Procept Biorobotics Corp (PRCT) 2023 Q1 法說會逐字稿

Good morning, and welcome to the PROCEPT BioRobotics First Quarter 2023 Earnings Conference Call. At this time, all participants are a listen-only mode. We will be facilitating a question-and-answer session towards the end of the call today. As a reminder, this call is being recorded for replay purposes. I would now like to turn the call over to Matt Bacso, Vice President of Investor Relations for a few introductory comments.

Good morning, and thank you for joining PROCEPT BioRobotics First Quarter 2023 Earnings Conference Call. Presenting on today's call are Reza Zadno, Chief Executive Officer; and Kevin Waters, Chief Financial Officer.

Before we begin, I'd like to remind listeners that statements made on this conference call that relate to future plans, events or performance, are forward-looking statements as defined under the Private Securities Litigation Reform Act of 1995. While these forward-looking statements are based on management's current expectations and beliefs, these statements are subject to several risks, uncertainties, assumptions and other factors that could cause results to differ materially from the expectations expressed on this conference call.

These risks and uncertainties are disclosed in more detail in the prostatic filings with the Securities and Exchange Commission, all of which are available online at www.sec.gov. Listeners are cautioned to not place undue reliance on these forward-looking statements which speak only as of today's date, April 27, 2023. Except as required by law, preceptorbatic undertakes no obligation to update or revise any forward-looking statements to reflect new information, circumstances or unanticipated events that may arise. With that, I will now turn the call over to Reza.

Good morning, and thank you for joining us. For today's call, I will provide opening comments and a business update followed by Kevin, who will provide additional detail regarding our financial performance and 2023 guidance before opening the call to Q&A. Starting with our quarterly revenue results. We are pleased to report another strong quarter with our customers and patients continue to realize the significant clinical benefit of population therapy. Total revenue for the first quarter of 2023 was $24.4 million, representing growth of 72% compared to the first quarter of 2022. Growth in the quarter was driven primarily by increased utilization from our expanded installed base and strong patient volume. We believe the combination of positive long-term clinical data increased private payer coverage, outstanding real-world patient outcomes and an expanded feel-based commercial team continued to drive surgeon interest and adoption of our AquaBeam Robotic Systems.

As we move to 2023, we believe there are several positive factors, which give us a high degree of confidence to achieve our increased full year financial guidance, and Kevin will touch on later. Longer term, we believe these underlying fundamentals reflect the business that is laying the foundation to become the BPH surgical standard of care, starting with the recent payer coverage. In early April, we announced that UnitedHealthcare updated its policy for prostate surgery and interventions to include Aquablation as medically necessary. This updated policy will go into effect on June 1, 2023, being one of the largest commercial payers in the United States with approximately 45 million covered lives, United's positive coverage policy will greatly improve accessibility of our Aquablation therapy for men suffering from BPH.

Additionally, in early March, we also obtained a positive coverage policy from Blue Cross Blue Shield of Michigan, which will be effective May first. Blue Cross Blue Shield of Michigan is the largest payer in the state of Michigan and covers approximately 5.7 million lives. With the additions of UnitedHealthcare and Blue Cross Blue Shield of Michigan, we now estimate roughly 95% of men in the U.S. have access to our population therapy. There is both a long-term and a short-term benefit of increasing commercial payer coverage. The obvious long-term benefit is increased utilization, which will take time as we penetrate the surgical market. The short-term benefit is the increased value proposition of our technology and the lowering of barriers to sell capital equipment to hospitals. Turning to clinical updates. This weekend at the American Urological Association Conference in Chicago, we will be releasing our 5-year WATER II Study Data.

As a reminder, WATER II was a prospective FDA study with an objective performance criteria for both efficacy and safety in large prostate ranging in size from 80 to 150 milliliters. The 5-year data were consistent with the previously reported primary endpoint with no change to safety results. The efficacy results as measured by change in IPSS and QMAX, also remained consistent at 5 years. Additionally, the 5-year water study abstract will be presented at AUA comparing efficacy and safety of Aquablation therapy versus TER for treatment of 50 to 80 milliliter prostates. As a reminder, our 5-year water data are the only prospective randomized double-line multicenter FDA pivotal study comparing the safety and efficacy of copulation therapy to TURP for prostate ranging from 30 to 80 milliliters. This abstract pools Aquablation therapy superior safety due to low irreversible complication and superior symptom rule.

In this abstract, Aquablation therapy at 5 years exhibited durability that was 2x better than compared to TURP. This is measured by patients going back to met or requiring surgical retreatment, which is represented by an approximate 1 person annual treatment rates. As a company, we have developed a significant and growing body of clinical evidence, which now includes 2, 5-year FDA durability studies, 7 other clinical studies and over 150 peer reviewed publications, all supporting the benefits and clinical advantages of Aquablation therapy. We believe this backdrop will continue to be a significant differentiator for our customers when choosing to replace the historical BPH surgical modalities with Aquablation therapy across all prostate sizes and shapes.

Next, I want to touch on our commercial organization. In the first quarter, we saw 25 AquaBeam Robotic Systems generating total U.S. system revenue of $8.8 million, which was at the low end of our Q1 guidance range. During our Q4 earnings call in late February, we provided a range of capital sales in Q1 in order to give investors insight into our sales pipeline and the impact timing can play quarter-to-quarter. Our expectation and guidance around full year 2023 system sales has not changed in the last 2 months since we issued 2023 guidance, and we still expect approximately 45% of our system sales to be in the first half of 2023. In terms of our pipeline, the number of robust placement opportunities continue to grow meaningfully, which has been driven by the addition of new capital reps in greenfield territories.

Additionally, the more recent positive catalysts associated with the UnitedHealthcare announcement and full extension of the transitional pass-through payment for all of 2023, strengthens our confidence in our full year guidance. Speaking specifically about our capital sales personnel, we entered the first quarter of 2023 with approximately 30 capital sales reps, 10 of which were added in late Q4 2022. As a reminder, the productivity curve for capital reps is approximately 6 months as they will be responsible for building out their respective pipelines. Thus, we do not expect the capital reps added in the fourth quarter of 2022 to start meaningfully contributing to U.S. system sales until the second half of 2023. Our 2023 guidance continues to be informed, but what we are seeing in our pipeline, how opportunities progress, what customers are telling us, the productivity ramp of new capital reps and overall close rates. All of these indicators have maintained positive momentum as awareness around elaboration therapy continues to grow, which gives us confidence in achieving our 2023 commercial objectives.

Next, I want to touch on our progress securing IDN contracts. We recently signed a national sales contract with the largest IDN that secures pricing for system placement and handpieces sold to its nationwide hospital network. This is a significant milestone for us as it will allow our sales team to operate in an expedited and more predictable manner as we partner with Aquablation surgeon champions at these contracted hospitals. As stated on our Q4 earnings call, we anticipate having the majority of large strategic IDNs in the U.S. under contract by the end of 2023. While there are many hospital networks in the United States, we categorize strategic ideas as having greater than or equal 20 hospitals in network. While analyzing the market, we estimate 17 strategic IDMs account for approximately 26% of the 860 hiding BPH hospitals and 29% of the total 2,700 BPH hospital. Thus, the importance of these contracts is meaningful to our ability to penetrate the U.S. market and provide increased visibility in our pipeline.

Turning to utilization and surgeon activity. We are extremely pleased with Q1 utilization where U.S. hands and consumable revenue increased approximately 165% compared to the first quarter of 2022. While the primary driver of monthly utilization continues to be active surgeon growth, there are 2 key trends that have emerged over the last 12 months that are extremely positive for us. The first is active surgeon retention. We define active sign retention as any surgeon who performs a case in both the current and previous quarter. In the first quarter of 2023, surgeon retention rates were greater than 90%. As a company, we benefit greatly from this high level of surgeon retention as our commercial team can focus on training new surgeons. We believe this demonstrates accumulation therapies of use and ability to treat all prostate size and shape, safely and effectively.

The second emerging trend is utilization among low-volume BPH hospital accounts. While we are primarily focused on the 860 high-volume BPH hospitals, we are also starting to see nice adoption from low-volume accounts, which accounts for roughly 30% of our current installed base. Many of these hospitals are large surgery centers, however, have historically not performed many BPH surgeries. While likely too early to make definitive claims regarding market expansion, we do believe Aquablation therapy has allowed low-volume accounts to treat patients they otherwise would have referred out. Given the expanded awareness of Aquablation therapy along with positive momentum in peer-to-peer interactions, we believe low-volume hospitals are very valuable target for our commercial team.

Lastly, with respect to international market development activities. In early February, Aquablation therapy received a med tech innovation briefing from the National Institute for Health Care Excellence or NICE for BPH in the United Kingdom. NICE has recognized that Aquablation therapies affected for the removal of prostate tissue for BPH patients. Clinical experts set the technology was innovative compared to the standard of care and offered additional benefits such as increased ability to preserve quality of life. Clinical experts associated with the review also stated that the technology has the potential to replace TURP and would challenge oleum laser inoculation of the prostate for larger prospects. While our presence in the U.K. is currently small, given this updated guidance from NICE and established reimbursement for Aquablation therapy at similar levels to that of the U.S., we believe the U.K. could be an attractive market for our company in the future.

In March, we also attended the European Association of Urology in Milan. At the conference, we received positive feedback from certain customers and met with hundreds of European and other international urologists who are enthusiastic about our strong clinical data, driving them to learn more about Aquablation therapy. In summary, I feel better about our business today than at any point and have a higher degree of confidence in our ability to achieve our long-term growth plan. Every metric we track is moving in the right direction and to summarize these catalysts, our pipeline and sales funnel continued to grow nicely.

We just signed a national contract with the largest IDN and expect to continue to finalize contracts with other large strategic IDNs throughout the year. We received a positive coverage policy from UnitedHealthcare, providing approximately 95% patient access to our Aquablation therapy in the U.S. and have full transitional pass-through payment through 2023. Utilization continues to exceed our expectations, and we have increased our full year guidance around this metric. And lastly, our recent sales rep hires are progressing very nicely as they build our respective greenfield territories. Given this positive momentum, we believe Aquablation therapy will truly revolutionize the treatment of BPH. With that, I will turn the call over to Kevin.

Thanks, Reza. Total revenue for the first quarter of 2023 was $24.4 million, representing growth of 73% compared to the first quarter of 2022. U.S. revenue for the quarter was $21.8 million, representing growth of 74% compared to the prior year period. In the first quarter, we sold 25 AquaBeam Robotic Systems, generating total U.S. system revenue of $8.8 million, representing growth of 13% compared to the first quarter of 2022. First quarter system average selling prices were $350,000, which was approximately 5% below our expectations. However, we still expect full year system average selling prices based on the deals in our pipeline to be in the $370,000 to $375,000 range. U.S. can pace and consumable revenue for Q1 was $11.8 million, representing growth of approximately 165% compared to the first quarter of 2022. Handpiece revenue growth was driven by an increase in the installed base of AquaBeam Robotic System, which has grown 106% from the first quarter of 2022.

Additionally, we have seen an increase in utilization from our installed base. Monthly utilization per account of 6.3% increased approximately 14% compared to the first quarter of 2022. Utilization outperformance in the first quarter was a reflection of strong commercial execution and surgeons taking the next step to adopt Aquablation therapy as their treatment of choice for all respective procedures. We view utilization as the true leading indicator of overall market adoption long term. We shipped approximately 3,400 hand pieces in the U.S. in the first quarter, representing unit growth of 139% compared to the first quarter of 2022 with average selling prices of approximately $3,140. International revenue for the first quarter was $2.6 million, representing growth of approximately 60%. International revenue in the quarter was driven by both increased system sales and improved utilization.

Gross margin for the first quarter of 2023 was 51%. Sequential gross margin expansion in Q1 was due to strong execution from our operations team and our ability to absorb overhead expenses. Given our favorable standard margin profile of both our robot and hand piece, we have increased confidence to further absorb overhead expenses and expect to show sequential gross margin expansion throughout 2023. Lastly, on margins, we continue to make nice progress with regards to our move to San Jose, California, which will increase our footprint by 4x to 160,000 square feet. As stated previously, we expect to move into our new San Jose location by the end of the third quarter of 2023.

Moving down the income statement. Total operating expenses in the first quarter of 2023 were $40.9 million compared to $23.4 million in the same period of the prior year and $35.7 million in the fourth quarter of 2022. The increase was driven by increased sales and marketing expenses primarily to expand the commercial organization, increased variable compensation expenses and increased research and development and general and administrative expenses. Total interest and other expense was $107,000 as quarterly interest expense from our $52 million term loan was offset by favorable interest income. Net loss was $28.5 million for the first quarter of 2023 compared to $17.2 million in the same period of the prior year. Adjusted EBITDA was a loss of $23.9 million compared to a loss of $13.5 million in the first quarter of 2022.

Our cash and cash equivalents balance as of March 31 was $181 million. The decrease in cash in the first quarter compared to our historical cash burn was impacted by 2 factors that will not impact future quarters in 2023. First, we had our annual company bonus incentive payment, which used roughly $9 million of cash. Second, due to both our increased revenue ramp, coupled with the move to San Jose in Q3, we have substantially built up our inventory balances in Q1 to meet second half 2023 demand and provide safety stock during this transition. Inventory increased by $10.4 million in the first quarter of 2023 and should not increase at these levels in subsequent quarters.

Moving to our 2023 financial outlook. We are increasing our full year 2023 total revenue guidance to $128 million, representing growth of approximately 71% compared to 2022. We are increasing our revenue guidance based on the following factors: first, are the strong underlying utilization trends in the business. We now expect full year monthly utilization to be approximately 6.5% across our average installed base for 2023. Given the strong ramp we are seeing within our accounts, our updated guidance assumes slight sequential improvement in utilization throughout 2023. Second, we have increased confidence and visibility to achieve our implied system sales of 140 units for the full year. We continue to expect approximately 45% of capital sales to occur in the first half of 2023. Additionally, we expect our new capital reps who were hired in Q4 of 2022 to become fully productive in the second half of 2023. We also expect U.S. average selling prices to be approximately $370,000 for the full year.

Lastly, given the strong first quarter and positive momentum, we now expect full year international revenue to be approximately $9.6 million, representing growth of approximately 33% compared to 2022. Additionally, we expect handpiece average selling price to be approximately $3,100 and for other consumable revenue to be approximately $5.4 million. Moving down the income statement. We now expect full year 2023 gross margins to be approximately 54%, which is a slight increase over our initial guidance of 53%. Based on my previous comments and given the current rate of overhead absorption, we expect to exit 2023 with Q4 gross margins in the mid-50% range and should see sequential margin improvement throughout the year.

Additionally, we forecast full year 2023 operating expenses to be approximately $167 million. This increase in operating expense is associated with strategic investments in R&D, commercial team expansion, noncash stock-based compensation and underlying general and administrative costs to support the business and puts us in a favorable position to execute on our long-term growth plan. Therefore, given the increase in revenue and improved margin profile, we continue to expect full year 2023 adjusted EBITDA to be approximately negative $70.5 million. At this point, I'd like to turn the call back to Reza for closing comments.

Thanks, Kevin. In closing, I want to thank our employees, customers and shareholders for all their support to help us along our journey to becoming the standard of care for BPH. We will continue to leverage our commercial and clinical investments to execute on our long-term strategy. Have a great day, and I look forward to seeing many of you at our AUA investor event tomorrow at 8 a.m. Central Time. At this point, we will take questions. Operator?

(Operator Instructions) Our first question comes from the line of Craig Bijou of Bank of America.

So I want to start with the system placements in Q1. Kevin, you obviously said you guys still feel comfortable of getting to that $140 million. So maybe, I guess, talk about why the 25, why the system placements came in at the lower end of the range. And then I guess, maybe a little bit more color on your confidence, one, in the strong Q2 sequential uptick in systems implied by your guidance and then your confidence in getting to that $140 million for the full year.

Yes. Thanks, Greg. So our thoughts really around the full year capital and even the first half of 2023, that cadence hasn't changed since our call in February. And in fact, we do have a greater degree of confidence today to achieve our full year system numbers than we did even 2 months ago. And I mean that's primarily based on the pipeline we're seeing and just the numerous catalysts that Reza mentioned in his prepared remarks. And this specific to Q1, we did have deals that we expected to close in March that we now see a high profitability of closing in the second quarter.

So there is a timing dynamic which we've been talking about now over the last few quarters, and that is why we gave a range of system sales in the first quarter. And perhaps a point of specificity in the first quarter around system sales and that dynamic around IDNs as we did see IDNs in the first quarter take a very cautious approach to capital purchases. And therefore, we didn't see many IDN purchases come through in the first quarter. But we're already seeing here being through the month of April, those same IDNs releasing funds being released in Q2 that now will make up Q2 purchases. So when you take all those dynamics together, it still gives us confidence around the first half being about 45% of total system sales, which is consistent with the guidance in February, albeit some of that timing shifted to Q2.

Got it. And maybe I'll stick with systems. So -- and just, I guess, 2 pieces here. One, on the ASP, it came in lower in Q1 than what it traditionally has been and what you expect for the year. So just wanted to understand if there was any -- what was driving that pressure? And then on the IDN, how much of that is kind of baked into that 140 systems? Or how should we think -- how are you guys thinking about the opportunity that the IDNs present, whether it's the contract that was just signed or future contracts you expect to sign? How much of that factors into that $140 million?

Yes. So I'll start with the capital pie. And we are pointing out the fact Q1 system ASPs were about $350,000. That's about 5% below kind of the guidance that we put forth in February. But as mentioned in my prepared remarks, we still do expect full year ASPs in the 3.70% to 3.75% range based on all the deals we see in the pipeline. So without getting into specifics of each sale and the deal, the lower ASP in Q1 is not reflective of, first, it's not any large IDN pricing. It's not any other factors that we believe will impact future ASPs. It's really just timing and the high degree of variability that we have around some of our capital sales.

And we have two levers in the business, right, one being systems and one being utilization. And we are willing at the business to be variable and flexible on capital pricing to ensure that we get that system sold and then to ensure that we get that utilization. And if you look at handpiece average selling prices, those have actually been remarkably consistent quarter-to-quarter and increasing. And at the end of the day, we're willing to be slightly flexible on capital. But again, given the visibility we have into the pipeline, we feel very confident in the full year ASP being in the 3.70% to 3.75% range.

And the second part of your question -- This is Reza. Related to IDN, I want to remind that we already have a few robots at the ATM. But having said that, we have not factored in multi-systems or commitment for 2023 from -- since last year, but we are already (inaudible) idea.

Our next question comes from the line of Josh Jennings of Cowen.

I want to just ask on 2 topics. The first is just on the low-volume accounts, representing about 30% of, I believe, the installed base, you said, Reza. But I wanted to maybe just help us understand the opportunity there and how this channel could expand the TAM. Are these mostly robotic prostatectomy surgeons that are familiar with robotic platforms and have been compelled to adopt the AquaBeam System and the Aquablation treatment? And then how do you see low-volume accounts contributing to system placements in 2023? And I just have one follow-up.

Yes. Thanks. Here, we are very pleased with the progress we have seen with these accounts. Again, just as a reminder, low volume does not necessarily mean a low-volume surgery. These are high-volume surgery but historically the have been doing lower number of BPH surgeries. The reason they are growing is they see better patient outcomes. They're standardizing the procedure. They can build their robust BPH practice and also allows them to recruit talented urologists. Yes, these are accounts that they have robots there, but they have not been using it for -- they were not using any BPH, but they are high-volume surgery centers. As we mentioned, 2,700 hospitals in the U.S., 86 of them were high volume centers. So these other 2,000 is a great opportunity for the future and growth of our business.

Great. And just a follow-up question. I wanted to better understand how your team is thinking about the replacement cycle as we get into '24 and 2025, I guess maybe the right way to phrase the question would be, when should we be thinking about AquaBeam 2.0 being commercialized? Anything you can share about what AquaBeam 2.0 or just the next iteration of AquaBeam or the enhancements that will be incorporated. And what do you think the replacement cycle period should -- will look like as we move into the out years.

Yes. Thanks, Josh, this is Kevin. The answer -- the replacement cycle is many years ahead, north of 2, 3 years. So it's not an immediate impact to the business in the near term. With that said, I think you are picking up that we are spending a lot of money in our R&D group, and we continue to be focused on our current system, and we feel our current system is more than sufficient to penetrate the majority of the high-volume hospitals in the near term, but at the same time, being a robotic company being an innovator, we're always going to be working on kind of next generational type of stuff. But at this point in time, it's not necessary for us to meet our near-term targets and therefore, we're not providing a lot of color around future platforms.

Our next question comes from the line of Ryan Zimmerman of BTIG.

Just want to follow up. I thought it was helpful in terms of the stat you gave on the percentage of low-volume hospitals. And I just want to follow up on kind of Josh's line of question in there. Are we doing for -- just from the math that you had about 16% penetration in high-volume accounts, if you just back out the low volume in the U.S. installed base. And then kind of help us understand what the expectation is in terms of the rate of penetration you think for that high-volume 860 hospitals? Because I think as we look at kind of consensus estimates a few years out, I think there's some lofty numbers in terms of high-volume penetration. And so it would be helpful to understand kind of your expectations on cadence for that high-volume segment.

Yes. Thanks, Ryan. So you pointed out a few stats that are -- that Reza mentioned in his prepared remarks, the first -- the current installed base is about 30% in low-volume centers -- low-volume BPH centers and our come that would assume that for the high volume, we're about 15% penetrated in the 860 high-volume hospitals in the U.S. And over the next few years, I mean, we think we're a great option for the majority, if not all, of those high-volume 860 BPH centers. So we don't feel that there's anything with our technology or outcomes that would limit us from being fully penetrated in the 860. I appreciate you're never going to get to 100%, but we don't see a reason why every high-volume BPH hospital over time would want to have an acumen system. So we feel there's a long ramp there. And to Reza's comments around the low-volume hospitals, it's great to see so early in our commercialization that we're seeing these low-volume centers that previously had to refer out patients and perhaps we're losing physicians to other hospitals to do BPH, start to adopt the technology and have good utilization of those accounts as well.

Got it. Okay. That's very helpful, Kevin. And then the second question, well, I guess 2 questions for me. One, what is the percentage of the IDNs, I think you called out 17 strategic IDNs that have more than one system today or you expect to have more than one system right now? I think that would be helpful to understand. And then the last question, and I'll hop back in queue is just -- and Craig asked this, but I'm not clear, why does pricing come back in the second quarter and through the remainder of the year if it were at 350, and why not can you spur more demand maybe at that lower price point than what you had previously?

Yes. So the first question on the '17 strategic IDNs. I mean those represent over 200 hospitals in the U.S. So we -- you should assume that at these IDNs that we signed with, we will have systems at the very hospital network. But if your question is around multi-systems within the same hospital, that's currently not part of our near-term growth plan. And we don't believe, given the current volumes today that most hospitals will not necessitate having a second system. So did I answer your question on audience, I want to make sure I cover that.

Yes. Maybe I'll take that offline. We can take that offline because I think I was just trying to understand kind of the potential for the '17 strategic IDNs, but I'll follow up...

Yes. I'll say we have very low penetration in those 17 strategic IDNs. So there's a lot of room for us to sell systems in the future there. And on pricing, again, one of the nice aspects of our business is we have a high degree of visibility into the funnel. So we can actually see the deals in the pipeline in the next 3 to 9 months. And that is why we feel comfortable talking about full year average selling prices in that $370,000 to $375,000 range based on deals we see in the pipeline. And really, we view Q1 just an anomaly in terms of the variability around pricing and settling at $350 million. We don't think this is reflective of any future ASP decreases on the capital side of the business.

Our next question comes from the line of Chris Pascal of Nephron Research.

Kevin, I want to circle back to that last point. I was hoping you could spell out a little bit more clearly what the typical sales cycle for AquaBeam looks like in terms of the time it takes for contracts to be finalized there. Can you talk about visibility into the pipeline, what pieces need to be in place for you to consider a system placement likely within a certain time frame?

Yes. So when we talk about pipeline, we are identifying for our investors, that means the surgeon champion has been identified and supports the technology. So we have a funnel that's much larger than our pipeline. But when a deal gets into our pipeline, we have a high degree of certainty of that deal to close. We don't have a lot of deals to fall out once a surgeon champion has been identified and wants to go to administration to purchase system. And given that dynamic, we can look forward to 6 to 9 months is the timing for that process from identifying a surgeon champion to selling the system. And that's the funnel and pipeline that we talked about that has been growing, and we feel has a high certainty to close.

Okay. And then can you talk about the competitive landscape within BPH, new da Vinci SP approval for the procedure? How do you expect that to impact demand for Aquablation? And just anything else you guys are highlighting at the meeting this week with surgeons.

Yes. Thanks. Definitely, we see that as an endorsement and confirmation of this large BPH market. We remain very excited about what we do and do not see that competition competitor as an obstacle to our growth. As a reminder, robotic for vasectomy is considered acceptable for large prostate. And for medium or small prostate, it's not used due to its invasive nature. I want to mention that we have already placed more than 90% of our systems at centers where there's already a device system. I think the best is I highly recommend that you speak with surgeons. We are at AUA or come to our investor meeting tomorrow and where you will see the benefits of our technology is the shorter surgery time, shorter recovery time and of course, the price of the robot. So as far as the utilization and competition is concerned in our utilization as we have said, majority of the cases that are done between 60 and 80 grams, although more than 70% RPO 100 are the turf and various laser conversion, we are very happy our progress. So I hope this answers your question.

Our next question comes from the line of Neil Chatterji of B. Riley.

Maybe just on the international growth, pretty strong in the quarter. Just curious if you could just talk about what key markets are driving that and just kind of your expectations for international over time, including both potential in China and then also with the need MIB in the U.K., what that U.K. opportunity could look like.

Yes. So we're really pleased with the international performance this quarter. It exceeded our expectations. And I feel international historically, there was much more of an impact, whether it's around staffing levels or COVID than we saw in the U.S. And it feels like we've really turned the corner in our key markets in Western Europe. And the outperformance really starts with the U.K. and the recent decision around reimbursement from NICE has been a nice tailwind to the business there.

We're already seeing robot purchases in that country at frankly, pricing levels that are higher than they've been historically, which is really good to see. We're also in Germany, Italy and Spain, although that's a much less of a contributor, we believe moving in the near term in the U.K. And longer term, I think you mentioned a few territories. We are excited about the Asia Pacific opportunity. We submitted for regulatory approval in China. We have regulatory approval now in Japan. We're actively selling in Korea. And while this revenue impact in 2023, it's not terribly material. I do think looking in the hour years, '24 or '25, we could see some nice contributions from international. That will provide more color on it as we get closer to those time lines.

Great. And just one follow-up. I noticed that you had a Midwest site with U.S. urology partners, the press release. Just curious what kind of impact that could have across that network or on influencing kind of the affiliated hospitals with those groups and his thoughts on impact from potentially large urology groups.

Yes. So Midwest urology in the quarter did purchase various robust. I'm not going to the specifics of the mountain, how many, but it is good to see a group like that make a commitment to occupation. And when we start looking at the large IDN networks, we had an account in a lane last year that we talked about. We've obviously talked about signing the largest strategic IDN now in the U.S. And we do think this could be a nice driver of the business, but I think it's just reflective of everything we talked about that Aquablation offers these centers the ability to retain patients they otherwise would have had to refer out. They make their procedure load, much more predictable and that they're having a great clinical on. So it was a nice mode of support for the business that we saw in the first quarter.

Our next question comes from the line of Richard Newitter of Truist.

A couple for me. Maybe just starting off on your -- you sound very confident in kind of the step up in 2Q placements implied by your first half guidance. And I appreciate the capital can be lumpy. But can you just maybe characterize where or what you see as the risk of potentially having some of whatever you anticipate coming in 2Q spilling into the back half, like it kind of did in 1Q as you came in at the low end of your range and it's billed into 2Q. Just to get a sense for where your confidence level is at this point, especially where you are in the quarter. Is this a pretty high confidence that your 2Q numbers based on what spills in 2Q from 1Q plus assuming your conversion rates hold, is this pretty much a stronger kind of visibility level than what you had heading into 1Q?

Yes. I mean, I don't know if I characterized as a stronger visibility because I feel like we had strong visibility in February into our funnel in the first half. So what you are seeing is some spillover into the second quarter, just primarily due to timing. And I'll go back to just our comments around our pipeline that once the deal enters the pipeline, it has a high degree of profitability of closing. Now could we have 1 or 2 or 3 Q2 deals still into Q3? That can happen from quarter-to-quarter. I mean timing could be variable. But we remain focused on kind of the full year number of achieving the guidance that we put out there on system sales. And we have a greater degree of confidence in that number today than we did when we released earnings 2 months ago, even though Q1 came in at the low end of the range.

And there are factors that we mentioned, the unit is covering the tail pass-through going for another 1 year the recent rep hires that we have made, they are making great progress. And on the surgeon front, we are seeing increased retention and literal and the largest IT and that we signed up. These are all the factors that gives us more confidence.

Well, actually, on that point, Reza, and it segues into a question I have on reimbursement broadly. But just you mentioned transitional pass-through extension as maybe being an incremental good guy in your discussions and getting capital to the finish line, that's transient. So does that mean that when that goes away in January 24, that flips to an incremental headwind? And then just secondly, when you answer that question, I'm just curious, we get questions from investors just on the overall reimbursement outlook. To the extent that you have discussions with the industry participants, do you have any sense as to how confident are that reimbursement stays at the levels that it is, which is right now pretty profitable.

Yes. So transitional pass-through was supposed to go away at the end of 2023, and we have stopped talking about it a few months in -- around the second half of 2022. So that wasn't an obstacle. Just the extension of that is a plus. We do not see that if it goes away, it's going to make any headwind because it's we have stopped talking about it end of 2022. As far as the -- and the reason for that when it was extended was because 2020 was a copier and many companies could not benefit from the transitional pass-through normal lease for 3 years. So that was extended for 1 year. As far as reimbursement is concept, we are -- as you know, we are at APC Level 6. And for the last 2, 3 years has stayed there. And in fact, if anything, around the last year for 2023 was a slight uptick on that payment. So we don't anticipate APC Level 6 to change because it's based on the cost of the system.

This is Kevin. That is why from a pricing standpoint, we're very disciplined about our handpiece pricing. And you can see over the last 8 quarters, if anything, can tie ASPs are trending upwards, not downwards. And based on that data we have, we would have a strong comp level given our pricing dynamics of staying at APC Level 6. If I could just squeeze one more in.

Just on the mix towards lower volume or low to mid-volume utilization accounts increasing as a percent of the installed base, -- just curious, should we be thinking about that ratio going up? And if so, or even if not, what kind of impact will this have on the utilization kind of growth rate? Does it drag it down?

Yes. I don't think -- I think 30% is the right way to think about it moving forward. I mean I appreciate I'm not being terribly specific there, but I don't see why in the near term, it should change from our historical norms and would be a drag on utilization. In fact, we are seeing many of these low-volume accounts start doing utilization at comparative levels. And one thing to keep in mind and Reza said it in his remarks is a low-volume account doesn't mean a low-volume surgery hospital. So these are hospitals that are very used to turning over patients, having a high volume of patients and having a lot of surgeons. They're just not doing a lot of BPH, and they're not doing a lot of BPHs because they frankly didn't have a great alternative previously, and now they do. So it's not as if we have to convert this hospital into now doing a lot of surgery. They're already doing surgery.

We remain focused on high-volume accounts and these low-volume accounts will happen opportunistically. And based on the case by case, we look at them.

Our next question comes from the line of Nathan Treybeck of Wells Fargo.

I just wanted to circle back to the capital placements in Q1. So you mentioned the IDNs we're taking a cautious approach and now you're seeing improvement in Q2. Can you give a color on why they're being more cautious? Is there a macro outlook out there that people were focused on? And what has changed now that they are opening up budgets?

Yes. Look, it's hard to tell if it's macro-related or IDM specific related, but what we did see are many of our large IDNs just not allocating capital fund in the first quarter and whether that's macro or specific to budget allocations that IDN. I'm sure it's a mixed bag. But what we are seeing to my comments is those funds now being released for Aquablation in the second quarter. And that is a very primary reason why the ramp in Q1 to Q2, we think is very achievable.

Okay. Kind of sticking to that. Last quarter, you gave a metric around the number of opportunities that you had a high level of confidence will close that increased 30%. Can you provide an update on where the funnel is now relative to the end of '22?

Yes. We didn't pin down a percent, but what we will say is it continues to grow. And what we are seeing is the new reps that we've hired are having meaningful additions to the funnel and the funnel continues to increase, and we continue to monitor it and continue to grow.

Our next question comes from the line of Matthew Mishan of KeyBanc.

I'll take the other side of this capital question. If you were to see -- I don't know how to try and figure out how I want to kind of raise it. You kind of tend to move at a predictable pace for net system adds. Do you see an opportunity as capital budgets are released and the procedural environment most good, do you see an opportunity to still exceed the 140 capital placements for 2023? Or is that a really good number that you really think you'll stick with?

Yes. Well, it's a number we have a high conviction of achieving the $140 million in given the opportunities and given how lowly penetrated we are in the current market and what's in front of us, I think we have a long runway ahead of us of capital sales. So it's not as if we are looking to sell 140 systems, and we don't have a future market to go attack. So there's much more upside to the 140 in the future given the current opportunities out there. But we feel very good about the 140 and the high degree of conviction around that.

Okay. And then just on the accounts where you've placed you've seen utilization increase on the system, which is a positive. Just how sticky are the procedures once a doc starts to use it? Have you seen any procedure slipping or somebody uses it and then not any, but seeing some people use it and they say, "Yes, I won't use it as much?" Or is it tending to really be sticky?

So it is, as you mentioned, speaking in the sense that we have more than 90% surgeon retention. And that's mainly because of the clinical outcomes and they standardized. But at the same time, I should mention, we have a highly trained commercial organization, both on the capital rep that were very collaboratively with the hospital administration and the clinical support staff that's present to support. In fact, we also had mentioned in our last quarter meeting that we had a Net Promoter Score of 92%. All of these come together as customer satisfaction. So they are using it both because of clinical outcomes and the support we are giving to them. And we have seen sequential utilization growth, and these are all the indicators.

I'm showing no further questions at this time. I'd like to turn the call back over to Reza Zadno, CEO, for any closing remarks.

Thanks, everyone, for attending this meeting. We look forward to seeing you in future meetings. And tomorrow, we have an Investor Day. Have a nice day.

Thank you. Ladies and gentlemen, this does conclude today's conference. Thank you all for participating. You may now disconnect. Have a great day.