直覺手術 (ISRG) 2023 Q3 法說會逐字稿

Thank you, everyone, for standing by. Welcome to the Intuitive Surgical Q3 2023 Earnings Release. (Operator Instructions)

謝謝大家的支持。歡迎來到 Intuitive Surgical 2023 年第三季收益發布。 （操作員說明）

I will now turn the conference over to your host, Head of Investor Relations, Intuitive Surgical, Brian King. Please go ahead.

現在我將會議轉交給主持人、Intuitive Surgical 投資者關係主管 Brian King。請繼續。

Good afternoon, and welcome to Intuitive's Third Quarter Earnings Conference Call. With me today, we have Gary Guthart, our CEO; Jamie Samath, our CFO; and Dr. Myriam Curet, our Chief Medical Officer.

下午好，歡迎參加 Intuitive 第三季財報電話會議。今天和我在一起的還有我們的執行長加里·古特特 (Gary Guthart)； Jamie Samath，我們的財務長；以及我們的首席醫療官 Myriam Curet 博士。

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 our Securities and Exchange Commission filings, including our most recent Form 10-K filed on February 10, 2023, and Form 10-Q filed on July 24, 2023.

在我們開始之前，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有重大差異。這些風險和不確定性在我們向美國證券交易委員會提交的文件中進行了詳細描述，包括我們於2023 年2 月10 日提交的最新10-K 表格和2023 年7 月24 日提交的10-Q表格。

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.

我們的 SEC 備案文件可以透過我們的網站或 SEC 網站找到。投資者應注意不要過度依賴此類前瞻性陳述。

Please note that this conference call will be available for audio replay on our website at intuitive.com on the 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網站直覺的投資者關係頁面下的「活動」部分進行音訊重播。今天的新聞稿和補充財務數據表已發佈到我們的網站上。

Today's format will consist of providing you with highlights of our third quarter results, as described in our press release announced earlier today, followed by a question-and-answer session. Gary will present the quarter's business and operational highlights, Jamie will provide a review of our financial results, Myriam will present clinical highlights, and I will discuss procedure details and provide our updated financial outlook for 2023. And finally, we will host a question-and-answer session.

今天的形式將包括向您提供我們第三季業績的亮點，如我們今天早些時候宣布的新聞稿中所述，然後是問答環節。 Gary 將介紹本季度的業務和營運亮點，Jamie 將回顧我們的財務業績，Myriam 將介紹臨床亮點，我將討論手術細節並提供我們最新的 2023 年財務展望。最後，我們將主持一個問題 -並回答會議。

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. In this third quarter, we saw a strong growth in procedures performed by our customers, solid new system placements and healthy growth in utilization amid market conditions that remain largely consistent with Q2.

感謝您今天加入我們。在第三季度，我們看到客戶執行的程序強勁成長，新系統部署穩固，利用率健康成長，市場狀況與第二季度基本一致。

Our new platforms continue to gain ground with Ion installs and procedure growth continuing, SP installs and procedure growth modestly accelerating and healthy growth in customer use of our digital tools.

隨著 Ion 安裝和程序的持續增長、SP 安裝和程序的適度加速以及客戶對我們數位工具的使用的健康增長，我們的新平台繼續取得進展。

Turning first to procedures. da Vinci procedure growth in the quarter was 19%. Areas of strength included general surgery for benign conditions, particularly in the United States and broad regional growth with Germany, Japan, the U.K. and India standouts. China procedure growth was in line with our global average in the quarter. U.S. dermal surgery procedure growth was led by cholecystectomy and colon resection.

首先轉向程序。達文西程式本季成長率為 19%。優勢領域包括良性疾病的普通外科手術，特別是在美國，以及廣泛的區域增長，其中德國、日本、英國和印度表現突出。本季中國流程成長與全球平均一致。美國皮膚外科手術的成長以膽囊切除術和結腸切除術為主導。

Ion procedures showed continued strength with 125% growth in the quarter. SP procedure growth accelerated with 54% global growth in the quarter driven by strength in the United States.

Ion 手術表現出持續的強勁勢頭，本季成長了 125%。在美國市場強勁的推動下，SP 程序成長加速，本季全球成長 54%。

On the capital front, we placed 312 systems in Q3 compared with 305 systems in Q3 of last year. Our clinical installed base now stands 8,127 multiport da Vinci systems, 490 Ion systems and 158 single-port da Vinci systems.

在資金方面，我們第三季投放了312個系統，而去年第三季投放了305個系統。我們的臨床安裝基地目前擁有 8,127 個多端口達文西系統、490 個 Ion 系統和 158 個單端口達文西系統。

Overall, our capital placement trends reflect demand for additional capacity in multiport, continued greenfield interest in our Ion system and a modest acceleration for placements of SP. The proportion of leases for new capital placements accelerated in the quarter with the U.S. using the highest leasing rates. We think the acceleration in leasing reflects the convenience of our leasing program and the maturity of our Generation 4 multiport systems.

總體而言，我們的資本配置趨勢反映了對多連接埠額外容量的需求、對我們的 Ion 系統的持續綠地興趣以及 SP 佈局的適度加速。本季新資本配置的租賃比例增加，其中美國使用的租賃利率最高。我們認為租賃的加速反映了我們租賃計劃的便利性和第四代多端口系統的成熟度。

While leasing reduces in-quarter revenue relative to capital purchase, total economics are healthy for our customer and for us. Leasing allows our customers to build clinical capacity when and where they need it and provides predefined pathways for our new technology as it enters the market.

雖然相對於資本購買而言，租賃減少了季度收入，但總體經濟效益對我們的客戶和我們來說都是健康的。租賃使我們的客戶能夠在需要的時間和地點建立臨床能力，並為我們的新技術進入市場時提供預先定義的途徑。

The growth rate in system utilization, defined as procedures per installed system per quarter was 6%, down from 9% last quarter while still above historical growth rates.

系統利用率（定義為每季每個已安裝系統的程式）成長率為 6%，低於上季的 9%，但仍高於歷史成長率。

Strong procedure growth and increased proportion of use in benign indications shortens average procedure times and needs of scheduling. Higher utilization increases our customers' return on invested capital and is economically healthy for us.

手術的強勁成長和良性適應症使用比例的增加縮短了平均手術時間和調度需求。更高的利用率可以提高客戶的投資資本報酬率，對我們來說在經濟上是健康的。

Turning to our finances. Our revenue grew 12% in the quarter and our operating expenses were within our spend guidance. Our spending reflects continued investments in research and development to support the growth of our platforms and digital tools, expansion of our manufacturing and commercial footprints and capital amortization.

轉向我們的財務。本季我們的收入成長了 12%，營運支出也在我們的支出指導範圍內。我們的支出反映了對研發的持續投資，以支持我們的平台和數位工具的成長、製造和商業足跡的擴大以及資本攤銷。

Looking at the broader picture, our fourth-generation da Vinci platform is operating at global scale and embedded in a robust ecosystem of instruments, accessories, training and services. Customer acceptance of our Ion platform is strong. Acceptance of our da Vinci SP is accelerating with new indications in the pipeline, and our digital tools are building momentum through their early stages.

從更廣泛的角度來看，我們的第四代達文西平台正在全球範圍內運行，並嵌入到由儀器、配件、培訓和服務組成的強大生態系統中。客戶對我們的 Ion 平台的接受程度很高。隨著新的適應症的出現，我們的達文西 SP 的接受度正在加速，我們的數位工具正在其早期階段積聚動力。

We welcome Dr. Myriam Curet, Intuitive's Chief Medical Officer to this call, and she will take us through our clinical perspective and some of the work we're doing to expand indications.

我們歡迎 Intuitive 首席醫療官 Myriam Curet 博士參加本次電話會議，她將向我們介紹我們的臨床觀點以及我們為擴大適應症所做的一些工作。

Our operations teams did a fantastic job supporting our customers through the supply chain shocks of the past several years. This unavoidable effort diverted resources away from product cost reduction and as supply chain stresses ease, we're now pivoting our attention to once again lowering our product costs.

我們的營運團隊在過去幾年的供應鏈衝擊中為客戶提供了出色的支援。這種不可避免的努力將資源從降低產品成本上轉移開，隨著供應鏈壓力減輕，我們現在將注意力轉向再次降低產品成本。

Areas of opportunity include our Ion program, our SP accessories portfolio and our multiport accessories in advanced instrument lines. Given the timing of facilities completion, manufacturing efficiency improvements for new products and other complex projects, we expect variability in gross margin over the coming quarters as we work through these programs.

機會領域包括我們的 Ion 計劃、我們的 SP 配件組合以及先進儀器系列中的多端口配件。考慮到設施完工的時間、新產品和其他複雜項目的製造效率的提高，我們預計在我們實施這些計劃的過程中，未來幾季的毛利率將會出現變化。

Turning to our digital offerings, customer use of our digital tools and channels is growing nicely. Our SimNow surgical simulators are installed at the majority of our customer sites and subscription renewal rates are outstanding. Routine use of My Intuitive app by over 10,000 da Vinci surgeons grew by 140% year-over-year and is receiving strong Net Promoter Scores that continue improving over time.

談到我們的數位產品，客戶對我們數位工具和通路的使用成長良好。我們的大多數客戶網站都安裝了 SimNow 手術模擬器，訂閱續訂率非常高。超過 10,000 名達文西外科醫生對 My Intuitive 應用程式的日常使用量同比增長了 140%，並且獲得了強勁的淨推薦值，並且隨著時間的推移，淨推薦值不斷提高。

Our Intuitive Hub media management and telepresence system installations grew 58% in the quarter, and Hub captured surgical cases grew 61%.

我們的 Intuitive Hub 媒體管理和遠端呈現系統安裝量在本季度增長了 58%，Hub 捕獲的手術病例增加了 61%。

In closing, core demand is healthy. We're focused on in our ecosystem internationally and driving our product cost down, particularly for our newer platforms. We are dogged in pursuit of significant long-term opportunity to improve the quadruple aim using our integrated ecosystem powered by analytics, and we are pacing our investments to catalyze that opportunity.

總之，核心需求是健康的。我們專注於我們的國際生態系統並降低我們的產品成本，特別是對於我們的新平台。我們堅持不懈地尋求重要的長期機會，利用由分析支援的整合生態系統來改善四重目標，並且我們正在調整投資節奏以催化這一機會。

I'll now turn the time over to Jamie, who will take you through our finances in greater detail.

現在我將把時間交給傑米，他將帶您更詳細地了解我們的財務狀況。

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

午安.我將描述我們在非公認會計準則或預估基礎上的績效亮點。我稍後也會在準備好的發言中總結我們的 GAAP 表現。我們的預估結果與公認會計準則結果之間的對帳已發佈在我們的網站上。

Core metrics continue to be healthy in Q3, with global procedure growth of 19% and an increase in the installed base of da Vinci systems of 13% and an increase in average system utilization of 6%. Our key financial indicators were also healthy. Third quarter recurring revenue grew 21%. Pro forma operating margin was 36%, and pro forma earnings per share increased 23% over last year.

第三季核心指標持續保持健康，全球流程成長 19%，達文西系統安裝基數成長 13%，平均係統利用率成長 6%。我們的主要財務指標也很健康。第三季經常性收入成長 21%。預計營業利潤率為 36%，預計每股收益將比去年增長 23%。

Procedures in the U.S. grew 17%, reflecting a lower benefit from patient backlogs as compared to the first half of 2023.

美國的手術量增加了 17%，反映出與 2023 年上半年相比，病患積壓帶來的效益較低。

Last quarter, we highlighted that our growth rate in bariatric's procedures in the U.S. had slowed given patient interest in weight loss drugs. In Q3, we continued to see double-digit growth albeit at a modestly lower growth rate as compared to Q2. Bariatric's procedures represent between 4% and 5% of total global procedures.

上個季度，我們強調，鑑於患者對減肥藥物的興趣，我們在美國減肥手術的成長率已經放緩。第三季度，我們繼續看到兩位數的成長，儘管成長率比第二季度略有下降。減重手術佔全球手術總數的 4% 至 5%。

Based on third-party data, we believe we continue to gain market share in the bariatric surgical segment.

根據第三方數據，我們相信我們將繼續獲得減重手術領域的市場份額。

OUS procedures grew 24% with relative strength in India, Germany, the U.K. and Japan. Procedure growth in China was consistent with our expectations, lower than last quarter due to a strong base period given the recovery from COVID-related lockdowns in the year ago quarter.

OUS 程式成長了 24%，其中印度、德國、英國和日本的相對強勢。中國的手術成長符合我們的預期，低於上季度，這是由於上一季從新冠疫情相關的封鎖中恢復以來基期強勁。

Consistent with recent trends, growth in non-neurology procedures outside of the United States was accretive, growing at approximately 31%. Within the larger cancer categories, our fastest-growing OUS procedure is colon resection, a high-value procedure led by adoption in Japan, Germany and the U.K.

與最近的趨勢一致，美國以外的非神經科手術的成長呈成長趨勢，成長率約為 31%。在較大的癌症類別中，我們成長最快的 OUS 手術是結腸切除術，這是一種高價值手術，在日本、德國和英國率先採用。

With respect to capital performance, we placed 312 systems in the third quarter as compared to 305 systems last year. As a reminder, system placements in Q3 of last year benefit from a delay in the shipment of approximately 15 systems from June into July as a result of supply chain challenges we encountered in June of last year.

在資本績效方面，我們在第三季放置了 312 個系統，而去年則為 305 個系統。提醒一下，去年第三季的系統佈局受益於我們去年 6 月遇到的供應鏈挑戰，導致約 15 個系統從 6 月到 7 月的出貨延遲。

Late in Q3, we started to see delays in tender processes in China, primarily as a result of anticorruption efforts by the central government, resulting in lower system placements in China in Q3. We expect tender delays to continue to impact system placements in China in Q4.

第三季末，我們開始看到中國的招標流程出現延誤，這主要是由於中央政府的反腐敗努力，導致第三季中國的系統佈局較低。我們預計招標延遲將繼續影響第四季度在中國的系統佈局。

Q3 revenue was $1.7 billion, an increase of 12% year-over-year. Q3 revenue growth was driven by procedure growth, partially offset by an 11% decline in systems revenue due to the significant increase in the mix of operating lease arrangements.

第三季營收為 17 億美元，年增 12%。第三季營收成長是由程式成長推動的，但由於經營租賃安排組合大幅增加而導致系統收入下降 11%，部分抵消了這一成長。

On a constant currency basis, third quarter revenue growth was also 12%. Given recent movements in exchange rates, at current rates, the U.S. dollar is approximately 3% stronger on a revenue-weighted basis as compared to the average rates realized in Q3. Revenue denominated in non-USD currencies represent approximately 24% of total revenue.

以固定匯率計算，第三季營收成長也為 12%。鑑於近期匯率變動，以當前匯率計算，與第三季實現的平均匯率相比，以收入加權計算，美元升值約 3%。以非美元貨幣計價的收入約佔總收入的24%。

Additional revenue statistics and trends are as follows: in the U.S., we placed 159 systems in the third quarter compared to 175 systems placed last year. Outside the U.S., we placed 153 systems in Q3 compared with 130 systems last year. Current quarter system placements included 60 into Europe, 32 into Japan and 10 into China compared with 54 into Europe, 32 into Japan and 15 into China in Q3 of last year.

其他收入統計和趨勢如下：在美國，我們第三季放置了 159 個系統，而去年放置了 175 個系統。在美國以外，我們在第三季部署了 153 個系統，而去年則為 130 個系統。當前季度的系統投放量包括歐洲 60 個、日本 32 個和中國 10 個，而去年第三季歐洲有 54 個，日本有 32 個，中國有 15 個。

62 of the 312 systems placed in Q3 were trading transactions compared to 71 trading transactions in the third quarter of last year. As of the end of Q3, there are approximately 440 SIs remaining in the installed base, of which 85 are in the U.S.

第三季放置的 312 個系統中有 62 個是交易交易，而去年第三季有 71 個交易交易。截至第三季末，已安裝的 SI 數量約為 440 個，其中 85 個位於美國。

Operating leases represented 52% of third quarter placements compared with 37% last year. In the U.S., 70% of system placements in Q3 were under operating lease arrangements compared to 48% last year. Of the 163 operating lease placements in the quarter, 93 were usage-based arrangements, an increase compared to 54% last year, reflecting customer preferences, particularly in the U.S.

經營租賃佔第三季安置額的 52%，去年為 37%。在美國，第三季 70% 的系統部署是根據經營租賃安排進行的，而去年這一比例為 48%。在本季的 163 項經營租賃安排中，有 93 項是基於使用的安排，與去年的 54% 相比有所增加，反映了客戶的偏好，尤其是在美國。

While leasing may fluctuate from quarter-to-quarter, we continue to expect that the proportion of placements under operating leases will increase over time.

儘管租賃可能會出現季度波動，但我們仍預期經營租賃的配售比例將隨著時間的推移而增加。

Q3 system average selling prices were $1.4 million as compared to $1.39 million last quarter from $1.5 million last year. The year-over-year decrease in system ASPs was primarily driven by lower pricing and geographical mix. We recognized $17 million of lease buyout revenue in the third quarter compared with $12 million last quarter and $17 million in Q3 of 2022.

第三季系統平均售價為 140 萬美元，上季為 139 萬美元，去年為 150 萬美元。系統平均售價較去年同期下降主要是由於定價較低和地理組合所致。我們在第三季確認了 1,700 萬美元的租賃買斷收入，而上季為 1,200 萬美元，2022 年第三季為 1,700 萬美元。

da Vinci instrument and accessory revenue per procedure of approximately $1,830, compared with approximately $1,840 last quarter and $1,800 last year. On a sequential basis, lower I&A per procedure reflected the impact of customer ordering patterns, partially offset by a full quarter impact from the I&A price increase that went into effect halfway through last quarter.

達文西儀器和配件每次手術的收入約為 1,830 美元，而上季度約為 1,840 美元，去年約為 1,800 美元。按順序來看，每個程序的 I&A 較低反映了客戶訂購模式的影響，但上季度中期生效的 I&A 價格上漲對整個季度的影響部分抵消了。

Turning to our Ion platform. In Q3, we placed 55 Ion systems as compared to 50 in Q3 of 2022. Third quarter Ion procedures of approximately 14,500 increased 125% as compared to last year. 16 of the systems placed in the third quarter were SP systems, 12 into the U.S. and 4 into Korea. SP procedures grew by 54%, and average system utilization growth continued to accelerate growing 21% compared to Q3 of last year.

轉向我們的 Ion 平台。第三季度，我們放置了 55 個 Ion 系統，而 2022 年第三季度為 50 個。第三季度 Ion 程序約為 14,500 個，比去年增加了 125%。第三季投放的系統中有 16 個是 SP 系統，其中 12 個投放到美國，4 個投放到韓國。 SP程序成長54%，平均係統利用率成長持續加速，較去年第三季成長21%。

Moving on to the rest of the P&L. Pro forma gross margin for the third quarter was 68.8% compared with 68.5% last quarter and 69.8% last year. As a reminder, pro forma gross margin in Q3 of last year included a onetime benefit of approximately 50 basis points related to the favorable conclusion of certain indirect tax matters.

繼續討論損益表的其餘部分。第三季預估毛利率為 68.8%，上季為 68.5%，去年為 69.8%。需要提醒的是，去年第三季的預期毛利率包括與某些間接稅問題的有利結論相關的約 50 個基點的一次性收益。

The remaining year-over-year difference in pro forma gross margin is primarily due to a higher mix of the Ion revenue, which currently carries significantly lower margins as compared to the da Vinci business and lower system ASP, partially offset by the I&A price increase.

預計毛利率的剩餘同比差異主要是由於 Ion 收入的組合較高，目前與達文西業務相比，其利潤率明顯較低，且系統平均售價較低，部分被 I&A 價格上漲所抵消。

Inventory increased to approximately 180 days in Q3, higher than historical averages, driven by 2 factors: first, we have modestly increased our inventory targets given supply chain stresses over the last couple of years; and secondly, given significant capital investments we are making in manufacturing facilities and capacity, we are building bridge inventory to facilitate an elevated number of line transfers to new locations. As a result, we expect higher levels of inventory relative to historical norms into 2025.

第三季庫存增加至約 180 天，高於歷史平均水平，原因有兩個：首先，考慮到過去幾年供應鏈的壓力，我們適度提高了庫存目標；其次，鑑於我們在製造設施和產能方面進行了大量資本投資，我們正在建立橋樑庫存，以促進更多的生產線轉移到新地點。因此，我們預計 2025 年庫存水準將高於歷史水準。

Third quarter pro forma operating expenses increased 8% year-over-year, driven primarily by higher headcount-related costs.

第三季預計營運費用年增 8%，主要是因為員工相關成本增加。

During the quarter, our head count increased by 489 employees, of which approximately 275 were for our manufacturing operations in support of revenue growth. SG&A expenses as a percentage of revenue were lower by 100 basis points as compared to Q3 of last year and largely reflected planned leverage in our enabling functions.

本季度，我們的員工數量增加了 489 名，其中約 275 名來自製造業務，以支持收入成長。 SG&A 費用佔收入的百分比與去年第三季相比下降了 100 個基點，這在很大程度上反映了我們支援職能中的計畫槓桿。

Pro forma other income in Q3 was $58 million compared to $42 million last quarter and $7 million last year. Other income primarily consists of interest income and the increase as compared to last quarter was driven by higher interest rates and higher average cash and investment balances. Pro forma other income in Q3 of last year also reflected higher than typical foreign exchange losses resulting from remeasurement of the balance sheet as a result of the strengthening U.S. dollar.

第三季預計其他收入為 5,800 萬美元，而上季為 4,200 萬美元，去年為 700 萬美元。其他收入主要包括利息收入，與上季相比的成長是由於利率上升以及平均現金和投資餘額增加所致。去年第三季的其他預期也反映出，由於美元走強，重新衡量資產負債表而導致的外匯損失高於典型的外匯損失。

Capital expenditures in Q3 were $256 million, primarily comprised of infrastructure investments to expand our facilities footprint and increase manufacturing capacity. Our pro forma effective tax rate for the third quarter was 22.5%, consistent with our expectations.

第三季的資本支出為 2.56 億美元，主要包括基礎設施投資，以擴大我們的設施足跡並提高製造能力。我們第三季的預期有效稅率為 22.5%，與我們的預期一致。

Third quarter pro forma net income was $524 million or $1.46 per share compared with $429 million or $1.19 per share for Q3 of last year.

第三季預計淨利為 5.24 億美元，即每股 1.46 美元，去年第三季為 4.29 億美元，即每股 1.19 美元。

I will now summarize our GAAP results. GAAP net income was $416 million or $1.16 per share for the third quarter of 2023 compared with GAAP net income of $324 million or $0.90 per share for the third quarter of 2022. The adjustments between pro forma and GAAP net income are outlined and quantified on our website and include excess tax benefits associated with employee stock awards, employee stock-based compensation, amortization of intangibles and gains and losses on strategic investments.

現在我將總結我們的 GAAP 結果。 2023 年第三季的GAAP 淨利為4.16 億美元，即每股1.16 美元，而2022 年第三季的GAAP 淨利為3.24 億美元，即每股0.90 美元。預計和GAAP 淨利之間的調整在我們的網站上進行了概述和量化。網站，包括與員工股票獎勵、員工股票薪酬、無形資產攤銷以及策略性投資損益相關的超額稅收優惠。

We ended the quarter with cash and investments of $7.5 billion compared with $7.1 billion last quarter. The sequential increase in cash and investments reflected cash from operating activities and proceeds from employee stock exercises partially offset by capital expenditures.

本季結束時，我們的現金和投資為 75 億美元，而上季為 71 億美元。現金和投資的連續成長反映了來自經營活動的現金和員工股票行使的收益，部分被資本支出所抵銷。

And with that, I would like to turn it over to Myriam, who will discuss clinical highlights.

接下來，我想將其交給 Myriam，她將討論臨床要點。

Thank you. Now turning to the clinical side for our business. Each quarter on these calls, we highlight certain 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.

謝謝。現在轉向我們業務的臨床方面。每個季度，我們都會在這些電話會議上強調一些我們認為值得注意的研究。然而，為了更全面地了解證據體系，我們鼓勵所有利害關係人徹底審查多年來發表的科學研究的廣泛細節。

In addition to relaying the results of one of these studies, I'd like to start by describing the status of some important Intuitive research projects underway that support our company's belief in the potential value of da Vinci systems specifically our single-port system for procedures requiring refined access to tight or difficult to reach anatomical areas.

除了轉述其中一項研究的結果之外，我想先描述一些正在進行的重要直觀研究項目的狀態，這些項目支持我們公司對達文西系統的潛在價值的信念，特別是我們的單端口程序系統需要精確地進入狹窄或難以到達的解剖區域。

In June 2021, Intuitive launched an FDA-approved clinical study focused on complex colorectal procedures, such as low anterior resection or right colectomy, performed using the SP platform. Currently, enrollment is complete with 60 patients across 9 sites in the U.S. and Korea.

2021 年 6 月，Intuitive 啟動了一項 FDA 批准的臨床研究，重點關注使用 SP 平台進行的複雜結直腸手術，例如低位前切除術或右結腸切除術。目前，美國和韓國 9 個地點的 60 名患者的入組工作已完成。

Another FDA-approved trials for rapid procedures in pulmonary lobectomy and thymectomy performed using SP completed enrollment in June of this year with 32 subjects enrolled across 6 centers in the U.S.

另一項經 FDA 批准的使用 SP 進行肺葉切除術和胸腺切除術快速手術的試驗已於今年 6 月完成入組，美國 6 個中心的 32 名受試者入組。

We believe that Intuitive single-port technology will enable thoracic surgeons to perform uniportal lobectomy, something that may be difficult using a VATS approach. Intuitive intent to submit data from these 2 studies to the FDA after the patient follow-up outlined in the study plan and the data analysis has been completed.

我們相信，直覺的單孔技術將使胸腔外科醫生能夠進行單孔肺葉切除術，而使用 VATS 方法可能很難做到這一點。在研究計劃中概述的患者隨訪和數據分析完成後，直覺意圖將這兩項研究的數據提交給 FDA。

Now I'll turn to a notable study published in the Annals of Surgery this past August. This study was not sponsored by Intuitive. Dr. Yogita Patel of McMaster University in Canada published early results from the RAVAL trial in a manuscript titled Robotic Lobectomy is cost effective and provides comparable health utility scores to video-assisted lobectomy.

現在我將轉向去年八月發表在《外科年鑑》上的一項著名研究。這項研究不是由 Intuitive 贊助的。加拿大麥克馬斯特大學的 Yogita Patel 博士在題為“機器人肺葉切除術具有成本效益，並提供與視頻輔助肺葉切除術相當的健康效用分數”的手稿中發表了 RAVAL 試驗的早期結果。

This study describes results from a multicenter, multinational, blinded, randomized controlled study comparing the da Vinci and VATS approach to pulmonary lobectomy. It analyzed 164 subjects, 81 in new robotic-assisted group and 82 in the VATS group. And all robotic-assisted lobectomies were performed with a da Vinci multiport platform.

本研究描述了一項多中心、跨國、盲法、隨機對照研究的結果，比較了達文西和 VATS 方法進行肺葉切除術。它分析了 164 名受試者，其中 81 名屬於新機器人輔助組，82 名屬於 VATS 組。所有機器人輔助肺葉切除術均使用達文西多端口平台進行。

Notably, the health utility score was significantly higher in the da Vinci arm at 7 weeks and 12 weeks post procedure, which suggests the quality of life for patients who underwent a da Vinci lobectomy was better than for patients undergoing the VATS procedure.

值得注意的是，達文西組在術後 7 週和 12 週的健康效用評分顯著較高，這表明接受達文西肺葉切除術的患者的生活品質優於接受 VATS 手術的患者。

Interestingly, and related to quality of life outcomes, the authors analyzed the incremental cost-effective ratio or ICER for the robotic group relative to VATS and reported the robotic group was associated with a gain of approximately $11,000 per quality adjusted life year.

有趣的是，與生活品質結果相關，作者分析了機器人組相對於 VATS 的增量成本效益比（ICER），並報告說機器人組與每個調整後生命年的收益相關，約為 11,000 美元。

In addition, the median number of lymph nodes examined and sampled were significantly higher in the da Vinci Group.

此外，達文西組檢查和取樣的淋巴結中位數明顯較高。

To summarize, the authors conclude that, "Early results from the RAVAL trials suggest that robotic pulmonary lobectomy is a cost-effective intervention, which is associated with comparable patient-reported health utility scores when compared to VATS lobectomy."

總而言之，作者得出結論：“RAVAL 試驗的早期結果表明，機器人肺葉切除術是一種具有成本效益的干預措施，與 VATS 肺葉切除術相比，它與患者報告的健康效用評分相當。”

And with that, I would like to turn it over to Brian who will discuss additional procedure highlights and provide our updated outlook for 2024.

接下來，我想將其交給 Brian，他將討論其他程序要點並提供我們對 2024 年的最新展望。

Thank you, Myriam. Our overall third quarter procedure growth was 19% year-over-year compared to 20% for the third quarter of 2022 and 22% last quarter. In the U.S., third quarter 2023 procedure growth was 17% year-over-year compared to 18% for the third quarter of 2022 and 19% last quarter. Q3 growth was led by procedure strength within general surgery, with particular strength in cholecystectomy and colon resection.

謝謝你，米里亞姆。我們第三季的整體流程年增 19%，而 2022 年第三季為 20%，上季為 22%。在美國，2023 年第三季手術量年增 17%，而 2022 年第三季為 18%，上一季為 19%。第三季的成長主要由一般外科的手術強度主導，尤其是膽囊切除術和結腸切除術的強度。

Outside of the U.S., third quarter procedure volume grew 24% compared with 24% for the third quarter of 2022 and 28% last quarter. OUS growth was led by procedures beyond urology, which now make up approximately 50% of total OUS procedures.

在美國以外，第三季的手術量增加了 24%，而 2022 年第三季為 24%，上一季為 28%。 OUS 增長由泌尿科以外的手術帶動，目前約佔 OUS 手術總量的 50%。

General surgery growth was strong, primarily in colorectal procedures followed by growth in gynecology procedures. Growth in urology continued to be healthy, led by kidney procedures, along with continued double-digit growth in prostatectomy.

普通外科手術成長強勁，主要是結直腸手術，其次是婦科手術。在腎臟手術的帶動下，泌尿外科持續健康成長，攝護腺切除術也持續兩位數成長。

In Europe, we experienced strong growth in Germany, the U.K. and Spain. In each of the regions noted, procedure growth was led by general surgery, primarily from colorectal procedures and specifically in Germany and the U.K., hysterectomy procedures also contributed to strong growth.

在歐洲，我們在德國、英國和西班牙經歷了強勁成長。在上述每個地區，手術增長均由普通外科帶動，主要來自結直腸手術，特別是在德國和英國，子宮切除手術也促進了強勁增長。

In Asia, growth was led by Japan. More than half of the incremental procedure growth in the country was led by strong growth in general surgery procedures, consisting largely of colorectal and gastrectomy procedures. In China, procedure growth was consistent with our expectations for the quarter.

在亞洲，成長由日本引領。該國一半以上的增量手術增長是由普通外科手術的強勁增長帶動的，主要包括結直腸和胃切除手術。在中國，程式成長符合我們對本季的預期。

Growth was driven primarily in neurology, notably by prostatectomy and kidney procedures.

增長主要由神經病學驅動，特別是前列腺切除術和腎臟手術。

In India, while in the early stage of adoption, saw strong growth in general surgery procedures, namely cholecystectomy and hernia repair and growth in gynecology procedures.

在印度，雖然處於採用的早期階段，但普通外科手術（即膽囊切除術和疝氣修復）以及婦科手術的增長強勁。

I will now turn to our financial outlook for 2023. Starting with procedures. On our last call, we forecasted full year 2023 procedure growth within a range of 20% to 22%. We are now raising the low end from 20% to 21% and expect full year 2023 procedure growth of 21% to 22%. The low end of the range reflects uncertainty around the duration of elevated procedure volumes with patients returning to health care, a continued slowing of bariatric growth rates in the U.S. and macroeconomic challenges that could impact hospitals and patient spending.

我現在將談談我們 2023 年的財務展望。從程序開始。在上次電話會議中，我們預測 2023 年全年手術成長將在 20% 至 22% 的範圍內。我們現在將低端成長率從 20% 提高到 21%，預計 2023 年全年流程成長率為 21% 到 22%。該範圍的低端反映了患者返回醫療保健時手術量增加的持續時間的不確定性、美國減肥增長率的持續放緩以及可能影響醫院和患者支出的宏觀經濟挑戰。

At the high end of the range, we assume macroeconomic challenges do not have a significant impact on hospital procedure volumes, and bariatric growth rates in the U.S. continue at the rate we experienced in Q3. The range does not reflect significant material supply chain disruptions or hospital capacity constraints.

在該範圍的高端，我們假設宏觀經濟挑戰不會對醫院手術量產生重大影響，並且美國的減重成長率繼續保持我們在第三季度經歷的速度。此範圍並未反映重大的材料供應鏈中斷或醫院容量限制。

Turning to gross profit. On our last call, we forecast our 2023 full year pro forma gross profit margin to be within 68% and 69%. We are now refining our estimate of pro forma gross profit margin to be within 68% and 68.5%. 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。在上次電話會議中，我們預測 2023 年全年預計毛利率將在 68% 和 69% 之間。我們目前正在將備考毛利率的估計細化至 68% 和 68.5% 之間。我們的實際毛利率將隨季度而變化，很大程度上取決於產品、區域和以舊換新的組合以及新產品推出的影響。

With respect to operating expenses, on our last call, we forecast pro forma operating expense growth to be between 12% and 15%. We are adjusting our estimate and now expect our full year pro forma operating expense growth to be between 12% and 14%. We are also refining our estimate for noncash stock compensation expense to range between $600 million to $610 million in 2023, lowering the range from our previous estimates of $600 million to $620 million.

關於營運費用，在我們上次電話會議中，我們預計預計營運費用成長將在 12% 至 15% 之間。我們正在調整我們的估計，現在預計全年預計營運費用成長將在 12% 至 14% 之間。我們也將對 2023 年非現金股票補償費用的估計進行細化，將其範圍從我們先前估計的 6 億美元到 6.2 億美元降低到 6 億美元到 6.1 億美元之間。

We are increasing our estimate for other income, which is comprised mostly of interest income, to total between $190 million and $200 million in 2023, an increase from our previous estimate of $160 million and $180 million. The increase primarily reflects the rise in interest rates.

我們正在提高其他收入（主要由利息收入組成）的預測，到 2023 年，總額將達到 1.9 億美元至 2 億美元，高於我們先前預測的 1.6 億美元至 1.8 億美元。這一增長主要反映了利率的上升。

With regard to capital expenditures, we are narrowing our estimate to range between $900 million to $1 billion, primarily for planned facility construction activities. With regard to income tax, we are also refining our estimate for the 2023 pro forma tax rate to be between 22% and 23% of pretax income, reducing the previous estimate of the upper end of the range from 24% to 23%.

關於資本支出，我們將估計範圍縮小到 9 億美元至 10 億美元之間，主要用於計劃的設施建設活動。在所得稅方面，我們也將對 2023 年備考稅率的估計細化為稅前收入的 22% 至 23%，將先前估計的範圍上限從 24% 至 23% 降低。

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。我們現在將開始電話詢問您的問題。

(Operator Instructions) We go to the first question from the line of Robbie Marcus, JPMorgan.

（操作員說明）我們回答來自摩根大通的 Robbie Marcus 的第一個問題。

Congrats on good quarter. Maybe to start, it's hard to escape it. GLP-1 is becoming a very big topic in med tech. And your -- it's impacting bariatric surgery here. It doesn't seem to be impacting anything else, particularly in the pipeline. But just wondering your thoughts overall, could GLP-1s ultimately be a positive as more people try weight loss surgery and come in the funnel? And any other impacts good or bad that you foresee on business?

恭喜季度表現良好。或許剛開始，就很難逃脫。 GLP-1 正在成為醫療科技領域的一個非常大的議題。而你的——它正在影響這裡的減肥手術。它似乎沒有影響其他任何事情，特別是在管道中。但只是想知道您的整體想法，隨著越來越多的人嘗試減肥手術並進入漏斗，GLP-1 最終是否會產生積極影響？您預見到的其他對業務的影響是好是壞？

Thanks, Robbie. I'm going to ask Dr. Curet as a bariatric surgeon to go ahead and weigh in on that first part of your question, and we'll talk about the broader implications after that.

謝謝，羅比。我將請作為減肥外科醫生的 Curet 博士繼續權衡你問題的第一部分，然後我們將討論更廣泛的影響。

I think you are correct. I think in the short term, we will see patients who are considering or are in the pipeline for bariatric surgery going to try the drug. However, given compliance issues, costs, side effects, we expect that many of them will not stay on the drug for longer than a year or 2. And at that time, we'll consider bariatric surgery. So I think overall, we'll see an increased interest in bariatric surgery, but that will get delayed in the short term.

我認為你是對的。我認為在短期內，我們會看到正在考慮或正在準備減肥手術的患者會嘗試這種藥物。然而，考慮到依從性問題、成本、副作用，我們預計他們中的許多人服用藥物的時間不會超過一年或兩年。到那時，我們將考慮減肥手術。因此，我認為總體而言，我們將看到人們對減重手術的興趣增加，但這在短期內會被推遲。

Robbie, any follow-up you wanted on GLP-1s?

Robbie，您想了解有關 GLP-1 的任何後續資訊嗎？

No, I had a financial question for Jamie, if that's okay, after.

不，我有一個財務問題想問傑米，如果可以的話，稍後再說。

Please.

請。

Jamie, it looks like the fourth quarter gross margin is ticking down a bit, and you're talking about the increased depreciation cost and some of these new investments here. I was wondering if you could size the amount, and I'm really looking for how to think about into next year with depreciation, so we could get our gross margin set based on whatever expansion or contraction we're all forecasting.

傑米，看起來第四季的毛利率有點​​下降，你正在談論增加的折舊成本和其中一些新投資。我想知道你是否可以確定金額，我真的在尋找如何考慮明年的折舊，這樣我們就可以根據我們都預測的擴張或收縮來確定毛利率。

Yes. For Q4, you're not really seeing significant depreciation and expense reflected in the range that we provided. That's really more next year as some of the manufacturing capacity in facilities come online.

是的。對於第四季度，您並沒有真正看到我們提供的範圍中反映的重大折舊和費用。明年，隨著一些設施的生產能力上線，這個數字確實會更高。

What you're seeing in Q4 really is a little bit of FX given how the rates have moved, a little bit of slower progress in some of the line transfers and product cost reduction plans that we have, that's not a large delay. It's just slightly slower than we had planned. And then there's some mix dynamics reflected in Q4. They now to be relatively small, but those are the dynamics as to why gross margin range for the year is at the midpoint, slightly lower than what we had previously.

考慮到匯率的變化，您在第四季度看到的確實是一點點外匯，我們的一些線路轉移和產品成本降低計劃的進展有點緩慢，這並不是一個很大的延遲。只是比我們計劃的慢一點。第四季反映了一些混合動態。現在它們相對較小，但這些就是為什麼今年毛利率範圍處於中點的動態，略低於我們之前的水平。

With respect to how '24 is shaping up, what I would just say is, as Gary said in his prepared remarks, we'll see some variability in gross margin over the next several quarters is the depreciation expense and the ongoing efforts to improve our product costs, particularly on the Ion side. And frankly, there are some accumulated inefficiencies just in our global manufacturing operations. They built up over COVID and because of the supply chain issues that we encountered that we're addressing. And a number of those will take time for us to resolve.

關於「24」的發展情況，我想說的是，正如加里在他準備好的講話中所說，我們將看到未來幾個季度毛利率的一些變化是折舊費用以及為改善我們的持續努力而所做的努力。產品成本，尤其是 Ion 方面。坦白說，我們的全球製造業務中累積了一些效率低下的問題。它們是在新冠疫情期間以及我們正在解決的供應鏈問題上累積起來的。其中許多問題需要我們時間來解決。

So I'd say let us give you '24 guidance for gross margin when we get to January because I think we still have to work through those plans.

因此，我想說，當我們到一月份時，讓我們為您提供 '24 毛利率指導，因為我認為我們仍然需要完成這些計劃。

We'll go to the next line, Travis Steed, Bank of America.

我們將轉到下一行，Travis Steed，美國銀行。

I guess to follow up on that. I know on the prepared remarks, it sounds like Gary said, manufacturing improvements for new products and other complex projects. So just curious if you could elaborate on some of those new products and complex projects and what those are that's impacting the gross margin.

我想跟進一下。我知道在準備好的演講中，聽起來就像加里所說的，新產品和其他複雜項目的製造改進。因此，我想知道您是否可以詳細說明其中一些新產品和複雜項目，以及影響毛利率的因素。

Yes. On the product side, we have real work to do on Ion. Ion is well accepted by the customer base, growing quickly. We need to iterate and drive manufacturability and manufacturing costs on Ion. So that was mainly what I was referring to.

是的。在產品方面，我們在 Ion 上還有真正的工作要做。 Ion 深受客戶群認可，成長迅速。我們需要迭代並提高 Ion 的可製造性和製造成本。這就是我主要指的。

Some of the accessories in the SP line are real opportunities. We want to be assertive there. So on the product side, that's most of what the reference is.

SP 系列中的一些配件是真正的機會。我們希望在那裡表現得自信。所以在產品方面，這就是大部分參考內容。

Just one other element. We are in-sourcing a high-volume accessory on the multiport side as part of in-sourcing that there's some differential automation in the line there. And so ramping that, there's some work to get that to be at our targets.

只是另一個元素。我們正在內購多連接埠側的大批量配件，作為內購的一部分，那裡的生產線有一些差異化自動化。因此，為了達到我們的目標，還需要做一些工作。

Great. Helpful. And coming into this year, on the procedures, some of the swing factors were China, staffing pressures and COVID. And I imagine like going into '24, there's bariatrics in China, some of the swing factors. Maybe you could just talk about some of the swing factors on 2024 procedures, pluses and minuses and do you think China and bariatrics are still going to be growing and adding to the growth in procedures in '24?

偉大的。有幫助。進入今年，在程序上，一些搖擺因素包括中國、人員壓力和新冠疫情。我想像進入 24 世紀，中國會出現減肥問題，一些搖擺因素。也許您可以談談 2024 年手術的一些搖擺因素、優點和缺點，您認為中國和減肥醫學是否仍將增長並促進 24 年手術的增長？

Travis, this is Brian. I guess thinking of 2024, nothing really to share at this point. Clearly, I think when we get into January, we'll be able to give you a bit more insight. But I guess I'll just leave it at that for now.

崔維斯，這是布萊恩。我想想想 2024 年，目前沒有什麼好分享的。顯然，我認為當我們進入一月份時，我們將能夠為您提供更多的見解。但我想我暫時就這樣吧。

Let me just pick up 2 topics you hit. On the China side, I think the procedure demand side remains robust. I think there's some government policy activity that's putting a little bit of a chill in the market. Some of that is economics, so price caps and value-based pricing and some of it is in any corruption probe that is giving hospitals some pause moving forward with other new programs.

讓我挑兩個你提到的主題。在中國方面，我認為程序需求面仍然強勁。我認為政府的一些政策活動為市場帶來了一點寒意。其中一些是經濟因素，例如價格上限和基於價值的定價，還有一些是在任何腐敗調查中，這讓醫院在推進其他新項目時猶豫不決。

We'll see. I think the China side is likely to -- some pressure on the China side is likely to persist for several quarters.

我們拭目以待。我認為中國方面可能會——中國方面的一些壓力可能會持續幾個季度。

On the bariatric side, I think we'll find a new normal in the next few quarters. It's hard to predict exactly when that will happen. We'll see that play out in the marketplace.

在減肥方面，我認為我們將在接下來的幾季找到新常態。很難準確預測這種情況何時會發生。我們將看到這一點在市場上發揮作用。

We go to next line, Larry Biegelsen, Wells Fargo.

我們轉到下一行，Larry Biegelsen，富國銀行。

Gary, your usage-based leasing program has gotten some scale. Can you talk about the utilization rates on those systems relative to the average? And any other themes you could share?

加里，您的基於使用的租賃計劃已經達到一定規模。您能談談這些系統相對於平均值的使用率嗎？還有其他可以分享的主題嗎？

Sure. I will turn to Jamie here on kind of utilization rates. So why don't you kick that off?

當然。我將在這裡向傑米詢問利用率的問題。那你為什麼不開始呢？

Yes. There's 2 ways to look at it, Larry, what is the absolute utilization rate compared to a regular leasing compared to a purchase arrangement. They are very similar. Actually, the tightness on the mean between those 3 structures is very tight.

是的。有兩種方法可以看待這個問題，拉里，與常規租賃相比，與購買安排相比，絕對利用率是多少。他們非常相似。實際上，這 3 個結構之間的平均值緊密度非常緊密。

Within those arrangements, you generally have a target procedure level that reflects success of the program for the customer and the economic objectives that we have. And if you accumulate again, the portfolio they run at slightly above the targeted procedure levels that we have embedded in the contracts. So they have run very well so far, and it's one of the reasons why we and the customer have expanded those so quickly in recent times.

在這些安排中，您通常有一個目標程序級別，該級別反映了客戶計劃的成功以及我們的經濟目標。如果你再次積累，他們的投資組合運行的速度略高於我們嵌入合約中的目標程式水平。因此，到目前為止，它們運作得非常好，這也是我們和客戶最近如此迅速地擴展這些專案的原因之一。

That's helpful. And leasing in the U.S., where do you see that going? I mean, it was almost -- it was over 70 this quarter and last quarter. Have we plateaued? Or does that continue to go higher?

這很有幫助。您認為美國的租賃業將走向何方？我的意思是，這個季度和上個季度幾乎超過 70。我們已經趨於穩定了嗎？還是繼續走高？

On a global basis, we expect the proportion of placements that are leased to continue to find. U.S. is pretty high, as you pointed out, Larry, 70% this quarter, 78% last quarter. There will be some larger IDNs that just routinely prefer to purchase just because of how that affects the metrics that are important to them. But even in the U.S., I think there's some room for that to continue to creep up a little bit, obviously, running out of room. We found a number of U.S. customers have really appreciate that as a way to manage through what are totally managed capital budgets.

在全球範圍內，我們預計租賃的安置比例將持續上升。正如你所指出的，拉里，美國的比例相當高，本季為 70%，上季為 78%。一些較大的 IDN 通常更願意購買，因為這會影響對他們來說很重要的指標。但即使在美國，我認為這種情況仍有持續成長的空間，顯然，空間已經所剩無幾。我們發現許多美國客戶非常欣賞這種透過完全管理的資本預算進行管理的方式。

Next, we have Brandon Vazquez, William Blair.

接下來是布蘭登·巴斯克斯和威廉·布萊爾。

Maybe my first one, I wanted to talk a little bit about general surgery, that's obviously been a nice growth path for you here in the U.S. My understanding is it's a little less penetrated international. What do you think needs to happen in the international markets to kind of get on that steep part of the adoption curve for general surgery as well? Are they kind of seeing time lines and catalysts in the U.S?

也許是我的第一個，我想談談普通外科，這顯然對你在美國來說是一條很好的成長道路。我的理解是，它在國際上的滲透率還比較低。您認為國際市場上需要發生什麼才能達到一般外科手術採用曲線的陡峭部分？他們是否看到了美國的時間表和催化劑？

Sure. Thank you for the question. On -- one way to think about it is that general surgery comprises both procedures that are done where cancer is the underlying cause and others that are benign indication.

當然。感謝你的提問。一種思考方式是，一般外科手術既包括以癌症為根本原因的手術，也包括其他良性適應症的手術。

On the cancer as an underlying cause, we're seeing nice early growth in several OUS markets. So there, I think that's healthy, and we're enthused. I think reimbursements are generally in place in many of the places that we are operating. I think that's what good in clinical data coming out has been supportive.

將癌症作為根本原因，我們看到幾個 OUS 市場出現了良好的早期成長。所以，我認為這是健康的，我們很興奮。我認為我們經營的許多地方普遍都有報銷。我認為這就是臨床數據的良好支持。

I think that as you think about benign indications, we're seeing some of the beginnings of benign indications in some markets, there may be reimbursement work or education of insurers that has to be done for those to progress further. So in that setting, we'll have additional work to do as it plays out.

我認為，當您考慮良性跡象時，我們在某些​​市場上看到了一些良性跡象的開始，可能需要對保險公司進行報銷工作或教育，以便進一步取得進展。因此，在這種情況下，我們將有更多的工作要做。

Great. And then maybe last one for me as a follow-up, I think last quarter, you guys were talking a little bit about launching, I believe it was called Case Insights, kind of the software AI platform. Any kind of updates on that end? How are things going so far? And maybe what's in the future for that program?

偉大的。然後也許是我作為後續行動的最後一個，我想上個季度，你們談論了一些關於發布的事情，我相信它被稱為 Case Insights，一種軟體人工智慧平台。這方面有什麼更新嗎？到目前為止事情進展如何？也許該計劃的未來會怎樣？

Yes. Thank you for the reference. So Case Insights is our machine learning AI program that looks at surgical science. We have our first installs and first cases going. We had talked about it with you last quarter. So far, early feedback, and it's super early. We're really in the early innings here is very good. Case Insights builds on some prior research that we had done with academic centers on something that we have described as a computational observer. So we have some pretty good scientific underpinnings for it.

是的。謝謝您的參考。 Case Insights 是我們研究外科科學的機器學習人工智慧程式。我們已經完成了第一次安裝和第一個案例。上個季度我們曾與您討論過這個問題。到目前為止，已經得到了早期回饋，而且還非常早。我們確實處於早期階段，這非常好。案例洞察建立在我們先前與學術中心進行的一些研究的基礎上，我們將其描述為計算觀察者。所以我們對此有一些很好的科學基礎。

We expect over time that, that program will feed insights into different parts of the hospital's analytic system from giving specific guidance to learning surgeons and care teams about where they might improve their technique and skills to giving suggestions to programmatics about efficiency and total cost management, to giving other insights for the company about how to improve procedures in the OR.

我們預計，隨著時間的推移，該計劃將為醫院分析系統的不同部分提供深入的見解，從為學習外科醫生和護理團隊提供有關他們可以在哪些方面改進技術和技能的具體指導，到為有關效率和總成本管理的程序提供建議，為公司提供有關如何改進手術室程序的其他見解。

So we think it's a long-term set of investments around really the science of surgery. We remain extremely excited about it. While we do have some revenue for it, we don't expect it to be a serious revenue driver. We think it is an ecosystem complementor. And we look forward to describing it more to you as time goes on.

因此，我們認為這是圍繞外科科學的一系列長期投資。我們對此仍然感到非常興奮。雖然我們確實有一些收入，但我們預計它不會成為一個重要的收入驅動因素。我們認為它是生態系的補充者。隨著時間的推移，我們期待著向您提供更多描述。

We'll go next to Matt Miksic, Barclays.

我們接下來是巴克萊銀行的馬特·米克西奇。

So I had one question on -- follow-up on kind of the bariatric trends and one on sort of the system leasing effect on pricing. So bariatric, if you could maybe talk about -- you mentioned the global percentage of procedures that bariatric represents maybe just the growth trajectory of that business in the second quarter and the third quarter and whether that's something you expect to grow at a similar trajectory or bottom out given your comments on folks getting on the drug or getting off saying a year or 2 to kind of suggest maybe a longer path to stabilization in that business line within. And then I'll just follow up briefly with the question on ASPs, if I could.

因此，我有一個問題是關於肥胖趨勢的後續行動，以及系統租賃對定價的影響。因此，如果您可以談論減肥治療，您提到減肥治療所代表的全球手術百分比可能只是該業務在第二季度和第三季度的增長軌跡，以及您是否期望以類似的軌跡增長或考慮到您對人們服用藥物或戒除藥物的評論，你說一兩年後，這可能表明該業務線可能有更長的穩定之路。如果可以的話，然後我將簡單地跟進有關 ASP 的問題。

Yes. Jamie, you might speak to kind of what the size or percentage of that business is for us and a little bit of the acceleration or deceleration trend.

是的。傑米，你可能會談到該業務對我們來說的規模或百分比，以及一些加速或減速的趨勢。

Yes. And I want to make sure I got it right, Matt. So come back to me if I have the wrong questions. But our total bariatric business represents about 4% to 5% of global procedures. What you saw in Q2 was in the U.S., which is where the majority of our bariatric procedure volumes are, in the U.S., the growth rate declined to about the U.S. average and then what we saw in Q3 was it modestly decline a little further in Q3. Were those your questions?

是的。我想確保我做對了，馬特。因此，如果我有錯誤的問題，請回來找我。但我們的減重業務總量約佔全球手術量的 4% 至 5%。你在第二季度看到的是美國，這是我們大部分減肥手術量的所在地，在美國，成長率下降到美國平均水平左右，然後我們在第三季度看到的是，它在Q3。這些是你的問題嗎？

Yes. No, that's very helpful. And then I guess, just your expectation -- you framed out in terms of your guidance, but I mean, is this -- I mentioned it just because one of the other competitors actually saw a decline, I guess, in laparoscopic bariatric or some (inaudible) open in the third quarter, single-digit decline, but it doesn't seem like you're in that zone, right? You're still at or slightly below your average growth rate in the U.S. Is that -- am I hearing you answer correctly?

是的。不，這非常有幫助。然後我想，這只是你的期望——你根據你的指導制定了框架，但我的意思是，這是——我提到它只是因為其他競爭對手之一實際上看到了腹腔鏡減肥或某一些領域的下降。（聽不清楚）第三季開盤價出現個位數下降，但看起來您並不處於該區域，對吧？您仍然處於或略低於美國的平均成長率。我聽到您的回答正確嗎？

Well, if you take our procedure growth in bariatrics relative to market, we're taking share and have been for some time. So the fact that we had double-digit growth in Q3 relative to another company that had a decline, that's just a reflection in part of the fact that we are taking share in bariatrics and continue to do so even though there's an impact to overall bariatric surgery because of GLP-1s.

好吧，如果你看看我們在減肥治療領域相對於市場的進展，我們正在佔據市場份額，而且這種情況已經有一段時間了。因此，相對於另一家出現下滑的公司，我們在第三季度實現了兩位數的增長，這在一定程度上反映了我們正在減肥領域佔據份額，並將繼續這樣做，儘管這對整體減肥領域產生了影響。由於 GLP-1 的影響而進行手術。

Got it. That's very helpful. And then the other -- just ASP, I understand the system ASP you give is not -- does not -- as your U.S. leasing goes up, as I understand it, those leased systems in the U.S. are not included in that ASP calculation. So if you could maybe just speak to -- I don't know, the way in which the increased leases have affected ASP or whether this is straight up year-over-year decline that suggested in sort of the overall numbers that you provide, if that's a clear question.

知道了。這非常有幫助。然後另一個 - 只是 ASP，我知道你提供的系統 ASP 不是 - 沒有 - 隨著你的美國租賃增加，據我了解，美國的那些租賃系統不包括在 ASP 計算中。因此，如果您可以談談——我不知道增加的租賃量對平均售價的影響方式，或者這是否是同比直線下降，這表明您提供的總體數據，如果這是一個明確的問題。

So everything you described is correct. Generally, although there can be exceptions for mix effect, generally U.S. system ASPs when purchased are accretive to the global average. So in effect, as leasing has grown significantly in the U.S., that in and of itself has an adverse effect for calculated system ASP.

所以你所描述的一切都是正確的。一般來說，儘管混合效應可能存在例外，但通常購買美國系統平均售價會高於全球平均。因此，實際上，隨著美國的租賃業務大幅成長，這本身將對計算系統的平均售價產生不利影響。

The other thing that you see then with now a greater proportion of systems used to calculate that system ASP being international FX can have an effect if you look on a 2-year horizon. So for example, the exchange rate in Japan based on how the U.S. dollar has strengthened, there's a 30% to 40% impact over a 2-year basis on system ASP in Japan as translated. So there is a geographical effect.

您會看到的另一件事是，如果您從兩年的角度來看，現在用於計算系統 ASP 的系統比例更大，那麼國際外匯可能會產生影響。例如，日本的匯率取決於美元的升值情況，在 2 年的基礎上，日本的系統平均售價會受到 30% 到 40% 的影響。所以存在地理效應。

And if you look at a long enough horizon, there's an FX effect in what we described in Q3 was in terms of the year-over-year decline in ASP, also a dynamic relative to pricing and that's really just as we expand our existing customers who are looking for a third, fourth, fifth system, those tend to be slightly lower ASPs than you've seen previously when they were greenfield accounts.

如果你把目光放得夠長，就會發現我們在第三季所描述的外匯效應是平均售價同比下降，這也是相對於定價的動態，這實際上就像我們擴大現有客戶一樣對於那些正在尋找第三個、第四個、第五個系統的人來說，這些系統的平均售價往往比您之前在綠地帳戶時看到的略低。

I would say that in China, we do see some competitive dynamics with respect to pricing just given the number of lower local players. And so there's been some competitive effect on system ASPs in China specifically. We don't really see that in other markets to this point.

我想說，在中國，考慮到本地企業數量較少，我們確實看到了定價方面的一些競爭動態。因此，特別是在中國，系統 ASP 受到了一些競爭影響。到目前為止，我們在其他市場還沒有真正看到這一點。

And we'll go to the next line. Jayson Bedford, Raymond James.

我們將轉到下一行。傑森貝德福德，雷蒙德詹姆斯。

Gary, I think you've expressed your views on the role of bariatric surgery in a GLP world. I'm just wondering if these views have changed in any way over the last quarter or 2? I know it's not a lot of time, but the adoption of this class of drugs is obviously ramping quickly. And then just as kind of a related follow-up, getting back to Robbie's question on the potential impact of GLPs beyond bariatrics. Do you expect an impact from some of your other procedure categories as GLPs get adopted?

加里，我想您已經表達了您對減肥手術在 GLP 世界中的作用的看法。我只是想知道這些觀點在過去一兩個季度是否發生了變化？我知道時間不多，但這類藥物的採用顯然正在迅速增加。然後，作為一種相關的後續行動，回到羅比關於 GLP 在減肥之外的潛在影響的問題。隨著 GLP 的採用，您預計其他一些程式類別會產生影響嗎？

On the first one, I think Myriam described it well. Our position on GLP-1s as it relates to bariatric surgery, I think she hit it well at the start of the call, no reason to reiterate it here.

對於第一個，我認為 Myriam 描述得很好。我們對 GLP-1 的立場，因為它與減肥手術有關，我認為她在電話會議開始時就很好地表達了這一點，沒有理由在這裡重申。

On the issue of potential impact beyond bariatrics, there may be some, although I think as you think through the analysis, I think it will be modest.

關於減肥以外的潛在影響問題，可能會有一些影響，儘管我認為正如您透過分析思考的那樣，我認為影響會很小。

And here's how we think about it. If you look at obesity and diabetes is risk factors in other domains and other diseases for which surgery is performed, they are sometimes positive correlated risk factors for that disease. In some weird cases, they are negative in cases that it's actually protective against disease. So it's not entirely obvious.

這就是我們的想法。如果你看看肥胖和糖尿病是其他領域和其他需要進行手術的疾病的危險因素，它們有時是該疾病的正相關危險因素。在一些奇怪的情況下，如果它實際上可以預防疾病，它們就會呈現陰性。所以這並不完全明顯。

In most of the diseases that we treat as we look at it, it is not the dominant risk factor. So as we look out and think about what could it be like in our TAM, we can kind of do a back of the envelope analysis. It is really early. I don't think anybody knows the exact number. What I can say is that it's not the dominant risk factor in most things that we look at. And we have a very large unpenetrated TAM. I think that we're still in the early innings of what we're trying to work on. So if these drugs are highly effective at avoiding other types of diseases, we will cheer. I still think we have a lot of upside opportunity to pursue.

在我們所治療的大多數疾病中，它並不是主要的危險因子。因此，當我們觀察並思考 TAM 中的情況時，我們可以進行粗略分析。時間確實還早。我認為沒有人知道確切的數字。我可以說的是，在我們所關注的大多數事情中，這並不是主要的風險因素。我們有一個非常大的未滲透的 TAM。我認為我們仍處於努力工作的早期階段。因此，如果這些藥物能夠非常有效地避免其他類型的疾病，我們就會歡呼。我仍然認為我們有很多上升的機會可以追求。

And we'll go to next line. Ryan Zimmerman, BTIG.

我們將轉到下一行。瑞安·齊默爾曼，BTIG。

I think you spoke about some of the new indications in SP. If I'm not mistaken, I think there's a 30-day follow-up on the thoracic trial. But I'm curious if you could expand maybe when complex colorectal and thoracic cases potentially could become growth drivers for SP adoption and when you expect those -- not just those trials to wrap up, but potentially clearances in the U.S. with that?

我想您談到了 SP 的一些新適應症。如果我沒記錯的話，我認為胸部測試有 30 天的追蹤。但我很好奇，當複雜的結直腸和胸部病例可能成為 SP 採用的增長動力時，以及當您期望這些——不僅是那些試驗結束，而且可能在美國獲得批准時，您是否可以擴大規模？

Sure. Myriam, I think you're best to answer.

當然。米里亞姆，我認為你最好回答。

Yes. So we are hoping to submit everything in the foreseeable future. After that, as you know, there's at least a 90-day turnaround for the IDEs and then -- excuse me, for the clearances. And then after that, we will have to put training together and the launches together. So I can't really give you a time line for when that would be, but we know what the work is that needs to be done, and we are starting and moving forward on that.

是的。因此，我們希望在可預見的將來提交所有內容。如您所知，此後，IDE 至少有 90 天的周轉時間，然後 - 對不起，還有許可。之後，我們必須將培訓和發布放在一起。所以我真的無法給你一個時間表，但我們知道需要完成哪些工作，我們正在開始並向前邁進。

Our biggest steps are get the data arranged, get it into the FDA and work with them to get clearances. And then as Myriam says, we'll go through a staged commercialization. So you can expect submissions in the first half of '24 and then response thereafter.

我們最重要的步驟是整理數據，將其提交給 FDA 並與他們合作以獲得許可。然後，正如 Myriam 所說，我們將進行分階段的商業化。因此，您可以期待在 24 年上半年提交意見，然後再回覆。

One of the other things, and I don't know if it's direct to you, Gary or Jamie, but you did talk about an opportunity to lower product costs as supply chain stresses ease and I know there were some comments earlier about '24 gross margins. But stepping aside from that, can you quantify the opportunity potentially for what that looks like? Have you gotten your arms around -- I know Marshall has been kind of shepherd in these processes. But at what point can you give the Street more color on what that opportunity looks like to drive gross margin gains?

還有一件事，我不知道這是否直接針對您，加里或傑米，但您確實談到了隨著供應鏈壓力緩解而降低產品成本的機會，我知道早些時候有一些關於“24 總成本”的評論邊距。但除此之外，您能否量化潛在的機會？你有沒有擁抱過——我知道馬歇爾在這些過程中一直是個牧羊人。但什麼時候你可以向華爾街提供更多關於推動毛利率成長的機會的資訊？

We have very well detailed plans for each of the areas that we're focused on. The teams have the capability and skill. It's going to take some time. I think the best way I would answer the question is we see a path over time probably in the midterm to get back above 70% gross margin.

我們對我們關注的每個領域都有非常詳細的計劃。團隊有能力和技巧。這需要一些時間。我認為回答這個問題的最佳方法是，隨著時間的推移，我們可能會在中期看到毛利率恢復到 70% 以上的路徑。

We go to next line. Anthony Petrone, Mizuho Group.

我們轉到下一行。安東尼‧佩特龍，瑞穗集團。

Maybe one on China and one on pricing on instruments. When we think about the quota size that National Health Commission in China put out, its new quota is 559 systems. Just wondering on anticorruption, could that shift that number over time whether it be that just fewer capital dollars going to projects or just from a timing element because things are getting elongated.

也許一項是關於中國的，另一項是關於工具定價的。當我們考慮中國國家衛健委發布的配額規模時，它的新配額是 559 個系統。只是想知道反腐敗問題，隨著時間的推移，這個數字是否會發生變化，無論是用於專案的資本減少，還是只是因為時間因素，因為事情正在被拉長。

And then the pricing question would be on instruments and accessories. The company put a 5% price increase in their first one in 14 years. Chairman Powell came out and said, look, inflation is going to be persistent and elevated for quite some time. If inflation stays high, could another 5% price increase beyond the table for 2024?

然後定價問題將涉及儀器和配件。該公司 14 年來首次提價 5%。鮑威爾主席出來說，看，通貨膨脹將在相當長的一段時間內持續併升高。如果通膨居高不下，2024 年價格是否會再上漲 5%？

With regard to the capital side in China, I'll jump into that. I think demand for our systems and for the procedures they support in China, raw demand is really high. So it's really being limited or titrated by policy. I don't see -- I haven't heard anything that says people want to go back and revisit or lower the quota, I think that would be resisted by customers who are looking for purchases.

關於中國的資本方面，我會直接談談。我認為中國對我們的系統及其支援的程序的需求，原始需求確實很高。所以它確實受到政策的限製或削減。我沒有看到 - 我沒有聽到任何說人們想要回去重新訪問或降低配額的消息，我認為這會受到正在尋求購買的客戶的抵制。

So I think it's more around delay and a kind of a timing thing. How long it is hard to predict, but months, not weeks.

所以我認為這更多的是關於延遲和一種時間安排。很難預測要持續多久，但可以預測是幾個月，而不是幾週。

On the pricing side, I'll speak to a general principle rather than projecting '24. What we try to do is a couple of things. One is be an outstanding manufacturer, really get high quality at low cost and make sure that we can invest in manufacturing prowess to do that. I think that's really powerful for us, gives us enormous flexibility to meet the customers' needs, kind of where they are.

在定價方面，我將談論一般原則，而不是預測「24」。我們嘗試做的有幾件事。一是成為一家傑出的製造商，真正以低成本獲得高品質，並確保我們可以投資於製造能力來做到這一點。我認為這對我們來說非常強大，為我們提供了巨大的靈活性來滿足客戶的需求，無論他們在哪裡。

With regard to pricing, we look at a couple of things, certainly price to us, cost to us, but also price elasticity, what the customer can do and achieve and that varies by market. And I think we've become increasingly sensitive to and sophisticated at understanding pricing.

關於定價，我們會考慮幾個因素，當然是我們的價格、我們的成本，還有價格彈性、客戶可以做什麼和實現什麼，這會因市場而異。我認為我們對定價的理解變得越來越敏感和成熟。

So raw material pricing and core inflation to us is an input to our pricing. That's why we took price up this last year but it's not the only thing, and you shouldn't expect us to be purely algorithmic tracking inflation on its own.

因此，原物料定價和核心通膨對我們來說是我們定價的一個輸入。這就是我們去年提高價格的原因，但這不是唯一的原因，你不應該指望我們純粹靠演算法來追蹤通膨。

And we'll go to the line of Michael Polark of Wolfe Research.

我們將轉向沃爾夫研究中心的邁克爾·波拉克（Michael Polark）。

I have big picture one modeling long term. There's an investor presentation out earlier this year and it -- Intuitive identified 6 million procedures globally for multi and single port for which you currently have line of sight. And on that same slide, identified that there's 20 million soft tissue surgery procedures overall. And if I look at where you're today, you're approaching 40% of that 6 million. And so my question is the delta between the 20 and the 6 to 14 kind of -- how do you expand the 6 towards the 20? And what are the major unlocks that you expect over the next 3 to 5 years that will move the 6 towards the 20 and kind of your feel for the pace of addressing more of the global procedure pie?

我有一個長遠的模特計劃。今年稍早有一份投資者介紹，Intuitive 確定了全球 600 萬個您目前可以看到的多連接埠和單埠程式。在同一張投影片上，我們發現總共有 2,000 萬例軟組織手術。如果我看看你們今天的情況，就會發現你們已經接近這 600 萬人中的 40%。所以我的問題是 20 和 6 到 14 之間的差異 - 如何將 6 擴展到 20？您預計未來 3 到 5 年內將有哪些重大進展，將 6 推向 20，您對解決更多全球手術問題的步伐有何感受？

Yes, it's a good question. I think the general tools that we use to get from 6 to 20 are kind of 3 buckets. Some of them are clearances in new markets. So making sure that a market we can address has access to the technologies that we already have. So when you think about something like Ion, for example, Ion is not yet available in all the markets in which we operate as it operates that it starts to open what we can do. That's kind of one bucket.

是的，這是一個好問題。我認為我們用來獲取 6 到 20 個數據的一般工具是 3 個桶。其中一些是新市場的清倉。因此，請確保我們可以解決的市場能夠使用我們已有的技術。例如，當你想到像 Ion 這樣的東西時，Ion 尚未在我們經營的所有市場中提供，因為它開始開放我們能做的事情。這就是一桶。

New indications are another one that some of the work that Myriam described earlier. That starts to open a new opportunity for us as we broaden the applicability of our platforms to new types of surgery and intervention.

新的跡像是 Myriam 之前描述的一些工作的另一個跡象。隨著我們將平台的適用性擴展到新型手術和乾預，這開始為我們帶來新的機會。

The third bucket or another bucket is reimbursement. There are places where we think additional data is required to get insurers to engage a little bit differently and open the market.

第三個桶或另一個桶是報銷。我們認為在某些地方需要額外的數據才能讓保險公司以不同的方式參與並開放市場。

And then lastly, there are new products and technologies that we're working on that we are not yet described that we think allow us to provide new solutions that are competitive in the marketplace.

最後，我們正在開發一些尚未描述的新產品和技術，我們認為它們可以讓我們提供在市場上具有競爭力的新解決方案。

Each of those operates on a little bit different time line. So it's not -- I can't give you a simple synopsis of how fast each one runs. Some of them take a lot of years, some reimbursement things or long lead. A product development can be long lead. Other types of access can happen more quickly. But that's a set of plans that we lay out. We're pretty disciplined about laying out what we want to do over time over a multiyear time horizon. And that's how we start to open that market.

每一個都在稍微不同的時間線上運作。所以它不是——我無法給你一個簡單的概要來說明每個人的運行速度。其中有些需要很多年的時間，有些需要報銷或需要很長時間。產品開發可能需要很長時間。其他類型的訪問可以更快地進行。但這是我們所製定的一套計畫。我們非常有紀律地制定我們在多年時間範圍內想要做的事情。這就是我們開始打開這個市場的方式。

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.

這是我們最後一個問題。最後，我們仍然相信存在大量且持久的機會從根本上改善手術和緊急幹預措施。我們的團隊繼續與醫院、醫生和護理團隊密切合作，追求客戶所說的四重目標：更好、更可預測的患者治療結果、更好的患者體驗、更好的護理團隊體驗以及最終更低的總成本的照顧。

We believe value creation in surgery and acute care is foundationally human. It flows from respect for and understanding of patients and their teams, their needs and their environment.

我們相信手術和急診護理中的價值創造本質上是人的。它源自於對患者及其團隊、他們的需求和環境的尊重和理解。

At Intuitive, we envision the future of care that is less invasive and profoundly better where diseases are identified earlier and treated quickly so patients can get back to what matters most.

在 Intuitive，我們設想未來的護理將是侵入性更小、效果更好的護理，能夠更早發現疾病并快速治療，以便患者能夠回到最重要的事情上。

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

謝謝大家。您的會議到此結束。我們非常感謝您的加入。您現在可以斷開連線。祝你有美好的一天。