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<p class="p1">As the maker of the pioneering da Vinci surgical systems, which use robotics to make surgery minimally invasive, Intuitive is on the cutting edge of health care. Now the question is whether the Sunnyvale, Calif., company can fend off a growing roster of rivals. The pandemic has temporarily slowed demand for the elective surgeries for which da Vinci systems are used. But the company is looking to make its $2 million surgical robots more affordable in order to extend their reach further in hospitals nationwide. Intuitive’s stock has quadrupled over the past five years.</p>

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Intuitive Surgical is a biotechnology company developing tools for minimally invasive, robotics-assisted surgeries. It joined the Fortune 500 list for the first time in 2024. Five years after its 1995 founding, Intuitive introduced its da Vinci robot, a system using a 3D endoscopic camera and small arms operated by a surgeon at a console. According to the company, the da Vinci model has been used in 14 million procedures, including tonsillectomies and hysterectomies. Its da Vinci 5 model gained FDA approval in March 2024.

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Q4 2024

Intuitive Surgical (ISRG): Company Profile, Stock Price, News, Rankings

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Intuitive Surgical

intuitive surgical

day and thank you for standing by. Welcome to the Q4 2024 Intuitive Earnings Conference Call. At this time, all participants are in a listen only mode. Please be advised that today's conference is being recorded. After the speakers' presentation, there will be a question and answer session.

I would now like to hand the conference over to your speaker today, Brandon Lam, Investor Relations for Intuitive Surgical.

Good afternoon, and welcome to Intuitive's 4th quarter earnings conference call. With me today, we have Gary Goodhart, our CEO Jamie Samath, our CFO Daniel Oh, our Senior Medical Officer Dave Rosa, our President and regular participant on this call is away from the office this week on a prior business commitment and will not be joining today. Doctor. Daniel Oh, Senior Medical Officer and practicing surgeon will join us on this call to describe clinical highlights. We will also we would also like to announce that Dan Connolly will be joining Intuitive as our VP and Head of Investor Relations.

Dan has worked at a global investment manager for the last 18 years and has actively followed surgical robotics since 2008. We look forward to Dan joining Intuitive in early February. 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 ks for the fiscal year ended December 31, 2023 and subsequent filings.

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. 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. Today's format will consist of providing you with highlights of our full year and 4th quarter results as described in our press release announced earlier today, followed by a question and answer session.

Gary will present business and operational highlights. Jamie will provide a review of our financial results and procedure highlights. Dan will present clinical highlights. Then I will provide our financial outlook for 2025. And finally, we will host a question and answer session.

Thank you for joining us today. I'll touch on our performance for the full year 2024 and share our perspective going into 2025. 2024 was a strong year for Intuitive with robust early adoption of our 5th generation multi port platform, da Vinci 5 and healthy procedure growth in many of our supported indications in countries, resulting in strong financial performance for the year. Adoption of our ION and da Vinci SP platforms continued with new global clearances and increased utilization. Our teams have been hard at work launching da Vinci 5 and learning from its early experience.

We are improving our products across all three of our platforms and helping our customers achieve their programmatic objectives. We started 2024 focused on 4 main thrusts. First, we expanded indications and launches of our new platforms by region with a particular focus on our first phase of da Vinci V launch. 2nd, we pursued increased adoption for focused procedures by country through training, commercial activities and market access efforts. 3rd, we drove quality and gross margin improvements in our global operations.

And finally, we focused on increasing our productivity, particularly in functions that benefit from industrial scale. Taken together, our team made excellent progress against these objectives. Moving to procedures. Growth for the full year was 17%. Areas of strength included general surgery in the United States and regional performance in countries including the U.

K. And Ireland, Japan and Germany. Distribution markets including Brazil, Spain and Italy were also strong in the year. This week, we announced the acquisition from AB Medica of the da Vinci business in Italy, Spain, Portugal and related territories. We're pleased with their performance and we look forward to welcoming these new staff to our team.

In the U. S, general surgery procedure growth was led by cholecystectomy with foregut and appendectomy procedures rising as well. Thoracic procedure growth was also healthy in the year. Bariatric procedures fell modestly for the full year 2024 given the rise in GLP-one medications. Procedure growth outside the United States continued to diversify beyond urology with nice growth in categories including general surgery and thoracic surgery.

Globally, benign indications grew approximately 200 basis points faster in the year than cancer indications. In flexible robotics, ion procedures showed continued strength with 78% growth for the full year. SP procedure growth accelerated in the year with 72% growth over a full year, a result of healthy growth in Korea, Japan and Europe and solid growth in the U. S. On the capital front, we placed 1430 multi port systems in the full year 2024 compared with 13 13 multiport systems in 2023.

I'm placements for the full year were 271 versus 2 13 prior year and SP placements were 96 for the full year versus 57 systems in the prior year. Globally, placements were strong in the United States, helped by the launch of da Vinci 5. Overall, our systems portfolio of da Vinci 5, da Vinci Xi, da Vinci X, da Vinci SP and ION combined with our flexible financing options allows our team to meet our customers' varying needs. Jamie will take you through placement dynamics in more detail later in the call. System utilization remains an important indicator of customer health because it is correlated to patient demand, care team satisfaction and hospital financial health.

Multi port utilization grew 3% in the year, SP utilization grew 12% in the year and Ion utilization grew 13%. Given our different platforms, their procedure mix and sites of care teasing apart system utilization by customer segment becomes increasingly important going forward. For example, a midsized community hospital lung program systems utilization can differ from a high volume community hospital general surgery program. As robot assisted surgery moves to the back half of adoption curves in some procedures, utilization growth rates may differ from prior year trends. Our performance supported revenue of $8,400,000,000 for the year, of which 84% was recurring and representing 17% growth over 2023.

Our operating expenses were at the lower end of our spend guidance. Our spending reflects 3 initiatives. 1st, we continue to invest in R and D to support innovation and adoption of our platforms and digital tools globally. 2nd, we're expanding our manufacturing and commercial footprints. And lastly, we have sought to leverage our enabling functions given our increased scale.

Our product margins also started to improve in the year as increased shipment volume allowed for better factory utilization as well as leverage in our component shipment and other logistics costs. Taken together, our net income grew by 29% in 2024 over 2023. Touching briefly on da Vinci V, our teams have done a nice job in executing a complex launch. We placed 3 62 da Vinci V in the year and over 2,500 surgeons have performed in total over 32,000 procedures on da Vinci V in 2024. Da Vinci V has broad clinical indications and over 40 different procedure types have been performed using da Vinci V to date.

We design our systems to allow for routine sequential upgrades to their capability over time. And daVinci 5 customers will receive hardware and software upgrades going forward starting this year. This year's upgrades will focus on digital features supported by our 10000 time increase in computing power. We'll share more details on these features as we bring them to market. As we enter 2025, our company priorities are as follows.

First, we will focus on the full launch of da Vinci 5, its regional clearances and follow on feature releases. 2nd, we'll pursue increased adoption for our focused procedures by country through training commercial activities and market access efforts. 3rd, we'll drive continued progress in building industrial scale, product quality and manufacturing optimization. And finally, we'll focus on excellence and availability of our digital tools. Jamie, over

to you. Good afternoon. I will describe the highlights of our performance on a non GAAP or pro form a basis and will also summarize our GAAP performance later in my prepared remarks. A reconciliation between our pro form a and GAAP results is posted on our website. Q4 and 2024 revenue, procedures and system placements are in line with our preliminary press release of January 15.

I will briefly review full year 2024 performance before describing our Q4 results in greater detail. 2024 financial performance was strong. Da Vinci procedures and total revenue each grew 17% over the prior year. Pro form a gross margin improved 100 basis points to 69.1 percent and pro form a SG and A expenses leveraged as compared to 2023. As a result, pro form a operating margin for 2024 improved 310 basis points to 37% and pro form a EPS increased 28%, building off of the 22% increase in 2023.

We placed 3 62 da Vinci V systems in our 1st year of the limited launch, of which 174 systems were placed in Q4, including our first three placements of da Vinci V in Korea. Turning to Q4, our financial performance was ahead of our expectations, driven by revenue growth of 25% and strength across the rest of the P and L, resulting in pro form a operating margin of 38%. Q4 revenue reflected a couple of favorable dynamics. 1st, a higher purchase mix of systems as compared to recent periods driven by multi system deals with certain U. S.

IDNs that prefer to purchase and a higher mix of placements through distributors. 2nd, we saw a higher mix of dual console placements for da Vinci 5 as we increased supply and were able to support more academic customers. And finally, we saw a higher system ASP resulting from a stronger mix of da Vinci V placements. Underlying core metrics were also strong with da Vinci procedure growth of 18%, growth in the installed base of da Vinci systems of 15% and average system utilization growth of 3%. In Q4, U.

S. Procedures grew 15% driven by growth in benign general surgery, including accretive growth in procedures performed after hours for emerging care. Bariatric procedures in the U. S. Declined in the lowtomidsingledigit range similar to last quarter.

OUS procedures grew 25%, driven by relative strength in India, the UK, Italy and Japan. Procedure growth in Korea improved sequentially in part driven by strong SP growth. However, our business there continues to be impacted by physician strikes. Consistent with the last couple of quarters, procedure growth in China was slightly below the corporate average, reflecting a continuation of the dynamics we have described on previous calls. Looking at OUS procedure performance in aggregate, we see strong growth in colorectal, benign general surgery and thoracic categories.

Reviewing capital performance, we placed 4.93 systems in the 4th quarter, 19% higher than the 415 systems we placed in the Q4 of last year. In the U. S, we placed 284 systems in Q4, an increase of 75 systems as compared to last year, reflecting several large multi system placements with a number of IDNs and an increase in the supply of da Vinci 5. Outside the U. S, we placed 209 systems in the 4th quarter compared with 206 in the same quarter last year.

This quarter, we placed 89 systems in Europe, 43 in Japan and 20 in China compared with 71 in Europe, 70 in Japan and 11 in China in Q4 of last year. Placements in the U. K. And Germany continue to be impacted by ongoing government budget pressures affecting healthcare capital spending. The 89 system placements in Europe included 39 systems into markets served by our distributors as compared to 24 systems last year.

In Japan, financial pressures caused some customers to delay capital investment decisions. 4th quarter revenue was $2,410,000,000 a 25% increase over last year. On a constant currency basis, revenue growth was 26%. Systems revenue grew 36% year over year, driven by a 19% increase in da Vinci system placements, a higher system ASP and the higher purchase mix previously referenced. Additional revenue statistics and trends are as follows.

Leasing represented 45% of Q4 placements compared with 58% last quarter, driven by the aforementioned mix of system placements from certain IDNs in the U. S. Who prefer to purchase and a higher mix of placements with our distributors. However, as we look forward, we continue to expect that leasing rates will increase over time. Q4 system average selling prices were $1,590,000 as compared to $1,420,000 last year, driven by higher mix of da Vinci 5 and a higher dual console mix, partially offset by lower pricing in China.

We recognized $28,000,000 of lease buyout revenue in the 4th quarter compared with $21,000,000 last year. Da Vinci instrument and accessory revenue per procedure was approximately $18.60 compared with approximately $1800 last year. The year over year increase in INA per procedure reflects customer buying patterns and a higher mix of SP procedures, partially offset by procedure mix in the U. S. Given a lower mix of bariatric procedures and a higher mix of cholecystectomy.

Turning to ION, there were approximately 28,000 ION procedures performed in the Q4, an increase of 70% as compared to last year. In Q4, we placed 69 ION systems compared to 44 in Q4 of 2023. As a reminder, supply constraints impacted ION system placements in the Q4 of last year. 7 of the 69 systems were placed in OUS markets. The installed base of ION systems increased 51% from last year to 805 systems and average system utilization increased 13% year over year.

4th quarter SP procedure growth continued to accelerate growing 81%, driven by Korea and early stage growth in Europe and Japan where we have clearance for a broad set of indications. We placed 30 SP systems in Q4 and 96 for the year, up from 57 placements in 2023. 4th quarter placements included 7 in Korea, 6 in Europe and 4 in Japan. Average system utilization for our SP platform grew 18% in Q4, reflecting in part growth of SP in markets, where we have a broad set of indications. We have received recent clearances in the U.

S. For thoracic and colorectal indications. However, we expect broad commercial efforts for SP in those procedure categories to commence once we obtain FDA clearance for a SP stapler. Moving on to the rest of the P and L. Pro form a gross margin for the Q4 of 2024 was 69.5% compared with 68% for the Q4 of 2023.

The year over year improvement in gross margin reflects fixed overhead leverage given revenue growth, lower inventory reserves and improvements in freight and logistics costs. In 2024, we executed on our plans to significantly improve product margins for our ION and SP platforms. While we have made substantial progress, ION and SP product margins continue to be dilutive and our teams have ongoing programs to deliver further improvement. With respect to our manufacturing expansion and capital investment plans, in 2025, we anticipate opening new facilities for DAVINCI V and ION system manufacturing in California and new endoscope manufacturing facilities in Germany and Bulgaria. As a result, and as we have previously indicated, we expect a significant increase in depreciation expense in 2025.

We will also continue to transfer mature products to facilities in Peachtree Corners, Georgia and Mexicali. Given these activities, we expect elevated inventory levels during 2025. As we complete this cycle of manufacturing expansion that is driven by our strategy to operate at industrial scale, we anticipate lower levels of capital expenditures in 20252026 as compared to recent periods. 4th quarter pro form a operating expenses increased 9% compared with last year, driven by increased headcount, higher variable compensation and increased legal expenses. 4th quarter 2024 operating expenses included a $45,000,000 contribution to the Intuitive Foundation as compared to a $40,000,000 contribution in Q4 of last year.

Looking at operating expenses for the year, we delivered on planned leverage in SG and A, which improved by 180 basis points as a percentage of revenue. While we will continue to look for opportunities within SG and A to leverage as we grow, we would highlight that in 2025, we expect increased depreciation expenses given recent capital expenditures and higher legal expenses given ongoing litigation. Innovation continues to be critical to helping our customers make progress in the quintuple aim and therefore you should expect us to prioritize investments in R and D. Pro form a other income was $87,600,000 for Q4, lower than $94,600,000 in the prior quarter, primarily driven by FX remeasurement of the balance sheet. Our pro form a effective tax rate for the 4th quarter was 20.5%, a little lower than our expectations, reflecting net discrete benefits of $11,000,000 related to statute of limitation expirations and other adjustments to certain tax items.

4th quarter 2024 pro form a net income was $805,000,000 or $2.21 per share compared with $574,000,000 or $1.60 per share for the Q4 of last year. I will now summarize our GAAP results. GAAP net income was $686,000,000 or $1.88 per share for the Q4 of 2024 compared with GAAP net income of $606,000,000 or $1.69 per share for the Q4 of 2023. As a reminder, Q4 2023 GAAP tax expense reflected one time benefits of $159,000,000 related to an increase in deferred tax assets associated with a statutory rate increase in Switzerland and receipt of certain tax benefits related to our Swiss operations. The adjustments between pro form a and GAAP net income are outlined and quantified on our website.

We ended the year with cash and investments of $8,800,000,000 compared with $8,300,000,000 at the end of Q3. The sequential increase in cash and investments reflected cash generated from operating activities, partially offset by capital expenditures of $312,000,000 With respect to the plans we announced on Tuesday to go direct in Italy, Spain, Portugal and associated territories, the base purchase price is €290,000,000 with an earn out of up to an additional €31,000,000 based on 2025 procedure volumes. While our primary motivation is to develop closer relationships with customers serving a combined population of approximately 118,000,000 people, we do expect this transaction, which we estimate to close in the first half of twenty twenty six to be slightly accretive to pro form a EPS. Before I turn it over to Dan to discuss clinical highlights, let me address the outlook for pro form a operating margins for 2025. Q4 performance of 38% was above our expectations.

Looking ahead to 2025, we anticipate pro form a operating margins in 2025 to be lower than Q4 due to several dynamics. First, as previously stated, leasing rates are expected to be higher than Q4, which results in revenue and profits for related system placements to be recorded over multiple years versus in the quarter of placement. 2nd, we anticipate significantly higher depreciation expense given recent capital expenditures. And finally, we expect a higher mix of da Vinci V, ION and SP revenue, which carry product margins below the corporate average. In addition, from a modeling perspective, I would also highlight a couple of additional considerations.

1st, revenue denominated in non USD currencies represents approximately 25% of our total revenue. On a revenue weighted basis, using current exchange rates, the U. S. Dollar is approximately 4% stronger than rates realized in Q4. 2nd, as we move into broad launch of da Vinci 5 in the middle of the year and customers have the opportunity to upgrade their fleets, we would expect trading credits for NXI to be significantly higher than recent periods, adversely impacting system ASPs.

Finally, given the increasing choice customers have as competitors bring robotic systems to the market and seek geographical clearances, we may see capital selling cycles lengthen as customers evaluate alternatives. Brandon will provide our outlook for 2025 later in this call. And with that, I would like to turn it over to Dan.

Thank you, Jamie. I'd like to share with you some recently published peer review literature that we found to be notable. In addition to the specific data highlighted on this call, we encourage you to consider the wide body of evidence detailing these topics and published scientific studies over the years. Today, we'll give an update on 2 recent publications. In the first study, Doctor.

Rokko Rokchayardi and colleagues from the Massachusetts General Hospital in Boston collaborated with the research team at NTUitive for the COMPARE study published in the Annals of Surgery. This landmark study compared perioperative outcomes of DAVINCI robotic assisted surgery to laparoscopic or thoracoscopic surgery as well as to open procedures. This was a meta analysis, which analyzes results from previously published evidence over time to obtain an overview of cumulative data. In this study, the investigators pool data from randomized controlled trials, prospective comparative cohort studies and large real world evidence database studies from the past 12 years in order to evaluate whether da Vinci procedures were associated with an improvement in short term patient outcomes across 7 commonly performed oncologic procedures from different specialties. Notably, over 1,000,000 patients were included in each of the da Vinci laparoscopic, thoracoscopic and open patient groups and included data from 22 countries.

The authors found that compared to standard minimally invasive surgery, patients undergoing da Vinci procedures had favorable perioperative outcomes. Specifically, da Vinci patients had a 56% lower chance of conversion to open, 21% lower chance of receiving a blood transfusion and 10% less likelihood to experience a complication within 30 days of the procedure. In addition, length of stay was significantly shorter with lower 30 day readmission and mortality rates. Similar favorable outcomes were found for da Vinci patients when compared to the open approach with even greater magnitude differences between the two approaches. The authors concluded that this meta analysis demonstrated multiple benefits for da Vinci procedures when compared to alternative minimally invasive or open approaches, noting that these results will be helpful to decision makers considering the use of robotics in multi specialty settings.

In the second study, Doctor. Michael Awad from Washington University School of Medicine and other colleagues published in surgical endoscopy the results of a preclinical study using Intuitive's novel force feedback technology incorporated in DA Vinci V. Across 28 surgeons with varying levels of experience, this study evaluated the forces applied to tissue when having force feedback technology on or off during core surgical tests, including retraction, dissection and suturing in a tissue model. Results from this study demonstrated a significant reduction in both the average and maximal forces exerted on tissue for all three surgical tasks, irrespective of surgeon experience levels. Notably, when using the highest sensitivity setting, up to a 55% reduction of the maximal force exerted on tissue during suturing was observed.

The authors concluded that this study demonstrated that force feedback technology may significantly decrease the forces applied at the tissue level when performing common surgical tests across novice, intermediate and experienced surgeons. They continue to note, This innovative technology has the potential to enable safer and gentler surgeries, resulting in better surgical outcomes for patients undergoing robotic assisted surgery. To me, the notable finding in this study is that the benefit of force feedback was observed not just in novice surgeons, which one might expect, but also inexperienced surgeons who had completed at least 200 da Vinci procedures. Now I'll turn it over to Brandon.

Thank you, Dan. I will now turn to our financial outlook for 2025. Starting with procedures. As described in our announcement earlier this month, total 2024 da Vinci procedures grew approximately 17% year over year to over 2,680,000 procedures performed worldwide. For 2025, we anticipate full year procedure growth within a range of 13% 16%.

The low end of the range assumes growth in China continues to be impacted by environmental and competitive dynamics, European governments continue to constrain hospital CapEx budgets, limiting the expansion of capacity in the field and bariatric procedure declines continue at rates similar to 2024. At the high end, we assume China procedure growth recovers relative to 2024, the CapEx environment improves in Europe and bariatric procedure declines moderate. Q1 full year 2025 will have approximately one fewer working day than 2024 due to the leap year. Turning to gross profit. In 2024, our pro form a gross profit margin was 69%.

In 2025, we expect our pro form a gross profit margin to be within a range of 67% 68% of net revenue. The lower estimate of pro form a gross profit margin in 2025 reflects significant incremental depreciation as we bring on new facilities, the impact of growth in newer products and the impact of the stronger U. S. Dollar. Our actual gross profit margin will vary quarter to quarter depending largely on product, regional and trade in mix and pricing.

The range does not include any potential impact of new tariffs on our business, which could be material. Turning to operating expenses. In 2024, our pro form a operating expenses grew 10%. In 2025, we expect our pro form a operating expense growth to be within a range of 10% 15%. The growth in operating expenses reflects increased depreciation from new facilities, investments in innovation to drive our growth objectives and an increase in legal expenses.

We expect our non cash stock compensation expense to range between $760,000,000 $790,000,000 in 2025. We expect other income, which is comprised mostly of interest income, to total between $370,000,000 $400,000,000 in 2025. With regard to capital expenditures, we expect the range to total between $650,000,000 $800,000,000 primarily for planned facility construction activities. With regard to income tax, in 2024, our pro form a income tax rate was 21.4%. As we look forward, we estimate our 2025 pro form a income tax rate to be within a range of 22% 23% of pretax income.

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

Thank you. Our first question comes from Larry Biegelsen with Wells Fargo. You may proceed.

Good afternoon. Thanks for taking the question and congrats on a really strong finish to the year. One for Gary, one for Jamie. So Gary, historically, you said procedures drive placement. In the second half of twenty twenty four, U.

S. System placements grew over 35%, utilization was about 2%. Is this a leading indicator of more procedures? Or will we have a digestion period to restore normal utilization? And I had one follow-up.

Yes. I think a couple of things are going on there. One of them is the as I said in the prepared remarks, as we get to the back half of some curves, the expectations of some of those programs may be different in terms of utilization as they participate. In other words, not every account is going to be a high volume account. And I think that's okay.

I think the economics can work and I think we can supply them. So some of that is going on. I think the other thing is new capital opportunities, new capital features can pull forward or otherwise have people delay a little bit and then acquire systems that can put a wave or a ripple through utilization. We're just going to have to see if that ripple plays through. So both of those effects are likely going on.

It is actually extremely hard analytically to tease them out. I think in the U. S. Over time, you're going to see utilization growth rates in multi port start to settle a little bit. I don't think they'll keep galloping.

At the same time, I think SP utilization has room to run and ion utilization has room to run.

Thanks, Gary. And Jamie, on the Q3 call, you said the gross margin will be a little lower in 2025 versus 2024. I think the 67% to 68% guidance was probably a little bit lower than expected. Can you quantify the drivers for the 69.1% this year in 2024 to the 67% to 68% and how to think about the path back to your goal of 70%? Thank you.

Yes. There's really 3 drivers, Larry, the largest of which is the impact of depreciation expense and associated fixed costs. So there's deleverage, in the 2024 to 2025 comparison, roughly ish depending on where you have the revenue model for 2025. That's about a point of the 160 point delta if you go from 24 actual to midpoint of 25. The other two dynamics roughly equalish in terms of impact are product mix with DV5, Ion and SP being a greater proportion of the revenue.

They all carry currently margins below the corporate average, so have a dilutive effect from a mix perspective. And then I think what's new from the last call is the impact of FX. So those three things are the drivers. There are some offsetting cost reductions the teams are delivering within that kind of gross margin range. I think what we've said with respect to gross margin is over the midterm, we think we can get back beyond 70%.

That is going to require us once we get past this kind of incremental depreciation to leverage over a multiyear period as we grow. We also have, as we've said, the work on product margins in ION and SP. There's still some work to be done there. And then on a more routine basis, our teams have to deliver cost downs.

Thank you. Our next question comes from Robbie Marcus with JPMorgan. You may proceed.

Great. Thank you. And I'll echo congratulations on a fantastic Q4. 2 for me. First, maybe for Gary.

You gave a lot of detail in the call about a midyear full launch and trade in cycle. Would love to just get your qualitative comments around how you're thinking about the mix of DA VINCI V versus XI going forward, the necessity or the speed of which an upgrade cycle can start and how you're thinking about XI versus da Vinci V placements in terms of mix going forward outside the U. S. Once approvals start rolling in? It all has implications for the model, so I'd love to get your thoughts on that.

Thanks. Amit, I was going to say, I'll tell you a little bit about, I think, perhaps the environmental aspects of that kind of the wrapping around it. I'll turn it over to Jamie for any modeling implications. I just what goes 2 things are driving what we call broad launch. 1 of them is getting our supply chains up to scale and volume for what we expect.

Demand could be when we start going out and looking at things like trade ins and also starting to get clearances around the world. So that's exciting. The next one is software updates and those software updates reflect both feedback from the field and then the integration of some of the technologies in our digital space from hub to some of the imaging things we can do that start to come out in the first set of launches, which is really great. I think those are digital tools that our customers and surgeons will appreciate and starts giving them a lot of access to data that helps them analyze the performance of themselves and of their programs. How compelling that is will determine how fast customers want to upgrade.

I think the upgrade cycle comes down to this kind of question of differential value. X and XR are outstanding machines. They work they are workhorses. They work really well. We're delighted to support them and support our customers who use them as they found increasing value in the features and content we bring to DaVinci 5, whether it's analytics or force reflection or ergonomics or better imaging, then that drives the trading cycle.

The question and I understand your modeling question well of how fast does it all move and what does that look like can be difficult to predict. Jamie, I'd turn it over to you and let you add your commentary.

Yes. While we don't have a specific percentage, the impact of moving to broad launch, the impact of getting additional geographical clearances, obviously then says directionally over time the proportion of placements that are DV5 generally should increase. Although I would recognize that Xi is a capable system and at some point we have the opportunity for a refurbished Xi. With respect to trade ins, you don't really see trade ins start to pick up until you get to broad launch, which is the middle of the year and it's going to be a function of the dynamics that Gary indicated. Of course, we can look back at what happened on the Xi launch and how those upgrades went And we have some indication from customers in our pipelines.

I think the best that we could say at this point given it's so early is that any trading cycle would be progressive.

Final point I'll make and I think you had asked, Ravi the question is part of this is, is there an opportunity for depreciated assets like X and Xi which are highly capable, we know how to service, we know how to support or to those open or create other opportunities in other markets that may be more capital price sensitive and the answer to that is yes.

Great. Maybe just one quick follow-up. Gary, you always give us a general state of the union on the health of the capital equipment environment around the world, U. S, OUS and I'm particularly thinking of China, where you had a really strong placement quarter and Q4. So any thoughts there would be great as we head into 2025?

Yes. I think Jamie usually does that. Jamie, why don't you take care of that?

I'd first say, I don't think we characterize the 20 systems we placed in China in Q4 as strong. Maybe it is on a year over year comparison basis, but the environment in China continues to be dynamic and challenging, as we've said, impacted by both domestic competition and a set of activities implemented by the government there. So I characterize the environment as relatively consistent and challenging. In terms of capital overall, I think in the U. S, it's been strong.

Part of that is interest in da Vinci 5 given it's a new product. And you see to some extent less sensitivity to capital budgets given just the proportion of placements in the U. S. In particular that are leased. We highlighted the challenges in the U.

K. And Germany. And new for us in Q4 for Japan was some delays because of the profitability in certain customers there. So I'd say we've seen relative strong strength in the U. S, some mixed dynamics in the OUS markets.

We don't really have enough tea leaves to predict how that plays out in 2025.

Thank you. Our next question comes from Travis Steed with Bank of America Securities. You may proceed.

Hey, I like my congrats as well. Gary, I wanted to ask a bigger picture question. You're kind of crossing over to $1,000,000,000 a year in R and D now and even after launching DV5. So maybe help us understand the R and D investment opportunity over the medium term and potentially moving into kind of new green spaces? Is that going to be more through the end of Luminal platform or are there still chunky categories like cardio that could be a minimal to robotics or is it more about geographic expansion side of care?

Just thinking to understand kind of the true opportunity left out there to capture?

I think it's a mix of all three of the things you just described. I think there are innovations in technologies, some of which are extensions to platforms you know about, some of which are platforms that are years away and you don't know about that I think open new opportunities for us over time. And we're diligent about them. They take a while, they take some investment and they take follow-up. There are existing platforms that could use additional indications and those can be geographic, in which case there's the regulatory and clinical work to secure those indications and so we spend money on that and go do it.

And then there's additional indications that come from things like additional instruments and accessories and imaging capabilities on existing platforms that if we develop them, we can bring to market and open the market for others. We also spend some money making sure that latecomers to robotics get what they need. It's not just that latecomers just need time to simmer and sooner or later they come find you. They sometimes have different needs, whether those needs are learning needs or economics needs And it takes some work, and but we think that work is worth it. And some of the things you see in da Vinci 5 are those types of things.

So short story is that we see opportunity in all of those buckets. We run a process that tries to balance those opportunities so that we're not totally overexposed to 1 or the other. And that incentive, we have multiyear horizon and a multi specialty horizon and it's geographically mixed.

Helpful. Thanks. And then Jamie, maybe just a shorter term OpEx question, the 10% to 15% growth kind of high and low end, how much of that's R and D versus SG and A? Any color there on how that can shape up and kind of what drives the high and low end? And potentially, since you did mention tariffs, just kind of curious how to size that or potential ways to mitigate that, if you can?

follow-up on Larry's margin question. Thank you.

Yes. With respect to how R and D and SG and A might grow, I'd characterize it as similar ish in terms of for that 10% to 15%. Obviously, R and D is a priority as we've stated. In SG and A, what you'll see is us add reps and commercial folks to support the procedure growth. We also have said that there'll be higher legal expenses in SG and A given ongoing litigation and a portion of the CapEx results in depreciation that goes into our SG and A expenses.

And so, they'll grow roughly ish about the same rate. In terms of the range of 10% to 15%, most of that is driven by the procedure range, meaning obviously to some extent we'll manage our expenses in accordance with how our business plays out. There are some opportunities for us to invest incrementally in R and D, but we'll do that as we make progress and achieve milestones. In terms of tariffs, obviously, we see a lot in the news where we're monitoring those events closely. We are internally evaluating what the impact of any potential tariff might be and therefore how we might respond.

We can say that the significant portion of our instruments are currently manufactured in Mexico. And so to the extent there are significant tariffs implemented there that could have a material impact for us. And of course, one response then that any company might consider is what would you do with pricing, nothing that we've decided there. And obviously, we're balancing the needs of our customers and their objectives with the needs of our own business. So stay tuned is what I'd say.

Thank you. Our next question comes from Rick Wise with Stifel. You may proceed.

Thanks. Good afternoon. Gary, in your very thoughtful comments during the JPMorgan comments, I think you talked about new digital features and you should make today again said hardware and software digital features coming. I was hoping and if you're not ready to give us truly specifics on all these, but maybe help us understand what areas this in what ways this might enhance the da Vinci V? Will it open up new procedures?

Will it be about productivity? Will it be about will it enable you to use the da Vinci 5 in a different setting? How does this expand the vision or the possibilities of da Vinci 5 in the near term? And then I'll have a follow-up if I could.

Yes. In early thinking here, just I think of it in 3 categories. If we can make it easier to get great outcomes for more care teams by giving them tools in the OR, just real time tools, We think that creates opportunities for them. I think it builds confidence. I think you get better care teams faster that way.

And this kind of does that give you access to new procedures? I think the way to say that is it probably gives you access to more patients. Are they new procedure categories? Not always, but there are patients that become easier for those surgeon and care teams to reach because they're more confident to reach them. So can it help us that way?

Intuitive Surgical (ISRG) Q4 2024 Earnings Call Transcript

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