直覺手術 (ISRG) 2022 Q1 法說會逐字稿

Ladies and gentlemen, thank you for standing by, and welcome to the Intuitive Q1 2022 Earnings Release. (Operator Instructions) And as a reminder, your conference is being recorded.

女士們，先生們，感謝您的支持，歡迎來到 Intuitive Q1 2022 收益發布。 （操作員說明）作為提醒，您的會議正在錄製中。

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

我現在想將會議轉交給您的東道主，投資者關係主管 Brian King。請繼續。

Good afternoon and welcome to Intuitive's first quarter earnings conference call. With me today, we have Gary Guthart, our CEO; and Jamie Samath, CFO.

下午好，歡迎參加 Intuitive 第一季度財報電話會議。今天和我在一起的是我們的首席執行官 Gary Guthart；和首席財務官 Jamie Samath。

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 3, 2022. Our SEC filings can be found through our website or at the SEC's website. Investors are cautioned not to place undue reliance on such forward-looking statements.

在開始之前，我想通知您，今天電話會議中提到的評論可能被視為包含前瞻性陳述。由於某些風險和不確定性，實際結果可能與明示或暗示的結果大不相同。這些風險和不確定性在我們的證券交易委員會文件中有詳細描述，包括我們於 2022 年 2 月 3 日提交的最新 10-K 表格。我們的 SEC 文件可以通過我們的網站或在 SEC 的網站上找到。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 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 first 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, then I will discuss procedure and clinical highlights and provide our updated financial outlook for 2022. 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一季度業績的亮點，然後是問答環節。 Gary 將介紹本季度的業務和運營亮點。 Jamie 將回顧我們的財務結果，然後我將討論程序和臨床亮點，並提供我們對 2022 年的最新財務展望。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.

感謝您今天加入我們。

In the first quarter, procedure demand for our products was healthy, recovering where COVID receded. Drivers of procedure performance included general surgery in the U.S. and non-urology procedures outside of the U.S., which are our areas of focus. Regardless of the healthy procedure demand, we were challenged by environmental stresses, including regional waves of COVID, staffing pressure at hospitals, component and raw material availability and logistic delays. While it's difficult to forecast how long these headwinds will persist, our teams are working hard to meet the challenge.

在第一季度，對我們產品的程序需求是健康的，在 COVID 消退的地方正在恢復。程序性能的驅動因素包括美國的普通外科手術和美國以外的非泌尿外科手術，這是我們的重點領域。無論對健康程序的需求如何，我們都受到環境壓力的挑戰，包括 COVID 的區域性浪潮、醫院的人員配備壓力、組件和原材料的可用性以及物流延誤。雖然很難預測這些不利因素會持續多久，但我們的團隊正在努力應對挑戰。

In the quarter, da Vinci procedures grew 19% compared to the first quarter 2021. The use of da Vinci in general surgery in the United States grew nicely, led by bariatric procedures, cholecystectomy, hernia repair and rectal surgery. Lobectomy growth was also healthy. Outside the United States, the U.K., China, Japan, Germany and Italy grew above our quarterly average growth rate, but I will note that some countries saw the beginnings of COVID slowdowns later in the quarter, in particular China and Korea.

本季度，達芬奇手術與 2021 年第一季度相比增長了 19%。達芬奇在美國普外科的使用增長良好，主要是減肥手術、膽囊切除術、疝修補術和直腸手術。肺葉切除生長也很健康。在美國以外，英國、中國、日本、德國和意大利的增長率高於我們的季度平均增長率，但我會注意到，一些國家在本季度晚些時候出現了 COVID 放緩的開始，特別是中國和韓國。

International use of da Vinci is diversifying beyond urology in several countries with growth in oncologic procedures in thoracic surgery, gynecology and general surgery. In Japan, MHLW increased reimbursement for robotically assisted gastrectomy and added another 8 procedures to reimbursement coverage in April, bringing the total number of covered da Vinci procedure types to over 25 in Japan. In our flexible robotics program, Ion procedures grew approximately 350% in Q1 compared with Q1 2021, reflecting continued strength in adoption and utilization of the platform.

隨著胸外科、婦科和普通外科腫瘤手術的增長，達芬奇的國際應用在幾個國家的泌尿外科之外也越來越多樣化。在日本，厚生勞動省增加了機器人輔助胃切除術的報銷，並在 4 月份在報銷範圍內增加了 8 種手術，使日本覆蓋的達芬奇手術類型總數超過 25 種。在我們的靈活機器人計劃中，與 2021 年第一季度相比，Ion 程序在第一季度增長了約 350%，反映出該平台的採用和利用持續強勁。

Turning to capital. Our team installed 311 da Vinci systems in the quarter compared with 298 systems in Q1 2021, bringing our total clinical installed base to 6,920 da Vinci systems. Placements varied by region with the U.K. standing out with a strong placement quarter. Capital placements have been historically lumpy and after several quarters of capital strength, we're seeing some near-term softening of our capital placement pipeline in the U.S. Contributing factors may include a pull-forward of Q1 2022 demand into Q4 2021 due to customer budget utilization at year-end, a reduction in the number of third-generation da Vinci systems available for trade-ins and an overall tightening of hospital finances.

轉向資本。我們的團隊在本季度安裝了 311 台達芬奇系統，而 2021 年第一季度安裝了 298 台系統，使我們的臨床總安裝量達到 6,920 台達芬奇系統。安置因地區而異，英國以強勁的安置季度脫穎而出。從歷史上看，資本配置一直不穩定，經過幾個季度的資本實力後，我們看到我們在美國的資本配置管道近期有所放緩。促成因素可能包括由於客戶預算將 2022 年第一季度的需求提前到 2021 年第四季度年末利用率、可用於以舊換新的第三代達芬奇系統數量減少以及醫院財務整體收緊。

With a 3-year CAGR in procedures of 15% from Q1 of '19 to Q1 of '22 and installed base growth of 11% over the same period, utilization of installed systems continue to climb through the pandemic and in the first quarter. This is increasing the value derived from the existing installed base for our customers and for us. Over the midterm, capital demand in mature robotic-assisted surgery segments is a function of procedure demand moderated by utilization growth. Jamie will give regional capital trends and Brian will give a more detailed procedure review later in the call.

從 19 年第一季度到 22 年第一季度，程序的 3 年復合年增長率為 15%，同期安裝基數增長 11%，已安裝系統的利用率在疫情期間和第一季度繼續攀升。這為我們的客戶和我們增加了從現有安裝基礎中獲得的價值。中期來看，成熟的機器人輔助手術領域的資本需求是由利用率增長緩和的手術需求的函數。 Jamie 將提供區域資本趨勢，Brian 將在電話會議的稍後部分提供更詳細的程序審查。

As we exit the first quarter, we continue to invest in global expansion, innovation initiatives and our business infrastructure. Our spending in the quarter was roughly in line with our target. In instruments and accessories, we received Chinese NMPA clearance for our 45-millimeter and 60-millimeter SureForm staplers, our Vessel Sealer Extend and our Endoscope Plus. These products support the utility of our Xi systems for several procedures, particularly general and thoracic surgeries.

隨著我們退出第一季度，我們將繼續投資於全球擴張、創新計劃和我們的業務基礎設施。我們在本季度的支出大致符合我們的目標。在儀器和配件方面，我們的 45 毫米和 60 毫米 SureForm 訂書機、Vessel Sealer Extend 和 Endoscope Plus 獲得了中國 NMPA 許可。這些產品支持我們的 Xi 系統在多種程序中的效用，特別是普通和胸外科手術。

Turning to Ion. We submitted our EU medical device regulation application for the platform to allow the entry of Ion into Europe. Our teams are also building production capacity and making improvements to customer workflow, planning software and reprocessing efficiency.

轉向離子。我們為該平台提交了歐盟醫療器械法規申請，以允許 Ion 進入歐洲。我們的團隊還在建設生產能力並改進客戶工作流程、規劃軟件和後處理效率。

In digital products, the My Intuitive app community tripled year-over-year. It is now available in the U.S., Japan, Germany, France, United Kingdom and Ireland and Switzerland with launches set for Italy, Spain and India in Q2. Building on our Orpheus technology, our teams in Israel and the U.S. have created Intuitive Hub, a unified hardware and software solution for the operating room. Intuitive Hub enables OR teams to capture, edit and share video clips from clinical procedures and collaborate virtually using existing workflows and Intuitive systems.

在數字產品方面，My Intuitive 應用程序社區同比增長了兩倍。它現已在美國、日本、德國、法國、英國、愛爾蘭和瑞士上市，並於第二季度在意大利、西班牙和印度推出。基於我們的 Orpheus 技術，我們在以色列和美國的團隊創建了 Intuitive Hub，這是一個用於手術室的統一硬件和軟件解決方案。 Intuitive Hub 使 OR 團隊能夠捕獲、編輯和共享來自臨床程序的視頻剪輯，並使用現有的工作流程和 Intuitive 系統進行虛擬協作。

In the quarter, we launched an upgraded interface to da Vinci systems that allows for automated video capture with integrated procedure annotation for key events, creating convenient video storage and review for da Vinci cases. Customer feedback for this integration has been encouraging. Across the installed base, the number of procedures in which Intuitive Hub was used grew approximately 60% year-over-year.

在本季度，我們推出了達芬奇系統的升級界面，允許自動視頻捕獲，並為關鍵事件提供集成的過程註釋，為達芬奇案例創建方便的視頻存儲和審查。客戶對此集成的反饋令人鼓舞。在整個安裝基礎上，使用 Intuitive Hub 的程序數量同比增長約 60%。

To our goal of adding Iris anatomical models, we're in conversations with FDA on how best to characterize some of its core AI technology, which will require a resubmission of our 510(k) for the next set of segmented organ models. Finally, the installed base of our virtual reality training simulator, SimNow, grew 33% in the quarter compared with a year ago.

為了我們添加虹膜解剖模型的目標，我們正在與 FDA 就如何最好地描述其一些核心 AI 技術進行對話，這將需要為下一組分段器官模型重新提交我們的 510(k)。最後，我們的虛擬現實訓練模擬器 SimNow 的安裝基礎在本季度與一年前相比增長了 33%。

For our single port program, da Vinci SP, we began the launch of our next-generation SP endoscope, which includes our Firefly Fluorescence Imaging technology and has 65% longer life. We also launched our next-generation core SP instruments that can apply higher forces during surgery and are more durable. Feedback on both has been encouraging.

對於我們的單端口計劃 da Vinci SP，我們開始推出我們的下一代 SP 內窺鏡，其中包括我們的螢火蟲熒光成像技術，使用壽命延長 65%。我們還推出了下一代核心 SP 器械，可以在手術過程中施加更大的力並且更耐用。兩者的反饋都令人鼓舞。

In Japan, we submitted our da Vinci SP for clearance to PMDA seeking broad indications. We continue to pursue additional indications for SP in the U.S., which is important for broader adoption, with an ongoing IDE trial in colorectal surgery and an approved IDE for thoracic surgery. COVID and some site-specific delays have slowed our progress in our colorectal trial. We're working hard to expand the number of participating sites to accelerate its completion.

在日本，我們向 PMDA 提交了達芬奇 SP 以獲得廣泛的適應症。我們繼續在美國尋求 SP 的其他適應症，這對於更廣泛的採用很重要，正在進行結直腸手術的 IDE 試驗和獲得批准的胸外科手術 IDE。 COVID 和一些特定地點的延誤減緩了我們在結腸直腸試驗中的進展。我們正在努力擴大參與站點的數量，以加快完成。

Stepping back, for 2022, our top priority is to support, supply and train our customers as they navigate a challenging environment. We are also focused on helping general surgeons in the United States adopt our technologies and diversifying our business outside the United States beyond urology and in executing on our new platforms and digital tools.

退一步說，到 2022 年，我們的首要任務是支持、供應和培訓我們的客戶，幫助他們在充滿挑戰的環境中度過難關。我們還專注於幫助美國的普通外科醫生採用我們的技術，並使我們在美國以外的業務多樣化，超越泌尿外科，並在我們的新平台和數字工具上執行。

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

我現在將時間交給 Jamie Samath，他將帶您更詳細地了解財務問題。

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.

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。

Overall, Q1 results reflected approximately 19% procedure growth as compared to the first quarter of 2021 and system placements of 311 systems, resulting in an expansion of the installed base of da Vinci systems of approximately 13%. As a result of our procedure and capital performance, Q1 revenue increased by 15% year-over-year.

總體而言，與 2021 年第一季度相比，第一季度的結果反映了約 19% 的程序增長和 311 個系統的系統佈局，導致達芬奇系統的安裝基礎擴大了約 13%。由於我們的程序和資本績效，第一季度的收入同比增長了 15%。

Key business metrics for the first quarter of 2022 were as follows. Within the 19% procedure growth, procedures in the U.S. increased 16% and OUS procedures grew by 25%. Procedures in the U.S. were impacted in January by the significant number of hospitalizations related to the Omicron variant. As rates of COVID-related hospitalizations declined in February and March, da Vinci procedures recovered quickly. On a 3-year compound annual growth rate basis, first quarter procedures grew approximately 15%.

2022年第一季度的主要業務指標如下。在 19% 的程序增長中，美國的程序增長了 16%，OUS 程序增長了 25%。 1 月份美國的手術受到與 Omicron 變體相關的大量住院治療的影響。隨著 2 月和 3 月與 COVID 相關的住院率下降，達芬奇手術迅速恢復。在 3 年復合年增長率的基礎上，第一季度的程序增長了約 15%。

First quarter system placements of 311 increased 4% from the 298 systems placed last year. The number of systems placed in conjunction with a trade-in of an older generation system declined by 18% from the first quarter of 2021. That decline was entirely driven by the U.S. Utilization of clinical systems in the field, measured by procedures per system, increased approximately 6% compared to last year. Using a 3-year CAGR, first quarter utilization grew 4%.

第一季度系統安裝量為 311 個，比去年安裝的 298 個系統增加了 4%。自 2021 年第一季度以來，與老一代系統以舊換新相結合的系統數量下降了 18%。這一下降完全是由美國在該領域的臨床系統利用驅動的，以每個系統的程序來衡量，與去年相比增長約 6%。使用 3 年的複合年增長率，第一季度的利用率增長了 4%。

During the quarter, the supply chain environment continued to be challenging and remains dynamic. In Q1, we continued to experience constraints in our ability to meet customer demand. And as a result, on-time delivery performance to our customers was lower than we have experienced so far during the pandemic.

本季度，供應鏈環境繼續充滿挑戰並保持活力。在第一季度，我們在滿足客戶需求方面繼續受到限制。因此，我們向客戶的準時交付績效低於我們在大流行期間迄今為止所經歷的。

In Europe, recently, we have experienced some geographically limited delays in fulfilling orders for some da Vinci instruments and accessories. These delays were due to a combination of the global supply chain and logistics issues, including our freight forwarder's unanticipated shutdown of its computer system. While these constraints did not have a material impact to our Q1 financial results, risks associated with potential disruption to our manufacturing operations and our ability to supply certain products to our customers remain significant. During the quarter, we also experienced higher logistics costs and manufacturing inefficiencies that impacted our gross margin.

最近，在歐洲，我們在履行某些達芬奇樂器和配件的訂單時遇到了一些地理上的延遲。這些延誤是由於全球供應鍊和物流問題的結合，包括我們的貨運代理意外關閉其計算機系統。儘管這些限制因素並未對我們的第一季度財務業績產生重大影響，但與我們的製造業務和我們向客戶供應某些產品的能力的潛在中斷相關的風險仍然很大。在本季度，我們還經歷了更高的物流成本和製造效率低下，影響了我們的毛利率。

U.S. procedure growth of 16% over Q1 of 2021 reflected continued relative strength in bariatrics, cholecystectomy and hernia repair. In Europe, we experienced strong growth in the U.K., reflecting in part the significant adverse impact of COVID in Q1 of 2021. Procedure growth in the U.K. also reflected strong early-stage growth in hysterectomy, colorectal and thoracic procedures. Procedure growth in Germany and Italy was also strong, while procedure growth in France was adversely impacted by COVID-mitigation measures in the first part of the quarter.

與 2021 年第一季度相比，美國手術增長 16% 反映了減肥、膽囊切除術和疝修補術的持續相對優勢。在歐洲，我們在英國經歷了強勁的增長，部分反映了 COVID 在 2021 年第一季度的重大不利影響。英國的手術增長還反映了子宮切除術、結直腸和胸腔手術的強勁早期增長。德國和意大利的手術增長也很強勁，而法國的手術增長受到本季度第一季度 COVID 緩解措施的不利影響。

Overall procedure growth in Asia was solid with growth across a broad set of procedure categories. Q1 procedures in China and Korea were slightly lower than our expectations given the impact of the Omicron variant later in the quarter. Procedure growth in Japan was strong, reflecting some recovery in urologic procedures and strong growth in rectal, hysterectomy and thoracic, key procedures that were granted da Vinci reimbursement in April of 2020.

亞洲的整體程序增長穩健，包括廣泛的程序類別。鑑於本季度晚些時候 Omicron 變體的影響，中國和韓國的第一季度程序略低於我們的預期。日本的手術增長強勁，反映出泌尿外科手術的一些恢復以及直腸、子宮切除術和胸外科的強勁增長，這些關鍵手術於 2020 年 4 月獲得達芬奇報銷。

The impact of the Delta variant in Q3 of last year and the impact of the Omicron variant in this past quarter highlight the continued risk of future COVID waves and the associated significant risks to the number of da Vinci procedures that may be performed. Brian will provide additional procedure commentary later in this call.

去年第三季度 Delta 變體的影響以及上一季度 Omicron 變體的影響突顯了未來 COVID 浪潮的持續風險以及可能執行的達芬奇手術數量的相關重大風險。 Brian 將在本次電話會議的稍後部分提供額外的程序評論。

As Gary indicated, during the quarter, we experienced a softening in our U.S. capital pipeline, which we expect to impact system placements in the near term. In the U.S., we placed 186 systems in the first quarter, lower than 190 in Q1 of 2021, reflecting a decline of 28 systems associated with trade-in transactions, partially offset by increased placements to greenfield customers. The remaining installed base of Si systems in the U.S. is approximately 268 systems.

正如 Gary 指出的那樣，在本季度，我們的美國資本管道出現疲軟，我們預計這將在短期內影響系統配置。在美國，我們在第一季度放置了 186 個系統，低於 2021 年第一季度的 190 個，反映出與以舊換新交易相關的 28 個系統減少，部分被新客戶放置的增加所抵消。美國剩餘的 Si 系統安裝基數約為 268 個系統。

Outside the U.S., we placed 125 systems in the first quarter compared with 108 in the first quarter of 2021. Current quota system placements included 78 into Europe, 19 into Japan and 9 into China compared with 59 into Europe, 8 into Japan and 23 into China in the first quarter of 2021. We placed 30 systems in the U.K. in Q1 driven in part by the timing of government budget cycles. We do not expect to place similar levels of systems in the remainder of 2022 in the U.K.

在美國以外，我們在第一季度放置了 125 個系統，而 2021 年第一季度為 108 個。目前的配額系統放置包括歐洲 78 個、日本 19 個和中國 9 個，而歐洲 59 個、日本 8 個和 23 個2021 年第一季度的中國。我們在第一季度在英國放置了 30 個系統，部分原因是政府預算週期的時間安排。我們預計 2022 年剩餘時間內不會在英國放置類似水平的系統。

Capital performance in Japan was driven primarily by greenfield accounts and some existing customers adding capacity in anticipation of the 8 additional procedure reimbursements taking effect on April 1. System placements in China were moderately impacted by longer logistic cycle times as a result of lockdowns in response to increased COVID cases. As of the end of Q1 2022, there were 55 systems remaining under the current quota in China, which may also be available to competitors that have received local regulatory clearance.

日本的資本表現主要受到新建賬戶和一些現有客戶增加產能的推動，因為他們預計將於 4 月 1 日生效的 8 項額外程序報銷。中國的系統佈局受到較長物流週期時間的適度影響，原因是為了應對增加的 COVID 病例。截至 2022 年第一季度末，中國現有配額內剩餘 55 個系統，也可能提供給已獲得當地監管許可的競爭對手。

Globally, trade-in transactions represented 35% of placements in the quarter compared to 38% for the full year of 2021 and 48% for the full year 2020. Given the lower number of older-generation systems in the field, we expect the volume of trade-ins to be significantly lower in 2022 as compared to 2021.

在全球範圍內，以舊換新交易占該季度的 35%，而 2021 年全年為 38%，2020 年全年為 48%。鑑於該領域的老一代系統數量較少，我們預計交易量與 2021 年相比，2022 年以舊換新的比例將顯著降低。

Hospitals continue to experience financial and operational pressures as a result of staffing shortages, the supply chain environment and resulting inflation. Since the start of the pandemic in 2020, the impact of COVID has placed a significant burden on hospitals. The financial pressures our customers have faced have been partially mitigated by government funding, such as the approximately $178 billion of CARES Act and other relief made available to hospitals in the U.S.

由於人員短缺、供應鏈環境和由此產生的通貨膨脹，醫院繼續面臨財務和運營壓力。自 2020 年大流行開始以來，COVID 的影響給醫院帶來了沉重的負擔。我們的客戶所面臨的財務壓力已通過政府資助得到部分緩解，例如大約 1780 億美元的 CARES 法案以及向美國醫院提供的其他救濟。

The rising interest rate environment increases debt servicing costs and may make access to new debt more challenging. To the extent that hospitals continue to face financial pressures, reductions in government funding and higher interest rates, hospital capital spending may be adversely impacted. In addition, as competition progresses in various markets, we will likely experience longer selling cycles and price pressure.

利率上升的環境增加了償債成本，並可能使獲得新債務更具挑戰性。如果醫院繼續面臨財務壓力、政府資金減少和利率上升，醫院的資本支出可能會受到不利影響。此外，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. Total first quarter revenue was $1.49 billion, an increase of 15% from last year. Leasing represented 35% of Q1 placements compared with 37% last year, last quarter rather. The slightly lower first quarter lease mix primarily reflected the mix of customers who prefer to purchase systems. While leasing will fluctuate from quarter-to-quarter, we continue to expect that the proportion of placements under operating leases will increase over time.

其他收入統計數據和趨勢如下。第一季度總收入為 14.9 億美元，比去年增長 15%。租賃佔第一季度安置的 35%，而去年為 37%，上個季度則相反。略低的第一季度租賃組合主要反映了更喜歡購買系統的客戶組合。雖然租賃會隨著季度的變化而波動，但我們仍然預計經營租賃下的配售比例將隨著時間的推移而增加。

First quarter system average selling prices were $1.54 million, higher than the $1.45 million last quarter. The sequential increase was primarily driven by a lower mix of bulk buy transactions with large customers and a favorable product mix, in particular a higher proportion of Xi dual system placements in the quarter.

第一季度系統平均售價為 154 萬美元，高於上一季度的 145 萬美元。環比增長主要是由於與大客戶的批量購買交易組合減少和有利的產品組合，特別是本季度 Xi 雙系統配置的比例較高。

We recognized $16 million of lease buyout revenue in Q1 compared with $26 million last quarter and $19 million last year. Lease buyout revenue has varied significantly quarter-to-quarter and will likely continue to do so.

我們在第一季度確認了 1600 萬美元的租賃收購收入，而上一季度為 2600 萬美元，去年為 1900 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。

Instrument and accessory revenue per procedure was approximately $1,870 per procedure compared with $1,940 per procedure in the fourth quarter of 2021 and down 4% from the $1,950 realized in the first quarter of last year. The year-over-year decrease primarily reflects the benefit of stocking orders in Q1 of 2021 associated with the launch of our extended use instruments program in the U.S. and Europe and an unfavorable FX impact from the stronger U.S. dollar. The sequential decline primarily reflects lower stocking orders associated with lower system placements, hospital ordering patterns and a small unfavorable impact from FX.

每次手術的儀器和附件收入約為 1,870 美元，而 2021 年第四季度的每次手術收入為 1,940 美元，比去年第一季度的 1,950 美元下降 4%。同比下降主要反映了 2021 年第一季度庫存訂單的好處，這與我們在美國和歐洲推出擴展使用工具計劃相關，以及美元走強帶來的不利外匯影響。環比下降主要反映了與較低的系統放置、醫院訂購模式和外彙的小幅不利影響相關的庫存訂單減少。

We placed 34 Ion systems in the quarter as compared to 14 Ion placements in the first quarter of last year. The installed base of Ion systems is now 163 systems, of which 70 are under operating lease arrangements. First quarter Ion procedures of just over 3,900 are up over 4x compared to the first quarter of 2021. Seven of the systems placed in the first quarter were SP systems, including 3 systems placed at customers in Korea. Our installed base of SP systems is now 106.

我們在本季度放置了 34 個離子系統，而去年第一季度放置了 14 個離子系統。目前 Ion 系統的安裝基礎為 163 個系統，其中 70 個處於經營租賃協議中。與 2021 年第一季度相比，第一季度剛剛超過 3,900 次的 Ion 程序增加了 4 倍以上。第一季度放置的系統中有 7 個是 SP 系統，其中 3 個系統放置在韓國的客戶處。我們的 SP 系統安裝基數現在是 106。

First quarter SP procedures grew approximately 36% year-over-year with approximately 50% growth in transoral procedures, a small but high-value segment. Growth of the SP platform will continue to be gated by additional clinical indications and clearances in markets beyond the U.S. and Korea.

第一季度 SP 手術同比增長約 36%，經口手術增長約 50%，這是一個小而高價值的部分。 SP 平台的增長將繼續受到美國和韓國以外市場的額外臨床適應症和許可的限制。

Moving on to gross margin and operating expenses. Pro forma gross margin for the first quarter of 2022 was 69.8% compared with 71.8% for the first quarter 2021 and 70.1% last quarter. Pro forma gross margin was lower than last quarter, primarily as a result of higher logistics costs and increased fixed costs relative to revenue as we invest in our infrastructure and manufacturing capacity to serve our long-term needs. While net inventory grew approximately $66 million quarter-over-quarter, there are still a number of components and products that are below our targeted levels.

繼續討論毛利率和運營費用。 2022 年第一季度的備考毛利率為 69.8%，而 2021 年第一季度為 71.8%，上一季度為 70.1%。備考毛利率低於上一季度，主要是由於我們投資基礎設施和製造能力以滿足我們的長期需求，物流成本增加和相對於收入的固定成本增加。雖然淨庫存環比增長約 6600 萬美元，但仍有許多組件和產品低於我們的目標水平。

Pro forma operating expenses increased 26% compared with the first quarter of 2021. The increase in first quarter operating expenses from a year ago reflected an increase in headcount, increased variable compensation and higher customer-facing costs, customer training, travel costs and marketing programs. As of the end of Q1, we had just over 10,500 employees, an increase of 26% from the first quarter of 2021 or an increase of 20% on a 3-year CAGR basis. Of the approximately 2,100 employees we have added over the last year, approximately 900 are manufacturing employees.

與 2021 年第一季度相比，備考運營費用增加了 26%。第一季度運營費用同比增長反映了員工人數的增加、可變薪酬的增加以及面向客戶的成本、客戶培訓、差旅成本和營銷計劃的增加.截至第一季度末，我們的員工人數剛剛超過 10,500 人，比 2021 年第一季度增長 26%，或者在 3 年復合年增長率的基礎上增長 20%。在我們去年增加的大約 2,100 名員工中，大約有 900 名是製造員工。

Capital expenditures in Q1 were $95 million, primarily comprised of infrastructure investments to expand our facilities footprint, increase manufacturing capacity and automation of certain production lines.

第一季度的資本支出為 9500 萬美元，主要包括基礎設施投資，以擴大我們的設施足跡、提高製造能力和某些生產線的自動化。

Our pro forma effective tax rate for the first quarter was 23.3%, slightly above our expectations primarily due to certain discrete tax items. Our pro forma tax rate was above the 22.2% for 2021, primarily due to a previous change in U.S. tax law that became effective on January 1, 2022. Our first quarter 2022 pro forma net income was $413 million or $1.13 per share compared with $427 million or $1.17 per share for the first quarter of 2021.

我們第一季度的備考有效稅率為 23.3%，略高於我們的預期，主要是由於某些離散的稅收項目。我們的備考稅率在 2021 年高於 22.2%，這主要是由於美國稅法的先前變更於 2022 年 1 月 1 日生效。我們 2022 年第一季度的備考淨收入為 4.13 億美元或每股 1.13 美元，而此前為 427 美元2021 年第一季度的 10 萬美元或每股 1.17 美元。

I will now summarize our GAAP results. GAAP net income was $366 million or $1 per share for the first quarter of 2022 compared with GAAP net income of $426 million or $1.17 per share for the first quarter of 2021. 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.

我現在將總結我們的 GAAP 結果。 2022 年第一季度 GAAP 淨收入為 3.66 億美元或每股 1 美元，而 2021 年第一季度 GAAP 淨收入為 4.26 億美元或每股 1.17 美元。備考和 GAAP 淨收入之間的調整在我們的概述和量化網站並包括與員工股票獎勵、員工股票薪酬、無形資產攤銷以及戰略投資損益相關的超額稅收優惠。

We ended the quarter with cash and investments of $8.4 billion compared with $8.6 billion as of December 31, 2021. The sequential reduction in cash and investments in the first quarter primarily reflected share repurchases, capital expenditures and unrealized losses on interest-bearing investments classified as available for sale, partially offset by cash from operating activities and proceeds from employee stock plans. During the quarter, we repurchased 398,000 shares at an average price of $268 per share for a total expenditure of $107 million.

截至本季度末，我們的現金和投資為 84 億美元，而截至 2021 年 12 月 31 日為 86 億美元。第一季度現金和投資的連續減少主要反映了股票回購、資本支出和分類為可供出售，部分被經營活動的現金和員工股票計劃的收益所抵消。本季度，我們以每股 268 美元的平均價格回購了 398,000 股，總支出為 1.07 億美元。

And with that, I would like to turn it over to Brian, who will discuss clinical highlights and provide our updated outlook for 2022.

有了這個，我想把它交給布賴恩，他將討論臨床亮點並提供我們對 2022 年的最新展望。

Thank you, Jamie.

謝謝你，傑米。

Our overall first quarter 2022 procedure growth was 19% compared to 16% for the first quarter of 2021. The 3-year compound annual growth rate was 15% between the first quarter of 2019 and first quarter of 2022. First quarter 2022 procedure growth benefited by 140 basis points from 1 additional workday in the quarter.

我們 2022 年第一季度的整體程序增長為 19%，而 2021 年第一季度為 16%。2019 年第一季度至 2022 年第一季度的 3 年復合年增長率為 15%。2022 年第一季度的程序增長受益本季度增加 1 個工作日起 140 個基點。

In the U.S., first quarter 2022 procedure growth was 16% year-over-year compared to 14% for the first quarter of 2021 and 16% last quarter. On a 3-year compound annual growth basis, U.S. procedure growth was 13%. In the U.S., first quarter growth was again driven by growth in procedures within general surgery. Bariatrics, cholecystectomy and hernia repair were the largest contributors to procedure growth, while growth in foregut and rectal resection were also strong contributors.

在美國，2022 年第一季度的程序同比增長 16%，而 2021 年第一季度和上一季度分別增長 14% 和 16%。在 3 年復合年增長率的基礎上，美國的手術增長率為 13%。在美國，第一季度的增長再次受到普通外科手術增長的推動。減肥、膽囊切除術和疝修補術是手術增長的最大貢獻者，而前腸和直腸切除術的增長也是重要的貢獻者。

Outside of the U.S., first quarter procedure volume grew approximately 25% compared with 23% for the first quarter of 2021 and 28% last quarter. On a 3-year compound annual growth basis, procedure growth was 20%. In Europe, we experienced strong growth in the U.K., Italy and Germany, partially reflecting the disruption caused by COVID in the first quarter of 2021. In the U.K., procedure growth was strong in general surgery and gynecology categories, supported by early-stage growth in hysterectomy, colorectal and thoracic procedures. Procedure growth in Germany and Italy was also driven by procedures outside of urology with growth driven by colorectal, hysterectomy and thoracic procedures.

在美國以外，第一季度的手術量增長了約 25%，而 2021 年第一季度和上一季度分別增長了 23% 和 28%。在 3 年復合年增長率的基礎上，程序增長率為 20%。在歐洲，我們在英國、意大利和德國經歷了強勁的增長，部分反映了 2021 年第一季度 COVID 造成的破壞。在英國，在早期增長的支持下，普通外科和婦科的手術增長強勁在子宮切除術、結直腸和胸外科手術中。德國和意大利的手術增長也受到泌尿外科以外的手術的推動，其中結直腸、子宮切除術和胸外科手術推動了手術的增長。

Capital placements were also strong in the U.K. with the placement of 30 systems, the highest number of systems placed in the U.K. in a single quarter, driven in part by government funding and the trade-ins of older-generation systems. In Japan, growth in general surgery, gynecology and thoracic continued to be strong with robust growth specifically in benign hysterectomy, gastrectomy and lobectomy. In addition, urologic procedures, specifically prostatectomy and partial nephrectomy, both experienced solid double-digit growth, reflecting a recovery when compared to the prior year, which was constrained by COVID.

英國的資本配置也很強勁，共安裝了 30 個系統，是英國單季度系統配置的最高數量，部分原因是政府資金和老一代系統的以舊換新。在日本，普通外科、婦科和胸外科的增長繼續強勁，尤其是良性子宮切除術、胃切除術和肺葉切除術的強勁增長。此外，泌尿外科手術，特別是前列腺切除術和部分腎切除術，都經歷了兩位數的穩健增長，與受 COVID 限制的前一年相比，反映了復甦。

In China and Korea, first quarter procedure growth was solid but slightly below expectations as we saw a resurgence in March of COVID infections, regional lockdowns and hospitalizations, which negatively impacted procedure volumes. In China, growth in urology was solid, in particular with growth in prostatectomy, nephrectomy and partial nephrectomy. We continue to see broad-based growth in general surgery, thoracic and gynecology as well. As we enter the second quarter this year, we are seeing the negative impact on procedure volume as a result of continued regional lockdowns.

在中國和韓國，第一季度的手術增長穩健，但略低於預期，因為我們看到 3 月份新冠病毒感染、區域封鎖和住院人數重新抬頭，這對手術量產生了負面影響。在中國，泌尿外科增長穩健，特別是前列腺切除術、腎切除術和部分腎切除術增長。我們繼續看到普外科、胸科和婦科的廣泛增長。隨著我們進入今年第二季度，我們看到持續的區域封鎖對手術量產生了負面影響。

Now turning to Ion, our robotic-assisted endoluminal platform focused today on minimally invasive lung biopsy procedures. First quarter 2022 Ion procedures totaled just over 3,900 in Q1 2022, an approximately 350% increase over the prior year and 34% over the prior quarter. Ion system placements were also strong, ending Q1 '22 with 163 installed systems, growing approximately 225% over the prior year.

現在轉向 Ion，我們的機器人輔助腔內平台今天專注於微創肺活檢程序。 2022 年第一季度離子程序在 2022 年第一季度總計剛剛超過 3,900 次，比去年同期增長約 350%，比上一季度增長 34%。離子系統佈局也很強勁，在 22 年第一季度末安裝了 163 個系統，比上一年增長了約 225%。

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. Paresh Shah, along with colleagues from the Robert I. Grossman School of Medicine at New York University and in collaboration with Intuitive, published a real-world body of evidence assessing open conversion rates during minimally invasive surgery using laparoscopic/thoracoscopic or da Vinci robotic surgery across 10 common procedures for benign or malignant conditions. Utilizing the Premier Healthcare Database, this study included over 275,000 adult patients who, between January 2013 and September 2015, underwent a minimally invasive procedure, including hysterectomy, sigmoidectomy, right colectomy, ventral or inguinal hernia repair, partial nephrectomy, lobectomy or low anterior resection.

在本季度，Paresh Shah 博士與紐約大學 Robert I. Grossman 醫學院的同事一起，與 Intuitive 合作，發表了一份真實的證據，評估使用腹腔鏡 / 的微創手術期間的開放轉化率。胸腔鏡或達芬奇機器人手術涉及 10 種常見的良性或惡性疾病手術。利用 Premier Healthcare 數據庫，這項研究包括超過 275,000 名在 2013 年 1 月至 2015 年 9 月期間接受微創手術的成年患者，包括子宮切除術、乙狀結腸切除術、右結腸切除術、腹側或腹股溝疝修補術、部分腎切除術、肺葉切除術或低位前切除術.

Overall, a 5% conversion to open rate for the MIS approach was observed across all procedures with a range of 1% to 24%. Converted to open patients were associated with a 1.8-day longer length of stay, 1.7x greater risk of readmission within 30 days of the procedure and a significantly higher in-hospital or perioperative 30-day total cost, adding approximately $2,900 to the in-hospital cost and $3,400 to the total 30-day cost. The researchers also compared differences in conversions between the laparoscopic/thoracoscopic and da Vinci cohorts. After performing propensity score matching, conversion rates for da Vinci procedures were significantly lower than LAP or VATS across all procedures. The volume-weighted conversion rate for da Vinci was approximately 2.8%, corresponding to a total relative conversion reduction for all study procedures of 58.5% compared to the laparoscopic or the thoracoscopic procedures.

總體而言，在所有程序中觀察到 MIS 方法的打開率為 5%，範圍為 1% 至 24%。轉為開放式患者的住院時間延長 1.8 天，手術後 30 天內再入院的風險增加 1.7 倍，住院或圍手術期 30 天總費用顯著增加，增加了約 2,900 美元的住院費用。醫院費用和 3,400 美元的總 30 天費用。研究人員還比較了腹腔鏡/胸腔鏡和達芬奇隊列之間的轉換差異。在進行傾向得分匹配後，達芬奇程序的轉化率在所有程序中都顯著低於 LAP 或 VATS。達芬奇的體積加權轉化率約為 2.8%，與腹腔鏡或胸腔鏡手術相比，所有研究程序的總相對轉化率降低了 58.5%。

The researchers concluded in part, "From the standpoint of population health or a hospital system, these high-level data indicated that a cumulative effect of conversions can be a significant burden. And that reduction of conversion has major benefits and leads to increased value for the patient, the hospital and society at large. The use of robotic-assisted surgery is associated with a significant decrease in the conversion rate for all 10 operations studied, and a multidisciplinary robotic program encompassing several specialties could result in significantly decreased conversion rates with an improved ability to deliver successful minimally invasive surgery to its patients."

研究人員部分得出結論：“從人口健康或醫院系統的角度來看，這些高級數據表明轉換的累積效應可能是一個重大負擔。轉換的減少具有重大的好處，並導致價值增加患者、醫院和整個社會。機器人輔助手術的使用與所研究的所有 10 種手術的轉化率顯著降低有關，包含多個專業的多學科機器人計劃可能會導致轉化率顯著降低提高了為患者提供成功微創手術的能力。”

I will now turn to our financial outlook for 2022, starting with procedures. On our last call, we forecast full year 2022 procedure growth within a range of 11% to 15%. We are now increasing our forecast and expect full year 2022 procedure growth of 12% to 16%. This range continues to reflect the uncertainty associated with the course of the pandemic. The low end of the range assumes ongoing COVID and staffing pressure at hospitals and assume some continued choppiness with COVID throughout the year. At the high end of the range, we assume COVID-19-related hospitalizations around the world decline throughout the remainder of 2022, and there are no additional significant impacts from further resurgences. As noted last quarter, the range does not reflect significant supply chain disruptions.

我現在將轉向我們對 2022 年的財務展望，從程序開始。在我們上次的電話會議上，我們預測 2022 年全年的程序增長在 11% 至 15% 的範圍內。我們現在正在提高我們的預測，並預計 2022 年全年程序增長 12% 至 16%。該範圍繼續反映與大流行病程相關的不確定性。該範圍的低端假設醫院持續存在 COVID 和人員配備壓力，並假設全年 COVID 持續出現波動。在該範圍的高端，我們假設全球與 COVID-19 相關的住院人數在 2022 年剩餘時間內下降，並且進一步復甦不會產生額外的重大影響。如上個季度所述，該範圍並未反映出供應鏈的嚴重中斷。

The steep increase in infections and subsequent recovery in the quarter from the Omicron variant in the U.S. and the trend in procedure volumes we have seen exiting the quarter in China highlight the risk to the number of procedures that may be performed. In the second quarter of 2022, our year-over-year procedure growth rate will likely be lower than recent quarters as Q2 2021 results reflected a strong recovery in procedures as COVID began to subside.

本季度感染的急劇增加和隨後從美國的 Omicron 變體中恢復，以及我們在中國看到的退出本季度的手術量趨勢突出了可能執行的手術數量的風險。在 2022 年第二季度，我們的程序同比增長率可能會低於最近幾個季度，因為 2021 年第二季度的結果反映了隨著 COVID 開始消退，程序的強勁復甦。

Turning to gross profit. On our last call, we forecast our 2022 full year pro forma gross profit margin to be within 69.5% and 70.5%. We are now slightly expanding the range of our pro forma gross profit margin to be within 69% and 70.5% of net revenue. The lower end of the range was updated to reflect the impact on input costs related to supply chain, inflation and some impact from a stronger U.S. dollar. 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。在我們上次的電話會議上，我們預測我們 2022 年全年的備考毛利率將在 69.5% 和 70.5% 之間。我們現在正在將我們的備考毛利率範圍略微擴大到淨收入的 69% 和 70.5% 以內。該範圍的下限已更新，以反映與供應鏈、通貨膨脹和美元走強相關的投入成本的影響。我們的實際毛利率將隨季度變化，主要取決於產品、區域和以舊換新組合以及新產品推出的影響。

With respect to operating expenses, on our last call, we forecast pro forma operating expense growth to be between 21% and 27%. We are refining our estimate and now expect our full year pro forma operating expense growth to be between 23% and 27%. We continue to expect our noncash stock compensation expense to range between $510 million and $550 million in 2022. We expect other income, which is comprised mostly of interest income, to total between $50 million and $60 million in 2022.

關於運營費用，在我們上次電話會議上，我們預測備考運營費用增長將在 21% 至 27% 之間。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 23% 至 27% 之間。我們繼續預計 2022 年我們的非現金股票補償費用將在 5.1 億美元至 5.5 億美元之間。我們預計其他收入（主要包括利息收入）在 2022 年將在 5000 萬美元至 6000 萬美元之間。

On last quarter's call, we forecast 2022 capital expenditures within a range of $700 million to $1 billion. We are now refining estimated capital expenditures for 2022 to be in the range of $700 million to $900 million based primarily on the current timing of planned facility construction activities. With regard to income tax, we continue to estimate our 2022 pro forma tax rate to be between 22% and 24% of pretax income.

在上一季度的電話會議上，我們預測 2022 年的資本支出在 7 億美元至 10 億美元之間。我們現在主要根據計劃設施建設活動的當前時間，將 2022 年的估計資本支出調整為 7 億至 9 億美元。關於所得稅，我們繼續估計我們 2022 年的備考稅率將在稅前收入的 22% 至 24% 之間。

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

我們準備好的評論到此結束。我們現在將打開您的問題的電話。

(Operator Instructions) And our first question is from the line of Amit Hazan.

（操作員說明）我們的第一個問題來自 Amit Hazan。

Maybe I'll ask my first question on your comments on the U.S. systems side and the capital spending environment. Would just love to have more color on that. And obviously, we're focused on the same numbers that you mentioned, which is just the greenfield unit placements. And if we kind of look back just as context of what we have just over the past 4 or 5 years, those tend to increase by about 10% a year, and it is pretty choppy year-to-year. Just using that as a proxy, how much help can you give us on whether that's a good kind of target for this year for the nontrade-ins in the U.S.? And then just color on what you're seeing here in the near kind of just immediate term that you mentioned, it sounded like a lot of risk factors. And I'm wondering if it's risk factors that you're citing or something that you're actually seeing in your customers delaying planned purchases.

關於您對美國系統方面和資本支出環境的評論，也許我會問我的第一個問題。只是希望有更多的顏色。顯然，我們專注於您提到的相同數字，這只是新建單位的位置。如果我們回顧一下過去 4 或 5 年的情況，這些數據往往以每年 10% 左右的速度增長，而且逐年波動很大。僅將其用作代理，您可以為我們提供多少幫助來確定這是否是今年美國非以舊換新的好目標？然後只是在你提到的近期內看到你在這裡看到的東西，這聽起來像是很多風險因素。我想知道這是您引用的風險因素，還是您在客戶中實際看到的延遲計劃購買的因素。

Yes. Let me take the second question first and then I'll ask Jamie to step in on, a little bit more on the trade-in side. So what we're seeing now where we're at is a little bit less delay of planned purchases, a little bit less what we're signaling, more around Q4 demand looks strong. Q1 in terms of the early parts of the pipeline process and some of the contracting, some of the later parts, we're seeing in the U.S. just a little bit lower volume.

是的。讓我先回答第二個問題，然後我會請傑米介入，在以舊換新方面多一點。因此，我們現在看到的是計劃購買的延遲減少了一點，我們發出的信號減少了一點，第四季度的需求看起來更強勁。第一季度，就管道流程的早期部分和一些承包，一些後期部分而言，我們在美國看到的只是銷量略低。

It may clear itself. It may entirely be that this was just a pull-forward of a little bit of demand and some budget flushing as hospitals got ready for the retirement of some of the government support for COVID. But it's not clear. We don't know yet. We know for sure that we're getting toward the end of the Si trade-in cycle in the United States. So that will soften some of the U.S. capital. And then there's forecasted additional pressures on hospitals and finances. The short answer to that is, we're going to have to see. We'll see if those come to fruition or not. So that's a little bit of where that lays out. With regard to kind of what does the trade-in ratio look like, let me turn it to you, Jamie.

它可能會自行清除。這可能完全是因為醫院已準備好退出政府對 COVID 的一些支持，這只是一點點需求和一些預算沖水的推動。但目前還不清楚。我們還不知道。我們確信我們正在接近美國的矽以舊換新周期的尾聲。因此，這將軟化一些美國資本。然後，預計醫院和財務將面臨額外壓力。簡短的回答是，我們將不得不看到。我們將看看這些是否實現。這就是其中的一點點。關於以舊換新比率是什麼樣的，讓我來告訴你，傑米。

Yes. If I just look back at last year, 2021, there's about 500-ish trade-ins done globally. Of that, about 80% were transactions in the U.S. So you can just kind of get a sense of the degree to which the U.S. has driven the trade-in cycle. As I said in my prepared remarks, as of the end of Q1, there's about 268 Sis left in the U.S. in the installed base. And so you can kind of use those 2 data points to do some estimate of how that will play out over time.

是的。如果我回顧一下去年，即 2021 年，全球大約有 500 次以舊換新。其中，大約 80% 是在美國進行的交易。因此，您可以大致了解美國在多大程度上推動了以舊換新周期。正如我在準備好的評論中所說，截至第一季度末，美國的已安裝基礎中約有 268 台 Sis。因此，您可以使用這兩個數據點來估計隨著時間的推移將如何發揮作用。

As you start to get towards kind of the end of the tail of remaining Sis, they probably last for a little longer than kind of the average when you're at the middle of the distribution. But that's what I'd say with respect to trade-ins.

當你開始接近剩餘 Sis 的尾部時，當你處於分佈的中間時，它們的持續時間可能比平均水平長一點。但這就是我對以舊換新所說的話。

I think, Amit, you had a question on greenfields. The way I would think about it in the U.S. is you kind of have your procedure estimates that you can take from our range. You can apply the usual model with respect to utilization. That gives you some sense of how the installed base might expand. And so you can kind of do that calculation. That obviously is a mix of greenfields and incrementals. And I would just reflect in that model then what is the potential risk from what we highlighted with respect to the softening U.S. capital pipeline that we saw in Q1.

我想，阿米特，你有一個關於綠地的問題。我在美國的想法是你有你的程序估計，你可以從我們的範圍內獲取。您可以在利用率方面應用通常的模型。這讓您對已安裝的基礎如何擴展有所了解。所以你可以做那種計算。這顯然是綠地和增量的混合。我只想在該模型中反映我們在第一季度看到的美國資本管道疲軟的潛在風險是什麼。

Just a capping remark on that. Final thought is the core driver in a mature multiport market segment in a country like the United States, the core driver is procedure demand. And we feel like procedure demand is healthy. It's healthy in our target areas. Our major focus is making sure that we can supply the customer with what they need in a way that's high quality and timely. So it's really managing the supply chain. If that goes well and we are successful in closing those gaps, I think capital demand will work itself out. It will play through because it ultimately in those markets is driven by core procedure demand.

只是一個封頂評論。最後的想法是美國這樣一個成熟的多端口細分市場的核心驅動力，核心驅動力是程序需求。我們覺得程序需求是健康的。它在我們的目標區域是健康的。我們的主要重點是確保我們能夠以高質量和及時的方式為客戶提供他們需要的東西。所以它實際上是在管理供應鏈。如果進展順利並且我們成功縮小了這些差距，我認為資本需求將自行解決。它將發揮作用，因為它最終在這些市場中是由核心程序需求驅動的。

And the second question, I always hate to ask this question, but I feel like investors want me to at this point in time, just get you to reflect on this. We always believe, as you stated, that you're working on at least one, if not 2, new platforms. We know you have that in the background. We see your R&D spend. That's obvious to everyone. I think the big question is always about timing. And for us, what we wanted to ask is, is this a situation at this point in time where technology just needs more time to incubate, whether maybe what we're seeing is more something that's related to FDA and the process that you go through and how that's evolved. How much color can you give us on just the process for getting new technology to market and where you are?

第二個問題，我總是討厭問這個問題，但我覺得投資者希望我在這個時間點上，讓你反思一下。正如您所說，我們始終相信您正在開發至少一個（如果不是 2 個）新平台。我們知道你在後台有這個。我們看到了您的研發支出。這對每個人來說都是顯而易見的。我認為最大的問題總是關於時機。對我們來說，我們想問的是，在這種情況下，技術是否需要更多時間來孵化，我們所看到的是否更多與 FDA 和您所經歷的過程有關以及它是如何演變的。關於將新技術推向市場的過程以及您所處的位置，您能給我們多少啟發？

Yes. It's a good question. What I'd say here is a couple. One is, as the technologies have matured and the installed base has gotten bigger, we've made an intentional decision to invest a lot in upgrading the capabilities of Gen 4 platforms that are out there. So the first thing has been that the Xi that somebody purchases today is more capable than the Xi that they had when it was first launched, and we keep doing that.

是的。這是個好問題。我在這裡要說的是一對。一是，隨著技術的成熟和安裝基數的擴大，我們已經做出了一個有意的決定，即投入大量資金來升級現有的第 4 代平台的功能。所以第一件事是，今天有人購買的 Xi 比剛推出時的 Xi 更有能力，我們一直在這樣做。

In part, that's easier, those kind of incremental adds to a platform architecture that's pretty mature are easier for the customer base to absorb. And they also compound utilization. They allow them to get more utility out of the capital they have. They get higher throughput through it, and they do more procedures with it. And in Gen 4, we're not done with that. We have continued to do it, whether it's instruments and accessories or endoscopy or software. And we have some things up our sleeves for that, too.

在某種程度上，這更容易，那些對非常成熟的平台架構的增量添加更容易被客戶群吸收。而且它們還復合利用。它們允許他們從他們擁有的資本中獲得更多的效用。他們通過它獲得更高的吞吐量，並且他們用它做更多的程序。在第 4 代中，我們還沒有完成。我們一直在做這件事，無論是儀器和配件，還是內窺鏡檢查或軟件。我們也為此準備了一些東西。

So that was intentional. We were doing more kind of structural changes early on in that product and we have intentionally moved some things into more incremental changes on Gen 4. We do think that there are bigger structural changes that will make sense. We are working on them. They are interesting. I think they have long-term implications for the surgical market segments we participate in. I'm excited about them. Some of those things are around technology development. Some of them are around manufacturing and supply chain development, and some of them are around clinical pathways and regulatory pathways. So all of those things play out.

所以這是故意的。我們在該產品的早期進行了更多類型的結構更改，並且我們有意將一些事情轉移到第 4 代的更多增量更改中。我們確實認為有更大的結構更改是有意義的。我們正在研究它們。他們有趣。我認為它們對我們參與的外科細分市場具有長期影響。我對它們感到興奮。其中一些事情與技術開發有關。其中一些圍繞製造和供應鏈開發，其中一些圍繞臨床途徑和監管途徑。所以所有這些事情都會發揮作用。

I will reinforce what you said. We work on incremental changes. We work on structural changes. And we work kind of multiple generations ahead. And that remains true. We continue to do that. Timing-wise, sometimes a little bit hard to predict perfectly based on both supply chain readiness and how FDA thinks about those things. For us, I want to make sure that every time we make a step that the customers value it, that it's done with them in mind rather than with us in mind. And we continue to have that philosophy and we'll pursue it.

我會加強你所說的。我們致力於增量更改。我們致力於結構性變革。而且我們提前了幾代人的工作。這仍然是正確的。我們繼續這樣做。在時間方面，有時很難根據供應鏈的準備情況和 FDA 對這些事情的看法來完美預測。對我們來說，我想確保每次我們邁出讓客戶重視的一步時，都是在考慮他們而不是考慮我們的情況下完成的。我們將繼續擁有這種理念，我們將繼續追求它。

The next question is from Rick Wise from Stifel.

下一個問題來自 Stifel 的 Rick Wise。

Maybe we could talk about, you could expand on your comments on Ion. Just a couple of things you said that I'd be curious to hear more about. Submitted for EU approval, maybe you could give us a little more color on the timing of the opportunity and I'm wondering whether it impacts '22. But maybe you could also talk a little bit about what you've been kind enough to describe in the recent past as sort of an inflection point for Ion. Maybe broadly speaking, what's the feedback you're getting from how the device is using? And maybe talk a little bit about what's next. I mean, it seems more like an execution kind of story at this point.

也許我們可以談談，您可以擴展您對 Ion 的評論。只是你說的幾件事，我很想知道更多。提交給歐盟批准，也許你可以給我們更多關於機會時間的顏色，我想知道它是否會影響 '22。但也許你也可以談談你在最近的過去一直很好地描述的事情，作為 Ion 的一個轉折點。也許從廣義上講，您從設備的使用方式中獲得了什麼反饋？也許談談接下來會發生什麼。我的意思是，在這一點上，它似乎更像是一個執行故事。

Thanks, Rick. On submission for Europe, we just submitted our dossier. Europe has changed over the framing of their medical device regulation. They call it EU MDR. It's relatively new for the world. As a result, projecting exact timing to get those clearances is a little different relative to historical norms. We don't anticipate it completing in 2022. It's a little bit of, what's the odds game, but we think it's several quarters to finish mostly because it's new for the regulators and it's new for us.

謝謝，瑞克。在向歐洲提交時，我們剛剛提交了我們的檔案。歐洲已經改變了其醫療器械法規的框架。他們稱之為歐盟 MDR。這對世界來說是相對較新的。因此，預測獲得這些許可的確切時間與歷史規範略有不同。我們預計它不會在 2022 年完成。這有點困難，但我們認為這需要幾個季度才能完成，主要是因為它對監管機構來說是新的，對我們來說也是新的。

On the point of how is Ion going, it's being driven right now on the single indication of biopsy and bronchoscopy. I think it's driving well because it meets a need. I think alternate technologies, manual and robotic, are less capable. And we see a lot of peer-to-peer word of mouth that is driving interest, and that's backed by data like the PRECIsE trial. So that's been helpful for us.

關於 Ion 的進展情況，它現在正以活檢和支氣管鏡檢查的單一適應症為動力。我認為它開得很好，因為它滿足了需求。我認為替代技術，手動和機器人，能力較差。我們看到很多點對點的口口相傳引起了人們的興趣，這得到了 PRECISE 試驗等數據的支持。所以這對我們很有幫助。

A lot of our focus here has been developing our manufacturing capacity, continuously improving the product in terms of usability, quality, robustness and efficacy. And the teams are doing a great job and working extremely hard to do all of those things, make sure that we can maintain supply and improve. I'm just delighted with what they're up to. They are both increasing capacity and improving robustness and quality simultaneously. So that's been wonderful, and I think we have room.

我們在這裡的很多重點一直是發展我們的製造能力，在可用性、質量、穩健性和功效方面不斷改進產品。團隊做得很好，並且非常努力地完成所有這些事情，確保我們能夠維持供應和改進。我只是對他們的所作所為感到高興。它們都在增加容量並同時提高穩健性和質量。所以這太棒了，我認為我們有空間。

We're seeing the combination of Ion bronchoscopic evaluation combined with robotic surgery thereafter. Sometimes people do it on the same day. And that has seen some real value for patients. It's not every part of the patient population, but there are some patients for whom that's a good solution. And we see a lot of excitement. So the tie-through of Ion diagnostics with follow-through treatment is creating patient value. It's shortening the time to definitive answers and then a surgery if a surgery is indicated. So that's been great.

此後，我們看到了離子支氣管鏡評估與機器人手術的結合。有時人們會在同一天完成。這已經為患者帶來了一些真正的價值。並非患者群體的每一部分，但對一些患者來說，這是一個很好的解決方案。我們看到了很多興奮。因此，離子診斷與後續治療的結合正在創造患者價值。它縮短了確定答案的時間，然後在需要手術的情況下進行手術。所以這很棒。

We think Ion as a platform has multiple future indications that it can provide, of clinical value that it can bring, and we are pursuing them assertively in various places. We are not yet publicly describing what those things are, in part because we have some technology to develop, in part there's some regulatory pathways and it's a competitive space. And so we're working down those elements. As we get a little closer, have a little bit better visibility into which ones, when, then we'll be sure to share.

我們認為 Ion 作為一個平台，它可以提供多種未來的跡象，它可以帶來臨床價值，我們正在各個地方堅定地追求它們。我們還沒有公開描述這些東西是什麼，部分是因為我們有一些技術要開發，部分是因為有一些監管途徑，這是一個競爭空間。所以我們正在研究這些元素。當我們離得更近一點時，可以更好地了解哪些，何時，然後我們一定會分享。

Got you. Procedure demand, as you clearly stated, it was healthy this quarter. It feels like it's likely to continue. So hopefully, as hopefully COVID headwinds settle back a little bit around the world, Intuitive always used to talk about the, let's see if I can say this correctly, Gary, the percentage of utilization for average utilization for da Vinci systems. And I'm sort of making this up from memory, but it used to be like when you got to 60% or 65% of da Vinci capacity, it would start to drive new discussions about new systems. Forgetting the specifics of my question, where do you feel like you are with the current installed base utilization? And is that a consideration that we should reflect on as we think about system placements going forward?

得到你。正如您明確指出的那樣，程序需求是健康的。感覺很有可能還會繼續。因此，希望隨著 COVID 逆風在全球範圍內有所緩解，直覺總是用來談論，讓我們看看我是否可以正確地說，加里，達芬奇系統平均利用率的利用率百分比。我在某種程度上是憑記憶彌補的，但過去就像當你達到達芬奇容量的 60% 或 65% 時，它會開始引發關於新系統的新討論。忘記我的問題的細節，你覺得你目前的安裝基礎利用率在哪裡？當我們考慮未來的系統佈局時，這是我們應該考慮的因素嗎？

There's absolutely a relationship between procedure growth and demand and increased utilization on capital, right? And it's inversely related. If you have lower utilization, you sell more capital to do the same number of procedures. We have believed and have pursued assertively that while higher utilization decreases the number of systems that we sell, it increases the utility, the economic value derived by our customers to get higher throughput. And so we put programs in, both in terms of design and workflow as well as consulting services to help them get higher utilization. We've been doing that for years.

程序增長和需求以及增加的資本利用率之間絕對存在關係，對嗎？並且是負相關的。如果您的利用率較低，您可以出售更多資金來執行相同數量的程序。我們相信並堅定地追求，雖然更高的利用率會減少我們銷售的系統數量，但它會增加效用，我們的客戶為獲得更高的吞吐量而獲得的經濟價值。因此，我們在設計和工作流程以及諮詢服務方面都投入了程序，以幫助他們獲得更高的利用率。多年來我們一直在這樣做。

It's a number that you can move in a sustained way, but it's hard to move quickly. And I'll turn it over to Jamie shortly. He'll talk a little bit about what the trend line and utilization growth has been. But from an intent point of view, we are happy to see increased utilization even if that pressures near-term capital because it creates better ROI conditions for our customers. And from a pure marginal economics point of view, at Intuitive, the marginal economics work out well for us, too. So it's a win-win even though at the top line in placements it may look like pressure.

這是一個可以持續移動的數字，但很難快速移動。我很快就會把它交給傑米。他將稍微談談趨勢線和利用率增長情況。但從意圖的角度來看，我們很高興看到利用率提高，即使這會給短期資本帶來壓力，因為它為我們的客戶創造了更好的投資回報條件。從純粹的邊際經濟學的角度來看，在 Intuitive，邊際經濟學對我們也很有效。所以這是一個雙贏的局面，即使在排名靠前的位置看起來像是壓力。

So then you had asked the question, kind of what is peak utilization and how do you think about that. I'll also turn that over to Jamie. It has a lot to do with mix and operating conditions in the hospital. It's a little bit less a technology question, a little bit more how they use it. So Jamie, perhaps a little bit on utilization.

那麼你問了這個問題，什麼是峰值利用率以及你如何看待這個問題。我也會把它交給傑米。這與醫院的混合和操作條件有很大關係。這不是一個技術問題，更多的是他們如何使用它。所以傑米，也許有點關於利用率。

If I just go back to pre-COVID for a second, Rick, if you look at 2019, average system utilization grew by 5% over 2018. If I look at recent times and use the CAGR approach to kind of normalize for COVID, last year, on a 2-year CAGR basis in 2021, utilization grew by 4%. This past quarter on a 3-year CAGR basis, again, back to 2019, grew by 4%. So you can see some relative consistency there.

如果我再回到 COVID 之前，Rick，如果你看看 2019 年，平均係統利用率比 2018 年增長了 5%。如果我回顧最近的時間並使用 CAGR 方法對 COVID 進行某種標準化，最後按 2021 年的 2 年復合年增長率計算，利用率增長了 4%。回到 2019 年，上一季度以 3 年復合年增長率計算，增長了 4%。所以你可以在那裡看到一些相對的一致性。

With respect to looking forward, I think that there is some dependency on the institution, the procedure mix within the institution. General surgery in combination with Xi gives you the opportunity to drive utilization differently than a different procedure mix, particularly given the lower procedure times in some of the benign low-acuity procedures. But it also reflects the number of surgeons that are trained and the commitment of the hospital to drive asset utilization. If you look at the distribution of utilization, today, it's relatively wide. I think there are a number of CFOs in hospitals that on a medium-term basis see opportunities to continue to drive utilization up, and we are supportive of that.

關於展望，我認為對機構有一定的依賴性，機構內的程序組合。與 Xi 相結合的普通外科手術讓您有機會以不同於不同手術組合的方式推動利用率，特別是考慮到一些良性低敏度手術的手術時間較短。但它也反映了受過培訓的外科醫生的數量以及醫院對推動資產利用的承諾。如果你看一下利用率的分佈，今天，它是比較廣泛的。我認為醫院中有許多 CFO 從中期內看到了繼續提高利用率的機會，我們對此表示支持。

And the next question is from Larry Biegelsen from Wells Fargo.

下一個問題來自富國銀行的拉里·比格爾森。

Just one on China for me and one on inflation and supply constraint. So on China, what have you guys seen so far from the lockdowns? And what are your expectations for the second quarter? Do you think you can still grow year-over-year in China? And related to that, Gary, what's the process and time line for the next quota? You're about to finish this quota. Is it possible the next quota could be larger or eliminated entirely? And I have one follow-up.

我只有一篇關於中國的文章，一篇關於通貨膨脹和供應限制的文章。那麼關於中國，你們到目前為止從封鎖中看到了什麼？您對第二季度的期望是什麼？您認為您在中國還能實現同比增長嗎？與此相關，Gary，下一個配額的流程和時間表是什麼？您即將完成此配額。下一個配額是否有可能更大或完全取消？我有一個後續行動。

I'll turn those both to Jamie.

我會把這兩個都交給傑米。

Yes. With respect to what we saw in procedures in Q1, as you saw, the COVID cases rises in places like Shanghai. And as the authorities lock down, and they lock down pretty strictly, we saw procedures impacted in March. That's continued so far into April, although it's obviously early. I think that there's risk in procedures in Q2 relative to what you would expect without COVID and those lockdowns.

是的。關於我們在第一季度的程序中看到的情況，如您所見，COVID 病例在上海等地有所上升。隨著當局的封鎖，而且他們封鎖得非常嚴格，我們看到程序在 3 月份受到了影響。這種情況一直持續到四月，儘管顯然還為時過早。我認為與沒有 COVID 和那些封鎖的情況相比，第二季度的程序存在風險。

China is our second-biggest marketplace, but it's still a relatively small proportion of overall procedures. U.S. is still about 70% of global procedures. But certainly, the way things look right now, you have some impact in Q2. What that ends up being really depends on how long the lockdowns last and how long COVID persists in China. I think a separate risk is kind of the impact of logistics and supply chains as we deliver product to China and from a more macro perspective just the port closures and the broader impact that we could see in China given the degree of exports they have just generally across the economy.

中國是我們的第二大市場，但在整個程序中所佔的比例仍然相對較小。美國仍佔全球程序的 70% 左右。但可以肯定的是，從目前的情況來看，你在第二季度會產生一些影響。最終的結果實際上取決於封鎖持續多長時間以及 COVID 在中國持續多長時間。我認為一個單獨的風險是物流和供應鏈的影響，因為我們將產品運送到中國，從更宏觀的角度來看，只是港口關閉以及考慮到中國的出口程度，我們可以在中國看到的更廣泛影響整個經濟。

With respect to the China quota, difficult to predict. The last couple of times, the quota has been issued in the third year of the quota period, which would be next year. We don't have great visibility into when that might be. And we don't have, honestly, great visibility into what the number would be. I don't think we are expecting or planning on a situation where we are exempt from a quota. But again, we don't have great insights to how that will play out.

關於中國的配額，很難預測。最近幾次，配額是在配額期的第三年發放的，也就是明年。我們對可能的時間沒有很好的了解。老實說，我們對這個數字沒有很好的了解。我不認為我們期望或計劃免於配額的情況。但同樣，我們對這將如何發揮作用並沒有很好的見解。

In general, if the quota is responsive to demand, we think demand is high, and the question is how responsive to that demand is the central government quota when they do it. Sorry, Larry, go ahead.

一般來說，如果配額對需求有反應，我們認為需求很高，問題是中央政府配額對需求的響應程度如何。對不起，拉里，繼續。

No. I'm sorry to interrupt you. Jamie, on inflation and supply constraints, are you able to quantify the impact on the gross margin that you're expecting from inflation? And on supply constraints, how are you addressing this? A lot of companies are buying forward inventory. And what are your expectations for when it gets better? I know you've talked about hand-to-hand combat. You've used that phrase almost on the last few calls.

不，很抱歉打斷你。 Jamie，關於通貨膨脹和供應限制，您能否量化您預期通貨膨脹對毛利率的影響？關於供應限制，您如何解決這個問題？許多公司都在購買遠期庫存。當它變得更好時，您的期望是什麼？我知道你談到了肉搏戰。您幾乎在最近幾次通話中都使用了該短語。

Yes. I would just maybe ground the impact of inflation a couple of ways. If you look back at history, our gross margin has been in, let's say, the 71%-ish range versus what we just guided, 69% to 70.5%. And there's really 2 drivers in the gap between our history and that range. One are the investments we're making in fixed costs in infrastructure and manufacturing capacity that's being invested effectively for long-term need. So some of that is ahead of when we will need it. But the lead times require that we put that in place ahead of time.

是的。我可能會以幾種方式來說明通貨膨脹的影響。如果你回顧歷史，我們的毛利率一直在 71% 左右，而我們剛剛指導的範圍是 69% 到 70.5%。在我們的歷史和那個範圍之間，確實有 2 個驅動因素。其中之一是我們在基礎設施和製造能力的固定成本方面進行的投資，這些投資正在有效地滿足長期需求。所以其中一些是在我們需要它之前。但是交貨時間要求我們提前將其落實到位。

The second impact is this impact from the supply chain and inflation in the form of logistics costs, higher component prices, et cetera. I can't give you perfect kind of delineation between the 2. I would say, roughly slightly more of that, the impact of that gap is on the fixed cost side. The remainder is in inflation, supply chain impacts.

第二個影響是供應鏈的影響以及物流成本、零部件價格上漲等形式的通貨膨脹。我無法在兩者之間給出完美的劃分。我會說，大約略多一點，這種差距的影響是在固定成本方面。其餘的是通貨膨脹，供應鏈的影響。

With respect to how we're managing through the supply chain, there are significant efforts by our operations team just to respond to the whack-a-mole that you described. It's a constant battle of issue resolution. And our #1 goal, as Gary described, is to ensure continuity of supply to customers. So that's where our efforts and focus is.

關於我們如何通過供應鏈進行管理，我們的運營團隊做出了巨大的努力來回應你所描述的打地鼠問題。這是解決問題的持續戰鬥。正如 Gary 所描述的，我們的第一目標是確保向客戶供應的連續性。這就是我們的努力和重點所在。

As the supply chain environment rebalances in whatever point that is in the future, certainly, we will kind of refocus our operations teams to focus on cost reductions, getting our manufacturing efficiencies back to our targets. But that's going to really be a question of when will that be. On the inventory side, you saw us actually increase inventories. I referenced in my prepared remarks almost $70 million sequentially. The mix of that, though, is clearly not perfect. We're replenishing inventory where we can if and as supply lasts. But we have an imbalance currently.

隨著供應鏈環境在未來的任何時候重新平衡，我們當然會重新調整我們的運營團隊的重點，專注於降低成本，讓我們的製造效率回到我們的目標。但這真的是一個什麼時候會發生的問題。在庫存方面，您看到我們實際上增加了庫存。我在準備好的評論中提到了近 7000 萬美元。然而，兩者的結合顯然並不完美。如果供應持續，我們將盡可能補充庫存。但我們目前存在不平衡。

Certainly, if you look at the medium to long term, we're going to look carefully at what levels of inventory we want to hold as one risk mitigation. I think the other thing we'll look at is how do we make ourselves less dependent on sole suppliers.

當然，如果您著眼於中長期，我們將仔細研究我們希望持有的庫存水平以作為一種風險緩解措施。我認為我們要看的另一件事是我們如何減少對唯一供應商的依賴。

Just a tiny bit of color on that capping sentence. The current situation, it's a little bit hard to predict the future because there's enough moving parts that determining what or forecasting exactly how it will move is probably difficult at this moment. Currently, the number of parts that are under stress has decreased, but the intensity of the stress around a few parts has increased. So the number of things that are a challenge is narrowing, but the ones that remain are more stubborn. And Jamie, your point of, we use various tools, whether it's buying ahead, buying safety stock or redundancy in the supply chain, we'll use any and all of those if we can to help mitigate the risk.

只是在那個封頂句子上加了一點顏色。在目前的情況下，預測未來有點困難，因為有足夠多的移動部件來確定或準確預測它將如何移動目前可能很困難。目前，承受應力的零件數量有所減少，但少數零件周圍的應力強度有所增加。因此，具有挑戰的事情的數量正在減少，但剩下的事情更加頑固。 Jamie，您的觀點是，我們使用各種工具，無論是提前購買、購買安全庫存還是供應鏈中的冗餘，如果可以的話，我們將使用所有這些工具來幫助降低風險。

Our next question is from Drew Ranieri from Morgan Stanley.

我們的下一個問題來自摩根士丹利的 Drew Ranieri。

Gary, just for you. I mean, I think Intuitive has like 2,200 U.S. hospital customers. That's more my guess than, I think, what you've ever laid out. But can you maybe talk about what it takes to get the remaining 4,000 hospitals really off the sidelines and using robotics? Just maybe how are you thinking about that in the U.S.? I mean, do you necessarily have to go everywhere? Are there really kind of still opportunities to get into the high-volume surgery centers, hospitals given some of the commentary about the trade-in cycle dynamics and your push for some higher utilization of the systems?

加里，只為你。我的意思是，我認為 Intuitive 擁有大約 2,200 名美國醫院客戶。這更像是我的猜測，而不是我認為你曾經列出的內容。但是，您能否談談如何讓剩餘的 4,000 家醫院真正退出市場並使用機器人技術？只是也許你在美國是怎麼想的？我的意思是，你一定要到處走嗎？考慮到一些關於以舊換新周期動態的評論以及您對系統利用率更高的推動，是否真的還有機會進入大批量手術中心、醫院？

I won't speak to the quantitative approach. And perhaps, Jamie, you have a perspective. But just to give you a little bit of a qualitative view, many of the hospitals out there that are greenfields, while they may not have one of our programs today are part of an integrated delivery network that somewhere in the system they have our products and knowledge. The way we work with that is collaboratively with IDN leadership. As they start to understand what the value of the programs are, they will start to move within their own system our products into locations they care about. And so we've seen a really nice move and collaborative expansion with our customer base into those spaces.

我不會談論定量方法。也許，傑米，你有一個觀點。但只是為了給你一點定性的看法，那裡的許多醫院都是綠地，雖然他們今天可能沒有我們的項目之一，但它們是綜合交付網絡的一部分，在系統的某個地方，他們擁有我們的產品和知識。我們的工作方式是與 IDN 領導層合作。當他們開始了解程序的價值時，他們將開始在他們自己的系統內將我們的產品轉移到他們關心的位置。因此，我們看到了一個非常好的舉措，並與我們的客戶群合作擴展到這些領域。

Increasingly, we have conversations about moving into different sites of care, especially as benign general surgery procedures and some other procedures that are benign and often done in smaller ambulatory environments become more prevalent in our workspace, we see that improving over time. So we think we can follow our customers where they want to go.

我們越來越多地討論轉移到不同的護理地點，特別是良性的普通外科手術和其他一些良性的、通常在較小的門診環境中進行的手術在我們的工作空間中變得越來越普遍，我們看到隨著時間的推移會有所改善。所以我們認為我們可以跟隨我們的客戶去他們想去的地方。

There is the concentrating effect of robotics and capital investment. It is capital investment. When that happens, it does concentrate regionally those patients and procedures into centers of excellence. We think that's good for our customer to get higher utilization. We think it's good for surgical outcomes because they get more practice. So I think it's a combination of the 2. I don't think we just look at it and think we have to go to where every patient is today. We do think consolidation helps and works, but it will expand from where it is in this moment. Jamie, I don't know if you want to add anything to that.

有機器人技術和資本投資的集中效應。是資本投資。當這種情況發生時，它確實會在區域內將這些患者和程序集中到卓越中心。我們認為這有利於我們的客戶獲得更高的利用率。我們認為這對手術結果有好處，因為他們得到了更多的練習。所以我認為這是兩者的結合。我不認為我們只是看著它並認為我們必須去每個病人所在的地方。我們確實認為整合有幫助並且有效，但它會從目前的位置擴展。傑米，我不知道你是否想添加任何東西。

The only thing I would say is the remaining greenfields tend to be, this is not always the case, but tend to be more in the rural setting, smaller number of beds. So what I think we've seen over the last 3, 4 quarters, as Gary described, is actually increases in the number of placements of greenfield accounts. These are hospitals, as Gary said, that are within existing IDNs. And that's largely a function of the success and experience those IDNs have had with benign procedures, particularly in general surgery, which tend to be a higher mix in these rural hospitals. And so they see the opportunity for effective robotics programs in that setting, whereas before maybe there was more skepticism or the financial picture was more challenging. We'll do that carefully and in conjunction with our IDN partners, and it has to be one that makes economic sense for us and for the customer.

我唯一要說的是剩餘的綠地往往是，情況並非總是如此，但往往更多的是在農村環境中，床位數較少。因此，正如 Gary 所描述的，我認為我們在過去 3、4 個季度中看到的實際上是新建賬戶的安置數量有所增加。正如 Gary 所說，這些是現有 IDN 內的醫院。這在很大程度上取決於這些 IDN 在良性手術方面的成功和經驗，特別是在普通外科手術中，這在這些農村醫院中往往是更高的組合。因此，他們看到了在這種情況下有效的機器人項目的機會，而在此之前，可能會有更多的懷疑或財務狀況更具挑戰性。我們將與我們的 IDN 合作夥伴一起謹慎地做到這一點，而且它必須對我們和客戶都具有經濟意義。

On the ASC side, we have a relatively small but growing installed base. Our procedure growth at ASCs in the U.S. is accretive, but that's probably because the number of systems that we have at hospitals or ASCs is relatively low. Those ASCs generally are ASCs affiliated in some way with our IDNs. That kind of gives us greater confidence in those accounts.

在 ASC 方面，我們的安裝基數相對較小但不斷增長。我們在美國 ASC 的程序增長是遞增的，但這可能是因為我們在醫院或 ASC 擁有的系統數量相對較少。這些 ASC 通常是以某種方式附屬於我們的 IDN 的 ASC。這讓我們對這些賬戶更有信心。

Drew, I'll give you a fast follow-up here at the end.

德魯，最後我會給你一個快速的跟進。

All right. Just on Japan, you talked about adding 8 more procedures, you're getting reimbursement for 8 more procedures. Can you maybe just put that in context of how you expect that ramp to maybe look like versus the prior wave of reimbursed procedures in Japan?

好的。就在日本，您談到要增加 8 個程序，您將獲得 8 個程序的報銷。您是否可以將其放在您期望該斜坡與日本前一波報銷程序相比可能看起來如何的背景下？

Drew, this is Brian. I guess I would say, really, the opportunity for adoption on those 8 newly reimbursed procedures, it's a bit difficult, I'd say, to estimate at this time, right? I mean, if you were to take procedures like colon resection as an example, it's highly penetrated by LAP today. So I think adoption of da Vinci will actually be dependent on, say, demonstrating clinical and economic benefits, which I think is going to take some time. And I think it's going to take some time to develop our training and proctoring capabilities and really to establish key opinion leaders. So I think it's just going to take some time. It's really hard to estimate how quickly da Vinci will adopt locally.

德魯，這是布賴恩。我想我會說，真的，這8個新報銷的程序的收養機會，我想說，這個時候估計有點困難，對吧？我的意思是，如果您以結腸切除術等手術為例，今天 LAP 已高度滲透。所以我認為達芬奇的採用實際上將取決於，比如說，展示臨床和經濟效益，我認為這需要一些時間。而且我認為需要一些時間來發展我們的培訓和監考能力，並真正建立關鍵的意見領袖。所以我認為這只是需要一些時間。很難估計達芬奇在當地採用的速度有多快。

A little color on that. I think over the midterm we're really excited about it. Over the near term, it takes more. Thank you, Drew. That was our last question.

上面一點顏色。我認為在中期我們對此感到非常興奮。在短期內，它需要更多。謝謝你，德魯。那是我們的最後一個問題。

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 to treat.

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；為患者提供更好的體驗；為他們的護理團隊提供更好的體驗；並最終降低治療的總成本。

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

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。在 Intuitive，我們設想了一個侵入性更小、效果更好的護理未來，疾病被更早地發現並迅速治療，這樣患者就可以回到最重要的事情上。

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

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。這結束了通話。

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

謝謝你。女士們先生們，今天的會議到此結束。感謝您的參與和使用 AT&T 電話會議服務。您現在可以斷開連接。