffing shortages or a resurgence of COVID-19. The high end of the range assumes that COVID-19-related hospitalizations in the U.S. continue the recovery that began in September and that COVID-related mitigation measures in OUS markets continue to ease.

從程序開始。上個季度，我們預測 2021 年的程序增長為 27% 至 30%。鑑於第三季度的結果和 Delta 變量的影響，我們現在正在縮小我們的預測，並預計 2021 年全年程序增長 27% 至 29%。該程序前景並未反映手術室人員短缺或 COVID-19 死灰復燃的重大影響。該範圍的高端假設美國與 COVID-19 相關的住院人數繼續從 9 月開始的複蘇，並且 OUS 市場中與 COVID-19 相關的緩解措施繼續放鬆。

Turning to gross profit. On our last call, we forecast our 2021 full year pro forma gross profit margin to be within 70.5% and 71.5% of revenue. We now expect 2021 pro forma gross profit margin to be within 71% and 71.5% of revenue. This range does not reflect any significant disruption associated with the current supply chain challenges. Our actual gross profit margin will vary quarter-to-quarter depending largely on product, regional and trade-in mix the impact of product cost reductions and manufacturing efficiencies and competitive pricing pressure.

轉向毛利。在我們上次的電話會議上，我們預測我們 2021 年全年的備考毛利率將在收入的 70.5% 和 71.5% 之間。我們現在預計 2021 年備考毛利率將在收入的 71% 和 71.5% 以內。該範圍並未反映與當前供應鏈挑戰相關的任何重大中斷。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、產品成本降低和製造效率的影響以及競爭性定價壓力。

With respect to operating expenses, on our last call, we forecast to grow full year pro forma 2021 operating expenses between 17% and 21% above 2020 levels. We are refining our estimate and now expect our full year pro forma operating expense growth to be between 17% and 19%. We expect our noncash stock compensation expense to range between $450 million and $460 million in 2021. With regard to pro forma other income, which is comprised mostly of interest income, we expect a range of between $50 million and $55 million in 2021. Finally, with respect to income tax, we expect our Q4 2021 pro forma tax rate to be approximately 21.5% of pretax income.

關於運營費用，在我們上次電話會議上，我們預計 2021 年全年備考運營費用將比 2020 年的水平增長 17% 至 21%。我們正在完善我們的估計，現在預計我們全年的備考運營費用增長將在 17% 至 19% 之間。我們預計 2021 年我們的非現金股票補償費用將在 4.5 億美元至 4.6 億美元之間。關於主要由利息收入組成的備考其他收入，我們預計 2021 年將在 5000 萬美元至 5500 萬美元之間。最後，關於所得稅，我們預計 2021 年第四季度的備考稅率約為稅前收入的 21.5%。

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

我們準備好的發言到此結束。我們現在將打開您的問題的電話。

(Operator Instructions) We'll go first to Amit Hazan with Goldman Sachs.

（操作員說明）我們將首先與高盛一起去 Amit Hazan。

I want to come back to the supply chain comment first. Just to ask you how visibility looks for componentry now versus maybe a little bit earlier this year, what lead times look like now, sounds tighter, just a little more color around that. And to what extent have you kind of already been able to either kind of double order or for lack of a better term, I guess, or stockpile this year and how viable of an option does that remain for you?

我想先回到供應鏈評論。只是想問你現在與今年早些時候相比，組件的可見性如何，現在的交貨時間看起來像什麼，聽起來更緊，只是周圍多了一點色彩。我猜，你在多大程度上已經能夠進行雙重訂購或缺乏更好的期限，或者在今年囤積庫存，這對你來說還有多大的可行性？

Yes. I think, Amit, this is Marshall. The environment as it relates to supply chain has deteriorated, gotten more difficult over time. And as we said, we've dedicated substantial resources to dealing with those shortages and has not to date created an issue with us supplying customer demand. But there is a risk and it's a real risk. And so we call it out to make sure that everybody is aware of that. From the perspective of cost, we saw some increased material costs last quarter. They were not significant. And we also incurred some expediting fees associated with freight, again, not material. But going forward, we do expect cost, increased cost that will probably hit the margin in Q4 or Q1. It's hard to predict exactly how much. And so I think that kind of summarizes it for you. It's a difficult environment right now.

是的。我想，阿米特，這是馬歇爾。與供應鏈相關的環境已經惡化，隨著時間的推移變得更加困難。正如我們所說，我們已經投入大量資源來應對這些短缺，並且迄今為止還沒有對我們滿足客戶需求造成問題。但這是有風險的，而且是真正的風險。因此，我們呼籲確保每個人都意識到這一點。從成本的角度來看，我們看到上個季度的材料成本有所增加。它們並不重要。而且我們還產生了一些與運費相關的加急費用，同樣，不是實質性的。但展望未來，我們確實預計成本，增加的成本可能會在第四季度或第一季度達到利潤率。很難準確預測多少。所以我認為這是為你總結的。現在是一個困難的環境。

I'd just say, I think our supply chain and manufacturing teams are doing great. I think they're working in a tough macro environment, and that macro environment will clear up when it clears up.

我只想說，我認為我們的供應鍊和製造團隊做得很好。我認為他們正在一個艱難的宏觀環境中工作，當它清理乾淨時，這個宏觀環境就會清理乾淨。

Next question, we go to Larry Biegelsen with Wells Fargo.

下一個問題，我們去富國銀行的拉里·比格爾森。

Just 2 for me, one on Ion, Gary, and then one on procedures. So the PRECIsE data looked good yesterday. I guess the question is, do you think the early data suggests your shape-sensing technology can lead to better yields and lower pneumothorax rates versus your main competitor, which uses a different technology? And how much of a catalyst do you think the data from yesterday will be for Ion? And I just had one follow-up.

對我來說只有 2 個，一個關於 Ion，Gary，然後一個關於程序。所以昨天的精確數據看起來不錯。我想問題是，與使用不同技術的主要競爭對手相比，您是否認為早期數據表明您的形狀感應技術可以帶來更高的產量和更低的氣胸率？您認為昨天的數據對 Ion 有多大的催化作用？而且我只有一次跟進。

Yes. I think that the architecture as a whole, the shape sensor, the way it works, the design choices about making a soft catheter that's quite thin and can go deep into the lung has been really strong for us, and I think the data speaks for itself. You can compare for yourself the data that folks using Ion are producing and that from Monarch. And we feel great about where we are.

是的。我認為整個架構、形狀傳感器、它的工作方式、製造非常薄且可以深入肺部的軟導管的設計選擇對我們來說真的很強大，我認為數據說明了一切本身。您可以自己比較使用 Ion 的人們生成的數據和來自 Monarch 的數據。我們對自己所處的位置感覺很好。

I think it is catalyzing. As we speak, I think that those results are helping us in the market. Our customers are giving us really good feedback. And we continue to invest in the operations part of that program as well as the innovation side. We feel really good about it.

我認為這是催化劑。正如我們所說，我認為這些結果正在幫助我們進入市場。我們的客戶給了我們非常好的反饋。我們將繼續投資於該計劃的運營部分以及創新方面。我們對此感覺非常好。

And then on procedures, I guess it sounds like most or if not all, major markets are moving in the right direction. I'd love to hear a little bit more color, particularly on the U.S. And it sounds like, Jamie, and by the way, congratulations on the new role. It sounds like we should expect normal seasonality in Q4. When we look at 2018 and 2019, the sequential procedure growth was very similar worldwide, U.S. and OUS. Is it possible that it could be a little stronger given that we're seeing a recovery?

然後在程序方面，我想听起來大多數或如果不是全部的話，主要市場都在朝著正確的方向發展。我很想听到更多的色彩，尤其是在美國。聽起來，傑米，順便說一句，祝賀新角色。聽起來我們應該期待第四季度的正常季節性。當我們查看 2018 年和 2019 年時，美國和 OUS 的連續程序增長在全球範圍內非常相似。鑑於我們正在看到復蘇，它是否可能會更強一些？

Yes. Thank you, Larry, by the way. I would say this, what's reflected in the high end of our procedure guidance is really 2 things that COVID-19-related hospitalizations in the U.S. continue the recovery that began in September, and that was kind of in the middle part of September that, that recovery commenced. So there's a progression there that continues through Q4.

是的。順便說一句，謝謝你，拉里。我想說的是，在我們的程序指南的高端中反映的是，美國與 COVID-19 相關的住院治療繼續從 9 月開始的複蘇，那是在 9 月中旬，恢復開始了。所以那裡有一個持續到第四季度的進展。

It also assumes that the mitigation measures in OUS markets, which are typically a little more conservative than we see in the U.S., continue to ease. And those also started to ease in September. At the low end, what we see is a slower recovery in the U.S. from what we saw in Q3 and choppiness OUS in terms of kind of the on/off of mitigation measures in various markets. And so that range of 27% to 29% that we provided really is just a function of the rate at which we recover from what occurred in Q3 with the Delta variant.

它還假設 OUS 市場的緩解措施（通常比我們在美國看到的要保守一些）繼續放鬆。這些也在 9 月開始緩解。在低端，我們看到的是美國從第三季度的複蘇放緩，以及在各種市場的緩解措施的開/關方面的波動性 OUS。因此，我們提供的 27% 到 29% 的範圍實際上只是我們從使用 Delta 變體的第三季度發生的情況中恢復的速度的函數。

A little color on that, it's me just jumping in. I think there's 2 things that are going on. One is, what will pace us is hospital availability for surgery, right? It's not infection rate. It's going to be resource consumption at the hospital and their ability to pivot their resources, both human capital and facilities back towards surgery. As you double-click on that, some of it is regional variance, but some of it is actually just hospital system variance. There's differences in how each hospital is managing it. So it's hard to generalize, I think, beware of averages.

有點顏色，我只是跳進去。我認為有兩件事正在發生。一是，我們的步伐是什麼是手術的醫院可用性，對吧？不是感染率。這將是醫院的資源消耗以及他們將資源（包括人力資本和設施）轉向手術的能力。當您雙擊它時，其中一些是區域差異，但其中一些實際上只是醫院系統差異。每家醫院的管理方式存在差異。所以很難一概而論，我認為，要注意平均值。

Next question comes from Bob Hopkins with Bank of America.

下一個問題來自美國銀行的 Bob Hopkins。

Just to follow up on that last question. So for Jamie or Marshall, I guess. Therefore, does the procedure volumes that you are forecasting for Q4, is that assuming improving year-over-year growth in Q4 versus the year-over-year growth in Q3 or about the same?

只是為了跟進最後一個問題。所以對於傑米或馬歇爾，我猜。因此，您預測第四季度的手術量是假設第四季度的同比增長與第三季度的同比增長相比有所改善還是大致相同？

Yes. I think what's implied by the guidance that we provided, at the low end, Q4 year-over-year growth will be 15%. At the high end, it will be 22%. So you compare that to what we showed in Q3 of 20%. Then you see kind of the range is above and below what we recorded in Q3. And I think, again, it just reflects both the year-over-year comparison in terms of the base for Q4 in 2020 as well as the range of scenarios in terms of what actually occurs with procedures in Q4.

是的。我認為我們提供的指導暗示，在低端，第四季度的同比增長將是 15%。在高端，它將是 22%。因此，您將其與我們在第三季度顯示的 20% 進行比較。然後您會看到範圍高於和低於我們在第三季度記錄的範圍。而且我認為，它再次反映了 2020 年第四季度基數的同比比較以及第四季度程序實際發生的情況範圍。

Okay. And then just one quick one for Gary. I was struck by your comments in your opening remarks about how your multiport systems now have 70 clinical uses. And I was curious if you could just elaborate on that a little bit. Is that 70 different surgical procedures or how are you characterizing clinical uses? That sounds like an interesting number.

好的。然後給加里一個快速的。我對您在開場白中關於您的多端口系統現在有 70 種臨床用途的評論感到震驚。我很好奇你能否詳細說明一下。那是 70 種不同的外科手術，還是您如何描述臨床用途？這聽起來是一個有趣的數字。

Yes. That's right. It's the number of kind of different procedures that's described in our labeling as to where this might be used in the body or in a subspecialty. So you look at urology, there's a handful of different procedures that it can be used for and likewise, gynecology, general surgery. And as you just walked through, that's a set of procedures for which we've engaged the agency and put in our labeling. So they're quite broadly applied.

是的。這是正確的。這是我們標籤中描述的不同程序種類的數量，這些程序可能用於身體或亞專科。所以你看看泌尿科，它可以用於一些不同的程序，同樣，婦科、普通外科。正如您剛剛介紹的那樣，這是我們與該機構合作並貼上標籤的一系列程序。所以它們的應用相當廣泛。

Okay. My model only has 10. So I guess I have some work to do.

好的。我的模型只有 10 個。所以我想我還有一些工作要做。

And we're not done. I think surgeons and we and regulatory agencies around the world continue to explore where else technologies like ours can go.

我們還沒有完成。我認為外科醫生和我們以及世界各地的監管機構繼續探索像我們這樣的技術可以去哪裡。

Next question comes from Tycho Peterson with JPMorgan.

下一個問題來自摩根大通的 Tycho Peterson。

I want to see if you can elaborate a little bit more on the staffing shortage comments. I know this isn't maybe fully baked in the guidance, but how much risk do you think this presents? How widespread is it? Obviously, it's a very tight labor market, but is this something you're seeing across most of your customers? Or how would you characterize it?

我想看看你能否詳細說明一下人員短缺的評論。我知道這可能並未完全包含在指南中，但是您認為這會帶來多大的風險？它有多普遍？顯然，這是一個非常緊張的勞動力市場，但這是您在大多數客戶中看到的嗎？或者你會如何描述它？

You're referring to the customer side?

你說的是客戶端？

Correct.

正確的。

Yes. Jamie, why don't you talk a little bit about it.

是的。傑米，你為什麼不談談它。

Yes. We've had anecdotal inputs from some customers that they're facing staffing shortages. Other customers have said to us that they're able to overcome those risks. And so given kind of the mix dynamics and the lack of clear evidence in terms of its impact on procedures. And what we've said is, the remainder of the year guidance does not reflect any significant disruption from OR staffing shortages, meaning that there's no deterioration in that phenomenon for hospitals.

是的。我們從一些客戶那裡得到了他們面臨人員短缺的軼事信息。其他客戶對我們說，他們能夠克服這些風險。因此，考慮到混合動力以及在其對程序的影響方面缺乏明確的證據。我們所說的是，今年剩餘時間的指導並未反映出手術室人員短缺造成的任何重大破壞，這意味著醫院的這種現像沒有惡化。

Okay. And then another dynamic you flagged was just kind of the selling cycle. Obviously, early days on the competitive front. But on the back of the CE mark for Medtronic, I'm just curious, out of Europe, what you're hearing from your sales reps just in terms of early interest, potential demos, things like that?

好的。然後你標記的另一個動態只是一種銷售週期。顯然，在競爭方面的早期。但是在美敦力的 CE 標誌的背面，我只是好奇，在歐洲之外，您從銷售代表那裡聽到的只是早期興趣、潛在演示等方面的內容？

Yes. I think with several of the other systems that are on the market and as you say, the most recent one, we see early engagement. Those first engagements tend to be a placement of clinical trial sites and training centers and so on. So they're not surprising. They're kind of the early access programs to get into the market. So far, there are a fair number of claims about what these new systems will do.

是的。我認為市場上的其他幾個系統，正如你所說的，最近的一個，我們看到了早期參與。這些最初的約定往往是臨床試驗地點和培訓中心等的安置。所以他們並不奇怪。它們是進入市場的早期訪問計劃。到目前為止，關於這些新系統將做什麼的說法相當多。

And I think the reality is time will tell. Their Gen 1 systems, I think evidence has to be generated to back up those claims. And so far, we don't see anything yet that looks like evidence, just a set of claims. So we'll keep serving our customer, doing what we can to make sure that they can achieve the quadruple aim and we'll see how other companies do.

我認為現實是時間會證明一切的。他們的第一代系統，我認為必須生成證據來支持這些說法。到目前為止，我們還沒有看到任何看起來像證據的東西，只是一組聲明。因此，我們將繼續為我們的客戶服務，盡我們所能確保他們能夠實現四重目標，我們將看看其他公司是如何做的。

Maybe last one. We on the sell-side always get the question about a new system from you guys. It seems like that's picked up a little bit lately. You're putting up good system numbers. I'm curious in your view, is that something the market needs right now? What are you willing to say if anything at all about the appetite for another system from you guys or anything you may be working on?

也許最後一個。我們賣方總是從你們那裡得到關於新系統的問題。好像最近有點起色了。您正在提供良好的系統編號。我很好奇你的觀點，這是市場現在需要的東西嗎？如果你們對另一個系統的胃口或者你們可能正在做的任何事情，你們願意說什麼？

First thing is that, we think there is room for innovation on all the platforms we have. So whether it's multiport and Gen 4, we continue to innovate. We've done a lot of sequential innovation on Gen 4. So our X and Xi are different. We continue to invest both in incremental opportunities and in deeper, bigger opportunities on multiport. And as we're ready to roll those out, you'll hear about it.

首先，我們認為我們擁有的所有平台都有創新的空間。因此，無論是多端口還是第 4 代，我們都在不斷創新。我們在 Gen 4 上做了很多連續創新。所以我們的 X 和 Xi 是不同的。我們將繼續投資於增量機會和更深層次、更大的多端口機會。當我們準備推出這些產品時，您會聽到的。

We brought to market SP. We continue to innovate on SP and get sequential products and clearances globally for SP. And likewise, Ion, which is having great success really in its first indication, but we think has opportunities deeper in the body and in different locations in the body, which will proceed and describe over time. So yes, I think you should expect continued innovation from us.

我們將 SP 推向市場。我們繼續在 SP 上進行創新，並在全球範圍內為 SP 獲得連續的產品和許可。同樣，Ion 在它的第一個適應症中確實取得了巨大的成功，但我們認為在身體更深處和身體的不同部位有機會，這將隨著時間的推移而進行和描述。所以，是的，我認為您應該期待我們不斷創新。

As to whether we think that we're in immediate need of something, we are innovating at a pace where we think we can bring things that matter to the quadruple aim, not so much an idea of what's our retail strategy, but more can we do something that changes quadruple aim or otherwise improves the customer experience. And that's what we're focused on.

至於我們是否認為我們迫切需要某些東西，我們正在以我們認為可以將重要的東西帶到四重目標的速度進行創新，與其說是我們的零售戰略的想法，不如說我們可以更多做一些改變四重目標或以其他方式改善客戶體驗的事情。這就是我們所關注的。

Next question comes from Rick Wise with Stifel.

下一個問題來自 Rick Wise 和 Stifel。

One focused question and then a larger picture one. Gary, in your opening comments, you mentioned that extended life instruments, if I understood you, have reached, I think your word was equilibrium. I just want to make sure I understood what you're implying. Does that suggest that the initial phase of adoption has happened and we're going to see better growth ex sort of an initial stocking ASP impact? And is there a second round of instruments? This has been so successful, how should we think about all that?

一個集中的問題，然後是一個更大的問題。加里，在你的開場白中，你提到延長壽命的儀器，如果我理解你的話，我認為你的話是平衡的。我只是想確保我理解你的意思。這是否表明採用的初始階段已經發生，並且我們將看到更好的增長，除了初始庫存 ASP 影響？還有第二輪文書嗎？這已經如此成功，我們應該如何考慮這一切？

With regard to what I meant by equilibrium, it was really that the initial stocking orders and the transition from older instruments to newer is largely taking place, but I'll let Jamie answer that more carefully than I just did.

關於我所說的平衡，實際上是最初的庫存訂單以及從舊儀器到新儀器的過渡在很大程度上正在發生，但我會讓 Jamie 比我剛才更仔細地回答這個問題。

Actually, I think that's right, Gary. There's a period of time when as we launched extended use instruments, customers in the U.S. and Europe in particular were ordering those instruments at a rate higher than their usage. As they consume their 10-life instruments, that took some time to get into parity. And so you saw in the end a positive benefit to I&A per procedure in Q1 and Q2, Q3 for those regions that largely came to parity.

事實上，我認為這是對的，加里。有一段時間，當我們推出擴展使用儀器時，特別是美國和歐洲的客戶訂購這些儀器的速度高於他們的使用率。當他們消耗他們的 10 生命儀器時，這需要一些時間才能達到平價。因此，您最終在第一季度和第二季度、第三季度看到每個程序對 I&A 的積極好處，這些地區在很大程度上達到了平價。

We did launch extended use instruments later in Asia and some of the rest of the world countries. And so they are still kind of working their way to parity. So there will be small downward pressure on I&A per procedure, holding everything else equal as they get to parity looking forward.

後來我們確實在亞洲和世界其他一些國家推出了擴展使用儀器。因此，他們仍在努力實現平等。因此，每個程序的 I&A 將面臨較小的下行壓力，保持其他一切平等，因為它們在未來達到平價。

The second half of your question, just to finish it, you talked about, are we done? Is that it for these kinds of ideas? And extended use instruments and da Vinci X, these were design and process investments that we made to pursue what we think of as the virtuous cycle. The idea that if we can improve quality and lower cost for our customers that they can use our products in more and different procedures and we're not done doing that. It may not look exactly like what we've done in the past. There are other things that we think we can do that allow them high-value systems at different price points or high-value instruments at different price points. So that line of reasoning has not exhausted itself.

你的問題的後半部分，只是為了完成它，你談到了，我們完成了嗎？是為了這些想法嗎？以及擴展使用儀器和達芬奇 X，這些是我們為追求我們認為的良性循環而進行的設計和工藝投資。如果我們可以為我們的客戶提高質量並降低成本，他們可以在更多不同的程序中使用我們的產品，我們還沒有這樣做。它可能看起來不像我們過去所做的那樣。我們認為我們還可以做一些其他的事情，讓他們可以在不同的價格點上使用高價值系統或在不同的價格點上使用高價值的工具。因此，這種推理方式並沒有用盡。

All right. And Gary, just one last big picture question. Obviously, you've created 2 new senior leadership roles here for Marshall and for Dave Rosa. Maybe just if you could just flesh out your thinking. Is it simply and it would be enough that Intuitive has gotten so large and complex and the future is so bright, you just need more senior leadership, focused leadership? Or what are you charging? What are you expecting? What should we expect from Marshall and Dave in coming years?

好的。加里，只是最後一個大問題。顯然，您在這里為 Marshall 和 Dave Rosa 創建了 2 個新的高級領導職位。也許只是如果你能充實你的想法。 Intuitive 變得如此龐大和復雜，未來如此光明，您是否只需要更高級的領導，專注的領導就足夠了？或者你在收費甚麼？你在期待什麼？未來幾年，我們應該對 Marshall 和 Dave 有什麼期待？

Thank you for that question. Over the last few years, we've had an expansion of business and expansion of opportunity, both are happening. On the business side, we want to make sure that we serve our customers at very high quality, quickly in local regions where we can and that we take advantage of a lot of the systems and enterprise data that we have to help drive the business in and help our customer. And that's something that Marshall has been doing, and I've asked him to double down on that, to make sure that we can really take advantage of our global scale and serve our customers and our business really well at that scale. And it's an opportunity and it's real work.

謝謝你的問題。在過去的幾年裡，我們的業務和機會都在擴大，兩者都在發生。在業務方面，我們希望確保在我們可以的地方快速為客戶提供高質量的服務，並確保我們利用大量系統和企業數據來幫助推動業務發展並幫助我們的客戶。這就是馬歇爾一直在做的事情，我已經要求他加倍努力，以確保我們能夠真正利用我們的全球規模並在這個規模上為我們的客戶和我們的業務提供良好的服務。這是一個機會，也是真正的工作。

The flip side is, I have never been more positive about the long-term opportunity for companies like ours that can master the kinds of things that we have to do to help minimally invasive care and interventions. And so there's real opportunity there. And I'd like us to get there quickly to have the agility and focus to be able to open new ideas and new architectures and new markets. And I can think of nobody more qualified to lead that effort than Dave Rosa, who has visited just about all parts of the company, started off as an engineer and scientist and has done many things for us. So we're really trying to get the advantages of scale to help our global customers and also be agile on capitalizing on growth opportunities as we see them.

另一方面，對於像我們這樣能夠掌握我們必須做的事情來幫助微創護理和乾預措施的公司而言，我從未如此樂觀地看待長期機會。所以那裡有真正的機會。我希望我們能夠快速到達那裡，擁有敏捷性和專注力，能夠打開新的想法、新的架構和新的市場。我認為沒有人比 Dave Rosa 更有資格領導這項工作，他幾乎訪問了公司的所有部門，最初是一名工程師和科學家，為我們做了很多事情。因此，我們真的在努力利用規模優勢來幫助我們的全球客戶，並靈活地利用我們看到的增長機會。

Next question comes from Matt Taylor with UBS.

下一個問題來自瑞銀的馬特泰勒。

I was hoping maybe, Marshall, you could talk a little bit more about the supply chain issues from the standpoint of just helping us get visibility or understand how close you are to the edge there. And meaning, you keep calling out this risk that exists, but it sounds like you've been doing a really good job of managing things so far. Is there any benchmark numbers you can give us to help us understand what the lead times are in some of these key things that could get disrupted or the likelihood that it will happen. Is it getting better or is there a real risk of you not being able to ship some kind of product is, I guess, the core of the question.

我希望馬歇爾，你可以從幫助我們獲得可見性或了解你離邊緣有多近的角度多談談供應鏈問題。意思是，你一直在呼喚存在的這種風險，但聽起來你迄今為止在管理事情方面做得非常好。您是否可以給我們提供任何基準數字，以幫助我們了解其中一些可能被中斷的關鍵事情的交貨時間或發生的可能性。我想，它是變得更好，還是存在無法交付某種產品的真正風險，這是問題的核心。

Well, I don't think I can say it's getting better. I actually think that it's a difficult situation and will continue for some time. If you think about the one that's been talked about the most is semiconductors. You've seen it in the auto industry as an issue in computers. And if you had to order any home goods that contained chips, you would know that there's a problem there.

好吧，我認為我不能說它變得更好。我實際上認為這是一個困難的情況，並且會持續一段時間。如果您考慮一下被談論最多的一個，那就是半導體。在汽車行業，您已經將其視為計算機中的一個問題。如果您必須訂購任何包含芯片的家居用品，您就會知道那裡有問題。

That will take a long time to remedy. It takes a long time to build fabs. It takes a long time to produce product. And I think that will go well into next year are the predictions that we're hearing. I think Gary told you, our team has done a marvelous job so far. So I think there are issues on a regular basis. And the issues so far, our team has been able to resolve those.

這需要很長時間才能補救。建造晶圓廠需要很長時間。生產產品需要很長時間。我認為我們聽到的預測將持續到明年。我想加里告訴過你，到目前為止，我們的團隊做得非常出色。所以我認為經常有問題。到目前為止，我們的團隊已經能夠解決這些問題。

I don't have any statistics to provide you on how often or what it means. I would just say that some, anecdotally, some lead times have extended beyond 6 months. That's not all products, and it's not an average you should apply to everything. But in some cases, it's pretty long. And so I think you -- it's a problem we highlight just to make sure that you're aware of the risk.

我沒有任何統計數據可以向您提供頻率或含義。我只想說，有些交貨時間已經超過了 6 個月。這不是所有產品，也不是你應該適用於所有產品的平均值。但在某些情況下，它很長。所以我認為你——這是我們強調的一個問題，只是為了確保你意識到風險。

We have a follow-up question from Amit Hazan with Goldman Sachs.

我們有一個來自高盛的 Amit Hazan 的後續問題。

Yes. So I thought maybe just to follow up on the supply chain question was just a little bit more on just inflationary headwinds generally. And Marshall, just how you're seeing labor cost growth today versus kind of early in the year or more normal times and raw material cost growth versus normal, more normal times? And just how to, for us to start thinking about these things along with what you commented on the supply chain for next year, just qualitatively as we start to think about where operating margins might go?

是的。因此，我認為也許只是跟進供應鏈問題，通常只是針對通脹逆風。馬歇爾，你如何看待今天的勞動力成本增長與年初或更正常的時間相比，以及原材料成本的增長與正常、更正常的時間相比？以及如何讓我們開始考慮這些事情以及您對明年供應鏈的評論，就像我們開始考慮營業利潤率可能會去哪裡一樣定性？

We've seen some cost increases. Again, they haven't been that significant. And frankly, our teams have done a marvelous job with sort of with efficiency and effectiveness to offset those increased costs. But we're hearing from suppliers that they're going to raise their prices. And so we're saying that, hey, we expect that costs will go up more. I'm not sure I want to say that the inflation word has hit us and it's here to stay, but we are seeing some suppliers raise cost.

我們已經看到一些成本增加。同樣，它們並沒有那麼重要。坦率地說，我們的團隊在抵消這些增加的成本方面做得非常出色，效率高。但我們從供應商那裡聽說他們將提高價格。所以我們說，嘿，我們預計成本會上漲更多。我不確定我想說通貨膨脹這個詞已經打擊了我們並且它會一直存在，但我們看到一些供應商提高了成本。

Our next question comes from Vijay Kumar with Evercore ISI.

我們的下一個問題來自 Evercore ISI 的 Vijay Kumar。

Gary, maybe 2 quick ones for you. The PRECIsE study, 83% diagnostic resolution. Is that good enough, Gary? I mean, certainly, the headline numbers when you look at other studies, it's a good number, but I'm just curious, is this the point where the market awakens to these numbers and should we see an inflection in adoption of Ion?

加里，也許給你 2 個快速的。 PRECISE 研究，83% 的診斷分辨率。夠好嗎，加里？我的意思是，當然，當您查看其他研究時，標題數字是一個很好的數字，但我只是好奇，這是市場對這些數字覺醒的時刻嗎？我們是否應該看到 Ion 採用的拐點？

And just one quick one on 3Q. I know you called out the Delta, but was there any labor shortage impact in 3Q itself? Because historically, we haven't seen the pandemic impact where Intuitive has outperformed peers. It's just perhaps a little excessive in 3Q. Was there something else going on?

在 3Q 上只有一個快速的。我知道你叫了三角洲，但是第三季度本身有沒有勞動力短缺的影響？因為從歷史上看，我們還沒有看到 Intuitive 表現優於同行的大流行影響。只是在第三季度可能有點過分。還有其他事情嗎？

Okay. On the first one, in terms of diagnostic yield, you had said 82%. And I guess what I'd advise everybody is, there's a couple of numbers that are important and they stay linked together. And that is, what is the size of the lesion? And then what's the positive diagnostic rate, the ability to definitively diagnose? That's what the interventional pulmonologists are looking at.

好的。在第一個方面，就診斷率而言，您說的是 82%。我想我會建議大家的是，有幾個數字很重要，它們保持聯繫在一起。也就是說，病變的大小是多少？那麼陽性診斷率是多少，明確診斷的能力是多少？這就是介入肺病學家正在研究的問題。

So the bigger the lesion, if it's a 3-centimeter lesion, your diagnostic yield rate is going to go up, your definitive diag, because it's easier to hit. So you got to look at both numbers. It's not a single metric. So 82% for smaller lesions is leading as far as I can tell for endobronchial approaches for that approach. Some folks can get to higher yield rates, but they're hitting bigger targets. So you need to look at both, and that's what I encourage you to do.

因此，病變越大，如果是 3 厘米的病變，您的診斷合格率就會上升，您的最終診斷會提高，因為它更容易被擊中。所以你必須看看這兩個數字。這不是一個單一的指標。因此，據我所知，82% 的較小病變領先於該方法的支氣管內方法。有些人可以獲得更高的收益率，但他們正在達到更大的目標。因此，您需要同時查看兩者，這就是我鼓勵您做的事情。

The second thing that I advise you is that, there are other ways to examine or get a biopsy. There can be outside the body, CT-guided needle biopsies. And those outside the body CT-guided needle biopsies have high success rates at gathering the tissue, but they have a lower safety profile than the endobronchial approach. So there's kind of a third dimension, which is, did you get the tissue you needed to get a definitive diagnosis? How big was the lesion you were trying to target? And what was the complication rate?

我建議您的第二件事是，還有其他方法可以檢查或進行活檢。可以在體外進行 CT 引導的穿刺活檢。那些體外 CT 引導的穿刺活檢在收集組織方面具有很高的成功率，但與支氣管內方法相比，它們的安全性較低。所以有一種第三維度，也就是說，您是否獲得了獲得明確診斷所需的組織？你試圖瞄準的病灶有多大？並發症發生率是多少？

And we think that Ion is really good at managing all 3 of those relative to competitive approaches. And we're seeing a nice uptick as a result. And is that a tipping point? We'll see. So far so good. That's what we had expected. This kind of performance, that's what we were targeting. But we're pleased to see it being borne out over multiple sites and multiple customers, and we think that's going to be helpful.

我們認為 Ion 非常擅長管理與競爭方法相關的所有這三個方面。結果，我們看到了不錯的增長。這是一個轉折點嗎？我們拭目以待。到現在為止還挺好。這正是我們所期望的。這種性能，這就是我們的目標。但我們很高興看到它在多個站點和多個客戶中得到證實，我們認為這會有所幫助。

With regard to your second question, you were talking a little bit about, are we seeing an unusual or more aggressive slowdown because of Delta than perhaps others? What I'd encourage you to think about there is, where in the world everybody is exposed and where they're seeing their growth. So in our case, we have a certain regional profile and where our procedures are being done. Other companies may have much bigger exposure to, say, markets or countries that had a lower impact having to do with Delta. Frankly, I think, it's as simple as that, but time will tell on that as well.

關於你的第二個問題，你談到了一點，由於達美航空，我們是否看到了不尋常的或比其他人更激進的放緩？我鼓勵你思考的是，世界上每個人都暴露在哪裡，他們在哪裡看到了自己的成長。因此，在我們的案例中，我們有一定的區域概況以及我們的程序在哪裡完成。其他公司可能在與達美有關的影響較小的市場或國家有更大的敞口。坦率地說，我認為，就這麼簡單，但時間也會證明這一點。

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

因此，讓我們繼續並得出結論。那是我們的最後一個問題。最後，我們仍然相信，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說的四重目標：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，並最終降低總成本的關心。

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

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、他們的需求和環境的尊重和理解。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。

Ladies and gentlemen, that does conclude your conference call for today. Thank you for your participation and for using AT&T Event Conferencing. You may now disconnect.

女士們，先生們，今天的電話會議結束了。感謝您的參與和使用 AT&T Event Conferencing。您現在可以斷開連接。