Intuitive Surgical Inc

NASDAQ:ISRG

Earnings Call Analysis

Solid Growth and Raised 2024 Outlook at Intuitive

In Q1 2024, Intuitive reported a robust performance with revenue reaching $1.89 billion, up 11% year-over-year, driven by a 16% increase in da Vinci procedures. The company placed 313 da Vinci systems, slightly above last year's 312 systems. Regional growth was strong, especially in the U.S. and China, but Japan and the U.K. faced challenges. The company expects a full-year procedure growth of 14%-17% and maintains its gross profit margin forecast at 67%-68%. Despite the ongoing supply constraints and competitive pressures, the launch of the da Vinci 5 and continued robust procedure growth position Intuitive well for the future.

Introduction to Intuitive’s First Quarter Performance

Intuitive Surgical, known for its robotics-assisted surgical platforms, had a solid first quarter of 2024. The company reported robust growth in procedures, notable capital placements, and significant progress on several key initiatives. Despite encountering some regional challenges, Intuitive remains optimistic about its future.

Procedure Growth and Regional Performance

During the first quarter of 2024, Intuitive saw a 16% increase in procedures compared to the same period last year. This growth was driven largely by general surgery in the United States and a variety of procedures outside the U.S. General surgery procedures such as cholecystectomy, colon resection, and foregut surgeries led the way globally. While procedure volumes in China, Germany, and the United Kingdom demonstrated robust growth, Japan experienced more moderate gains due to high levels of urology penetration from prior years. Korea, on the other hand, saw lower growth than expected, impacted by a physician strike.

Capital Placements and Utilization

In Q1, Intuitive placed 313 da Vinci systems worldwide, with 289 being multiport systems. The placements were particularly strong in the U.S., global distribution markets, and Germany. However, there were placement weaknesses in the U.K., where NHS financial pressures limited access to capital, and in China, where local competition and delayed tenders posed challenges. The installed base of systems grew to 8,887, representing a 14% increase. Average system utilization grew by 2%, a slower pace compared to recent trends, as last year saw significant post-COVID procedural backlog clearances.

Launch of Next-Generation Products

Intuitive marked key milestones, including the launch of the da Vinci 5 multiport platform and the da Vinci SP platform in Europe. The da Vinci 5 offers enhanced precision, imaging, efficiency, and ergonomics, with initial feedback from surgeons being positive. The company is in a measured rollout phase, focusing on optimizing supply chains and incorporating customer feedback. Additionally, the SP platform saw a 60% growth in procedures, with significant traction in Korea, the U.S., and early stages in Japan.

Financial Performance and Outlook

The company reported a pro forma gross margin of 67.6%, slightly lower than last quarter, owing to higher fixed costs and the da Vinci 5 launch. Operating expenses increased by 7% compared to last year, driven by higher R&D investments. Pro forma net income was $544 million, or $1.50 per share, up from $444 million, or $1.23 per share, last year. GAAP net income reached $547 million, or $1.51 per share, versus $361 million, or $1 per share, in the previous year.

Updated Guidance for 2024

Intuitive raised its full-year 2024 procedure growth forecast to a range of 14% to 17%, reflecting confidence in sustaining robust procedure volumes. This guidance factors in potential continued weakness in bariatric procedures and challenges in China. The company expects pro forma gross profit margins to remain between 67% and 68%, with operating expenses projected to grow between 11% and 15%.

Challenges and Strategic Focus

Intuitive faced some regional challenges, particularly in China and the U.K. In China, local robotic competition and governmental delays affected placements, while NHS financial constraints impacted the U.K. market. Despite these hurdles, the company is focusing on manageable aspects like improving supply chains and supporting surgeon adoption of new procedures. Looking forward, Intuitive is committed to enhancing product margins and quality, ensuring productive global operations, and rolling out new platforms strategically.

Conclusion

The first quarter of 2024 illustrated Intuitive's strength in maintaining growth and innovation amidst external pressures. The company's strategic investments in new technologies and global market expansions position it well for continued success. While regional challenges may persist, Intuitive's proactive measures and strong product pipeline are expected to drive sustainable growth moving forward.

Earnings Call Transcript 2024-Q1

[Operator]

Thank you, everyone, for standing by, and welcome to the Intuitive Q1 2024 Earnings Release Call. [Operator Instructions] As a reminder, today's call is being recorded.

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

[Brian King, executive]

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

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 annual report on Form 10-K 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 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 2024. And finally, we will host a question-and-answer session.

And with that, I will turn it over to Gary.

[Gary Guthart, executive]

Thank you for joining us today. The first quarter of 2024 was a solid one for Intuitive, where core measures of our business remain healthy. including solid procedure growth and capital placements. Furthermore, our teams delivered important milestones across several parts of our Intuitive ecosystem, including launching our next-generation multiport platform da Vinci 5, launching our da Vinci SP platform in Europe and improving our supply constraints for ion catheters. Some regional challenges existed in the quarter, which we'll describe today. Taken together, we remain enthusiastic about our opportunity and we'll work through near-term pressures by focusing on what we can control. Starting first with procedures, we experienced solid growth in the quarter of 16%, and compared with a strong Q1 of 23, that was a result of elevated patient volume from the return of patients post pandemic. Q1 of 2024, procedure performance was led by broad growth in general surgery in the United States, and by procedures beyond urology outside the United States.

Globally, cholecystectomy, colon resection and foregut procedures led the way. Regional performance included strength in China, Germany and the United Kingdom. In Japan, we saw a moderation of growth in urology as we reach higher levels of penetration and Q1 2023 benefited from the return of patients in backlog. In Korea, growth was lower than our expectation, primarily due to a physician strike in the country, which began in February and has continued.

Turning to capital. We placed 313 da Vinci systems in the quarter, of which 289 were multiport systems, compared with 302 multiport systems in Q1 of '23. SP placements were 24 in the quarter versus 10 systems a year ago, and in placements for the quarter were 70 versus 55 a year ago. Capital placements were solid in the United States, our global distribution markets and in Germany. Placements in China appear to be impacted by delayed tenders and an apparent increase in provincial preference for domestic robotic competition. We saw some placement weakness in the U.K. as financial pressures in the NHS constrained access to capital. System utilization defined as procedures per installed system per quarter or 1% globally year-over-year for our multiport platform, lower than last quarter, and our historical trend, a result of a strong placement year in 2023 in which the multiport clinical installed base grew 14%, when customers addressed a COVID-related backlog.

For our newer platforms, utilization grew 10% for SP and 14% for ion in the quarter. Utilization is an important indicator of customer health and is a reflection of customers driving value from their systems.

Turning to our finance. The quarter reflects solid procedure performance and capital placements. Average system selling prices declined modestly due to regional and product mix. Product margins were within our expectations, reflecting a higher mix of newer platforms. Operating expenses came in slightly below plan, resulting in pro forma operating profit growth of 18%. Jamie will take you through our finances in greater detail later in the call.

In the quarter, we made good progress with our new platforms. In March, we received FDA clearance for our next-generation multiport platform, da Vinci 5. Within the quarter, we placed 8 da Vinci 5 systems and surgeon completed their first cases. As we engage with customers during their activation of da Vinci 5, our customers are noting and appreciating improved precision, improved imaging improved efficiency for surgeon and staff, improved ergonomics, and they are exploring the potential of force feedback, where early surgeons are excited to test hypothesis about its procedural, clinical and learning value.

Digital analytical capabilities of da Vinci 5 are also drawing positive reviews. In parallel with customer support, we're working hard to optimize our supply chains and manufacturing capabilities for da Vinci 5 components. We will remain in our measured rollout as we stabilize supply and respond to customer input.

Turning to ion, our teams have made meaningful progress on resolving supply challenges for our catheter and Ion's Vision Pro, although work still remains to be done. Earlier this month, FDA reviewed our set of design and production changes and cleared an increase in an ion catheter lives from 5 lives to 8 lives alleviating some supply constraints while improving the economics for us and our customers. Also in March, we received NMPA clearance for Ion in China through a special review process for innovative medical devices. While NMPA clearance is only the first step towards commercialization in China, we believe ion can play an important role in helping to address the significant burden of lung cancer in the country.

Turning to we received CE Mark in Europe with a broad set of indications in the quarter, and we placed 8 systems. First cases in Europe were performed this April, and we're encouraged by early customer interest for SP.

In closing, for 2024, our priorities are as follows: first, we'll support the measured launch of da Vinci 5 and our other new platforms by region. Second, we're focused on supporting surgeons' adoption of focused procedures. Third, we're focused on improving our product margins and quality. And finally, we're focused on improving productivity in those functions that benefit from global scale.

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

[Jamie Samath, executive]

Good afternoon. I will describe the highlights of our performance on a non-GAAP or pro forma basis and 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. In Q1, da Vinci procedures grew 16% and the installed base of systems grew 14% to 8,887 systems and average system utilization increased by 2%, lower than recent trends because of the strength in procedure growth and utilization in Q1 of last year that reflected a significant benefit from the treatment of patient backlogs. U.S. procedures grew 14%, driven by broad growth in general surgery. Bariatrics procedure growth in the U.S. continued to moderate and was flat year-over-year. OUS procedures grew 20%, reflecting strong growth in general surgery and thoracic procedures. Brian will provide additional detail on our clinical performance later in the call.

Turning to capital. We placed 313 systems in the first quarter compared to 312 systems in Q1 of last year. Excluding trading transactions, net new system placements grew 16% to 284 systems. In the U.S., we placed 148 systems in Q1, including 8 da Vinci 5 placements compared with 141 systems placed in Q1 of last year. Given constrained supply of da Vinci Five, system placements may be choppy this year as some customers that are interested in da Vinci 5 decide whether to acquire a fourth generation system with an upgrade rig or wait for adequate supply. Outside the U.S., we placed 165 systems in Q1 compared with 171 systems last year. Current quarter system placements included 84 into Europe, 20 into Japan and 10 into China compared with 101 into Europe, 16 into Japan and 18 into China of Q1 of last year.

Placements in the U.K. were below our expectations and lower than Q1 last year because of the reallocation of NHS capital funding to help address industrial actions in the NHS.

Placements in China continue to reflect the impact of domestic robotic competition and delayed tenders due to a broader central government focus on systematic governance across sectors, including health care. First quarter revenue was $1.89 billion, an increase of 11% from last year. On a constant currency basis, revenue growth was 12%. Additional revenue statistics and trends are as follows: Leasing represented 51% of Q1 placements compared with 42% in Q1 of last year. Given customer preference for our usage-based models in the U.S. and the launch of da Vinci 5, we continue to expect the proportion of systems placed under lease arrangements to grow over time. Q1 system average selling prices were $1.39 million as compared to $1.47 million last year. System ASPs were negatively impacted by regional and platform mix and lower pricing in China, partially offset by lower trade-ins. We've recognized $29 million of lease buyout revenue in the first quarter compared with $21 million last quarter and $24 million last year.

Da Vinci instrument and accessory revenue per procedure was approximately $1,780, flat to last year and down $20 compared to last quarter. The sequential decline in I&A per procedure is primarily a result of procedure mix in the U.S. given strong growth in cholecystectomy and the moderation of growth in bariatrics. We have also seen larger IDNs in the U.S. look for operational efficiencies by reducing inventory.

Turning to Ion. There were approximately 19,500 ion procedures in the first quarter an increase of 90% as compared to last year. Since launching the Ion platform in 2019, on a cumulative basis, more than 100,000 procedures have now been performed. In Q1, we placed 70 Ion systems compared to 55% in Q1 of 2023 and 44% last quarter. Q1 results reflected a partial recovery from last quarter as catheter supply improved. Our team continued to work on stabilizing supply of the catheter and VisionPro. Q1 results included 4 Ion system placements in the U.K. following European clearance last year. The installed base of Ion Systems increased 61% year-over-year to 604 systems, of which 244 are under operating lease arrangements. 24 of the systems placed in the quarter were SP systems, including 8 systems in Europe, reflecting clearance early in the quarter. First quarter SP procedure growth was 60% and with healthy growth in Korea and the U.S. and early-stage growth in Japan.

In the U.S., during the quarter, we completed a 510(k) submission for a thoracic indication made continued regulatory progress toward a colorectal submission and enrolled additional patients in our IDE for nipple-sparing mastectomy. The SP installed base grew 55% from the year ago quarter to 201 systems.

Moving on to the rest of the P&L. Pro forma gross margin for the first quarter of 2024 was 67.6% and compared with 67.2% for the first quarter of 2023 and 68% last quarter. The sequential reduction in pro forma gross margin primarily reflects higher fixed costs including depreciation expense for expanded manufacturing capacity and higher costs associated with the launch of da Vinci 5. Our manufacturing and business unit teams made progress in the quarter on activities to improve gross margin over the medium term. This remains an area of key focus for us. First quarter pro forma operating expenses increased 7% compared with last year, slightly lower than expectations due to the timing of certain expenses. Pro forma operating expenses as a percentage of revenue were 140 basis points lower than Q1 last year, reflecting planned leverage and enabling functions, partially offset by increased R&D to fund innovation and future growth. Pro forma other income was $72.5 million for Q1, higher than $67.1 million in the prior quarter, primarily due to higher interest income. Our pro forma effective tax rate for the first quarter was 22.5%, consistent with our expectations. First quarter 2024 pro forma net income was $544 million or $1.50 per share compared with $444 million or $1.23 per share for the first quarter of last year.

I will now summarize our GAAP results. GAAP net income was $547 million or $1.51 per share for the first quarter of 2024 compared with GAAP net income of $361 million or $1 per share for the first quarter of 2023. First quarter GAAP tax expense was a benefit of $9 million, reflecting excess tax benefits associated with employee equity plans of $111 million. The adjustments between pro forma and GAAP net income are outlined and quantified on our website and include excess tax benefits associated with employee equity plans, employee stock-based compensation, amortization of intangibles, litigation charges and gains and losses on strategic investments. We ended the quarter with cash and investments of $7.3 billion, flat to the end of last year, the sequential changes in cash included cash generated from operating activities, offset by capital expenditures of $242 million and the net impact of employee equity plans of $46 million.

And with that, I would like to turn it over to Brian.

[Brian King, executive]

Thank you, Jamie.

Overall, first quarter procedure growth was 16% year-over-year compared to 26% for the first quarter of 2023 and 21% last quarter. In the U.S., first quarter 2024 procedure growth was 14% year-over-year compared to 26% for the first quarter of 2023 and 17% last quarter.

First quarter growth was led by procedures within general surgery, with strength in cholecystectomy, colon resection and forgot procedures. Growth in bariatrics procedures continued to moderate and was flat year-over-year. Outside of the U.S., first quarter procedure volume grew 20% compared with 28% for the first quarter of 2023 and 29% last quarter. Over 70% of procedure volume growth, led by procedures beyond urology with strength in colon resection, hysterectomy and lung resection procedures. In Europe, first quarter growth continued to be led by general surgery and gynecology procedure categories. Germany and the U.K. procedure performance led the region with both experiencing strong growth in colon and rectal resection, and hysterectomy procedures. In Asia, growth in the first quarter was led by China, with strong procedure performance in urology and gynecology procedures. Year-over-year procedure growth in the country benefited from a comparison period, where procedures were beginning to recover from COVID during the first quarter of 2023.

In Japan, while we experienced a moderation in growth in urology, overall procedure growth was healthy with strength in general surgery procedures such as colon and rectal resection in gynecology procedures. Effective June 1, 2024, 5 additional procedures will have reimbursement in Japan with 2 existing rectal resection procedures receiving an increase in reimbursement for equivalency to laparoscopic surgery. The opportunity for these procedures is relatively modest, but continues to support the adoption of minimally invasive robotic surgery across a growing set of procedures.

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.

In the first quarter of this year, Dr. Jay Han Chan and team from University of South Florida and Tampa, Florida, published a meta-analysis of randomized controlled trials, describing outcomes of robotic-assisted abdominal pelvic surgery in the journal surgical endoscopy. This analysis included a review of 50 publications published through April 2021, included over 4,800 patients from randomized controlled studies and covered a variety of abdominal pelvic surgical procedures, including anti-reflux, gastrointestinal, colorectal, urologic, hernia repair and gynecologic procedures. The authors compared robotic-assisted outcomes with those from both open and laparoscopic procedures. When compared to the open approach, robotic-assisted procedures had lower rates of postoperative complications with a 32% lower risk of postoperative complications across all procedures as well as less estimated blood loss with a mean difference of 286.8 milliliters. Furthermore, length of stay was on average 1.7 days shorter for robotic-assisted procedures.

Relative to the laparoscopic approach, rates of conversion to open for the robotic assisted group, was approximately half the rate of the laparoscopic approach. Length of stay was also shorter for robotic-assisted procedures.

Interestingly, the authors also reported an analysis on the impact of surgeon experience comparing inexperienced versus experienced surgeons and found that the experienced robotic-assisted surgeons had a lower risk of intraoperative complications with significantly less risk in the experience group as compared with the laparoscopic group as well as a lower risk of conversion to open for the experienced surgeon relative to the laparoscopic group with comparable operative times compared to laparoscopy with experienced surgeons. The authors concluded in part that their results suggest robotic surgery may shorten length of stay and rates of conversion to open when compared to laparoscopy with experience mitigating potential differences in operating time, while improving rates of intraoperative complications and conversions to open surgery.

In March this year, Dr. Nicole Len Arti from the University of Texas Southwestern, along with colleagues from other hospitals and data support from the Intuitive health economics outcomes research team, reported outcomes describing the use of robotic technology in emergency general surgery cases. Published in JAMA Surgery, this analysis used the PIC AI health care database, a database that collects data from over 800 facilities to identify adult patients undergoing urgent or emergent cholecystectomy, colectomy, inguinal and ventral hernia repairs between 2013 and 2021. For reference, emergent procedures were described as those required for life-threatening or potentially disabling conditions, while urgent procedures were those where immediate intervention was needed and prioritized as first available. Over 1 million urgent or emergent procedures were identified. During the study period, the use of robotic-assisted surgery for all procedures experienced a 3.5-fold increase in cholecystectomy, a 6-fold increase for colectomy and 3-fold increase in inguinal hernia repairs. Notably, increases in the robotic-assisted approach corresponded to decreases in the open approach for these procedures as well as a decrease in laparoscopy for cholecystectomy and colectomy procedures. Furthermore, a propensity score matched analysis demonstrated a lower risk of conversion to open for the robotic-assisted approach when compared to laparoscopy. Cholecystectomy procedures with a 45% lower risk of conversion, colectomy me with a 63% lower risk, inguinal hernia repair with a 79% lower risk and ventral hernia repair with a 70% lower risk of conversion. The authors concluded, "The application of robotic surgery and emergency general surgery has steadily increased in the past decade, which is especially useful in older patients with several comorbidities. As observed in this cohort study, compared with laparoscopic surgery. Robotic surgery appears to have resulted in lower rates of conversion to open surgery from 2013 to 2021.

Robotic surgery also leads to a shorter or comparable post-operative length of stay in the hospital. Nevertheless, open surgery remains a key component for most emergency general surgery. As robotic surgery continues to increase in emergency general surgery, barriers to implementation need to be addressed and optimized through coordinated efforts across stakeholders."

I will now turn to our financial outlook for 2024. Starting with procedures. On our last call, we forecasted full year 2024 procedure growth within a range of 13% and 16%. We are now increasing our forecast and expect full year 2024 procedure growth of 14% to 17%. The low end of the range assumes further weakness in bariatric procedures, along with challenges in China from increasing provincial robotic competition and delayed tenders impacting capital placements and therefore, procedure growth. We also assume there is no benefit of patient backlog in the year. At the high end of the range, we assume bariatrics continues at flat to slightly positive growth rates and factors in China don't have a significant impact on our business. In addition, we assume any backlog of patients would decline throughout the year.

Turning to gross profit. We continue to expect our pro forma gross profit margin to be within 67% and 68% of net revenue. Pro forma gross profit margin in 2024 reflects the impact of growth in our newer products, da Vinci 5, Ion and SP and the impact of capital investments that will come on to support the growth of our business. 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 mix.

Turning to operating expenses. We are holding our guidance for pro forma operating expense growth to be between 11% and 15%. We continue to expect our noncash stock compensation expense to range between $680 million to $710 million in 2024. We are holding our guidance for other income, which is comprised mostly of interest income to total between $290 million and $320 million in 2024.

With regard to capital expenditures, we continue to estimate a range of $1 billion to $1.2 billion, primarily for planned facility construction activities. With regard to income tax, there is no change to our guidance of 2024 pro forma income tax rate to be between 22% and 24% of pretax income. That concludes our prepared comments. We will now open the call to your questions.

[Operator]

[Operator Instructions] We will go to the first question at this time, and that's from Robbie Marcus, JPMorgan.

[Robert Marcus, analyst]

Great. And congrats on a very nice quarter. I was hoping you could touch on what surprised me the most was the procedure volume off a really difficult quarter here, 16% maybe walk us through your view of what's driving it? Obviously, you gave color on some of the procedures, but it's a really strong number. And what gives you the confidence that it's sustainable with the raised guidance through the rest of the year?

[Gary Guthart, executive]

Yes, I'm going to turn that first question over to Jamie. Thanks, Marcus. Jamie, why don't you go, and then I'll add a few thoughts thereafter.

[Jamie Samath, executive]

Yes, where we saw particular strength regionally was in the U.S. and the U.K. in particular. What you also see in OUS markets as Brian described, is the continuing growth in procedures beyond geology. That first is focused on cancer procedures, colorectal thoracic hysterectomy some early-stage growth in benign in our international markets. So the combination of those things, I think, were behind the performance in Q1. And as you kind of look at there and the inputs from the teams as we get feedback from our customers, I think then we kind of reflect that in the rest of the year guidance. Obviously, the guidance is only up a point at the low and the high end of the range. So it's something we're watching carefully.

[Frederick Wise, analyst]

Maybe just as a quick follow-up at the SAGES conference now, and the doctor feedback is phenomenal on da Vinci from our end and the doctors we spoke to. I was hoping you could just give us some early feedback on what you've heard across the field. Doctors willingness and hospitals' willingness to not just add new systems, but upgrade the fleet and just what you've been hearing.

[Gary Guthart, executive]

Yes. In terms of early feedback, we're hearing -- I think what we were hoping for in terms of our design intent. They're appreciating the improvements to precision and imaging to workflow and the teams efforts on human factors design and user interface, strong commentary on ergonomics. And I think force feedback is something that is new and will create opportunities to really understand the clinical implications of Fortis application during surgery. I think that will be exciting and powerful over time. I think it's really hard for us sitting where we are today to predict the depth and timing of a replacement cycle. We're excited. I think that folks are excited about what's the potential of the product. That said, XI IS great. Xi has a lot of clinical indications. And we're going to have some supply constraints here as we work through our launch. Jamie, I don't know if there's anything you'd like to add to that, today?

[Operator]

We'll go to the next line, Larry Biegelsen, Wells Fargo.

[Larry Biegelsen, analyst]

It's Rabi the question, I think Rabi's congratulations on a nice quarter here. Just 2 on da Vinci 5 for me me. Maybe starting with Gary, the supply constraints. When do you expect those to be resolved how long into 2025 were the limited launch last? And what will trigger the phone launch?

[Gary Guthart, executive]

Yes. Thanks, Larry, there's 3 things that are going on for us. One of them is optimizing the supply chain, making sure that we have the quality that we want, that will, for sure, go through all of '24 in some part of the early part of '25. So that's one. The second thing is we want to incorporate feedback from our customers. We want to make sure that we're adjusting the things that we need to adjust to make sure they're highly satisfied. And then the last thing is we have additional feature content and hardware improvements and other things that are planned that our design teams are going to execute on, whether it's software or other updates or some of the things we can do in imaging, that we want to do as we bring it through. So it's kind of a 3-part set of activities. And we think it's pretty well planned out. I wouldn't expect big changes from our plan. And if there are changes in the future, then we'll be sure to talk about them.

[Larry Biegelsen, analyst]

That's helpful. And Gary, you haven't been specific about new indications that da Vinci 5 could open, but can you help us understand what the features are of da Vinci 5 that could allow physicians to do new procedures and lots.

[Gary Guthart, executive]

Yes. Our first thought here and bringing the system to the market has been to allow surgeons to go deeper into the existing indications we have already. So the indications for da Vince 5 largely mirror the Xi, an ex indications that we had already. But we do think that it will invite new surgeons and care teams into robotic-assisted surgery. I think it allows us to deepen our relationship with that customer base, and we're excited about it. In terms of core capabilities, da Vinci 5 has some really core things. Better imaging that right now today is better and will get better over time. precision and high performance and tracking performance allows for really subtle and find surgical motions. And we think that's really powerful, and it's a core capability, faster workflow opens new opportunities for people, too. So we do think there are additional clinical indications we can pursue. We are evaluating them. We have not finalized on everything yet, and likely, they will require conversations with FDA. So we're not prepared at this time to tell you what they might be. But as we get a little closer and work through it, then we'll describe it once we've settled our approach.

[Operator]

And we will go to the next line, Travis Steed, Bank of America.

[Travis Steed, analyst]

I wanted to ask a little bit more color on the strong Xi placements and the capital environment even ahead of the DV5 lauch. And it sounded like the message changed on system placements in 2023. I think or 2024, I think before it was system places could be lower than, '24 and, now it's just choppy. So does that mean there's a chance that system placements are or up in 2024?

[Gary Guthart, executive]

No, Jamie, go ahead and take it. Our apologies.

[Jamie Samath, executive]

Yes. I think the first dynamic is trading given the limited supply in DV5 those placements will be during the measured launch focused on incremental placements. So not a lot of trade activity coming from DV5. And if you look at what's left in the installed base for our third gen SI, you've got about 350 systems globally, of which 50 are in the U.S. So we do expect trading volumes to be down quite a bit in '24. With respect to overall system placements, I know we made the comments on the last call, but generally, we don't guide system placements. So we'll let you run that through your models, given the update our procedure guidance, but certainly, we've acknowledged that placements could be choppy, while we're constrained on DV5. In Q1, we didn't really see any customers pushing back on, I don't want an Si, we want to wait for DV5. But since the launch, which obviously was only in March, we've had our Connect conference. We've had Sage this week, a significant number of surgeons and executives have now seen DV5 put their hands on it. So we're acknowledging that customers may choose to weight. We don't have enough evidence or indication yet to see which way that will go.

[Travis Steed, analyst]

Great. And, maybe, Gary, if you could spend some time just kind of a bigger picture question on DV5 and the capabilities it brings to training, being able to practice some of the edge cases helping with Proctering. I'm just curious how you see the impact on robotic surgery adoption and driving better outcomes from some of these DV5 training capabilities that's going to roll out? And how long some of this stuff actually is going to take?

[Gary Guthart, executive]

In terms of raw capability, I think that it will help care teams acquire skills more quickly, and it also helps them in the case. You can kind of think of that as contact sensitive help. The device is kind of aware of where it is and what it's doing and can share that information with the care team as they're doing things, whether it's changing tools or setting it up. It provides real-time health to help cut them through it. And I think that's a really good thing. It just makes it easier. Intuitive hub has integration technologies that start with da Vinci 5, and we'll get better over time as we release software updates and hardware updates. And so that starts to close an analytical loop for our customers from what they're seeing in the case to video review to video analytics to feeding back information to their phones and their laptops and whatever the their means are consuming that data is. And so that gives them an analytical loop, which should also help. And we'll also continue to evolve our simulation training in some of our other packages or online learning that will help them as well. So I think all of this is going to take a little bit of time. But I think the design concept, I think our designers did a beautiful job. I think the design concept of integrating these ideas, making it easy for care teams for surgeons to follow that journey should help us. The final point I'll make is that in our labs and during our early experience with da Vinci 5, it looks like force reflection helps novice new to robotics, new to robotics system surgery require their skills faster. So it should invite more surgeons in and ease their journey, remains to be proven. It's not done and done, but we think it's encouraging. And so stay tuned. I think keep asking that question. And as the data starts come out, we'll be pleased to share it with you.

[Operator]

And we'll go to the next slide. Rick Wise, Stifel.

[Frederick Wise, analyst]

Gary, maybe it would be helpful to hear in a little more detail, your thoughts on a couple of points that maybe some of the headwinds bariatrics flat year-over-year. I wasn't sure completely what I was hearing about trends. Is it getting worse, still is the rate of pressure easing I appreciate talking about the guidance. You talked about a range given the range of outcomes. But I just want to make sure I understood what you're seeing.

[Gary Guthart, executive]

Yes. Let me share my perspective. Rick, thanks for the question. And then Brian, I'll kick it to you to talk about the range. I think what we can tell you is what we see, and what we've seen is continued deceleration such that it's flat year-over-year. There are a lot of opinions out in the field, and we can all talk to them. I think the reality is nobody really knows yet. We're going to have to live through it together. And as a result, it's going to be dynamic. We do know that bariatric surgery is well tolerated and it's a good option. And we also know that people are interested in pharmaceuticals and in that the pharmaceuticals work as long as you take them for a subset of the population and then stop working if you don't. What that means for future surgery, I think there's a range of opinions and I would not hang a lot of confidence on any of them just yet. And that's why we have a range. And Brian, perhaps you can just touch on how you see bariatric surgery affecting the range, just reiterate that, if you would.

[Brian King, executive]

Sure. And just to reiterate again, the low end of the range assumes that there's further weakness in bariatric procedures, right? So at the low end of the range, further weakness in bariatric procedures. At the high end of the range, we assume that bariatric continues at flat to slightly positive growth rates. And I think, again, to Gary's point, it will be dynamic, and we're just going to have to see how it plays out throughout the year.

[Frederick Wise, analyst]

Okay. Great. And let me turn to some of the new and incremental features you talked about, Gary. I'm sure all of us on the call have been talking to doctors that I've been hearing a variety of additional features, some quite compelling. Can you give us any flavor -- I mean, first of all, I'd be happy to hear from you what some of them could be. But how quickly given what you know today, how -- when could we see those features that, again, I would assume would enhance the value? Are we going to see them this year, second half? Or is it more likely that's something for next year as you get the supply chain where you want it to be.

[Gary Guthart, executive]

Yes. I think as we add capabilities in time, we have some imaging things that we want to do. We have some things in terms of software upgrades and analytics power and some things we want to do in terms of integration. That's much more likely to be '25 and later than '24. A lot of '24 will be making sure that we and our suppliers feel great about what we've got and then adapting to any immediate feedback that we see.

[Operator]

And we will go to the next line. Adam Maeder, Piper Sandler.

[Adam Maeder, analyst]

I wanted to start by asking about the force feedback instruments. I was hoping, Gary, you could share a little bit more color on the feedback that you're getting from clinicians thus far into launch. And then if I understand correctly, you have 6 force feedback instruments that are used across different common procedures will you look to expand the portfolio of that technology going forward? And if so, what might that look like? And then I have a follow-up.

[Jamie Samath, executive]

Sure. We're getting a variety of feedback on the instruments themselves. Just a reminder for everyone, they have very sensitive sensors that are built into the distal land, in the body end of the instruments that are sterilizable and cleanable and they report back contact forces with tissue, which at a sensitive way, which has been a goal for us and for surgery for a long time. So it's a hard technology. We've been really excited to bring it to market. We will hear everything from, hey, I'm getting great results with da Vinci X and Xi today that has very limited version of haptics. It really doesn't have in body sensing. It does have a little something, but it's not it's not sensing in a technical sense. And that's true. They're getting great results. So it's a new sense. That said, people are quite interested to explore where we'll take them. And what's interesting is that when you're using a for sensing instrument, it's sensing whether you turn on force reflection into the surgeon's hands or not. So the surgeon can feel it. They can turn it on. or they can turn it off, but still measure so that they have the feeling experience of an X or an Xi. And what they find when they turn it on and off is that the amount of force that they apply during surgery to tissue decreases when force reflection into the hands is on. And so the big question is, what's the clinical value of that? What will be the implications for patient outcomes by procedure and by technique. And that's what they're going to go explore, and we will help them do that exploration. So now we're talking about the future of what could happen. I suspect, I believe, it's a personal opinion. There will be types of procedures and types of patients where having lower force applied to tissue during the surgery is going to be clinically meaningful, and we have to go prove that. So I think it's quite interesting. The technology is sophisticated. We are with our manufacturing partners, learning how to make these at scale with good yield and robust. It's a worthy endeavor, but it is not easy, and we're going to focus on it and make sure that we get what we want. We want to make sure we have robust and high-yield products. We want to extend their lives to help the economics of our customers and our economics. So that is our first focus. As to the 6 instruments, I'm going to look to Jamie as to whether the number is right, I think it is. Certainly, over time, we have the opportunity to extend it to other instruments. But that first set of 6 are the ones that we thought were right. is the right number, Jamie.

It is. And it's a combination of graspers and needle drivers and those instruments are used in very common tasks, dissection, retraction, and suturing

[Operator]

We'll go to the next line on Andrew Ranieri, Morgan Stanley.

[Andrew Ranieri, analyst]

Maybe just on SP for a moment with the indication expansion in Europe. Can you talk about that a bit more, Gary, and was hearing from a surgeon today that the CRSA conference in November in Rome could be pretty important for just getting broader adoption from European surgeons. But does that inform how you could approach the U.S. market with a broader indication? And then I just had a follow-up.

[Gary Guthart, executive]

Yes. Yes. I'm actually here in Europe have been for the last couple of weeks talking to SPE surgeons here. I think the early uptake and early excitement is quite palpable. Where we've had broad indications, as you know, in Korea and now Japan, we've seen nice uptake in adoption and good study, good clinical study. And I think that the surgeons here are building on that. They're learning from and adapting what they see in the rest of the world. and getting excited about it. So I'm encouraged. How deep that goes. It's still early days here in Europe. We will see. But we're starting to see fairly long case studies. In things like colorectal surgery coming out of Asia and other places. We have submitted, as Jamie had mentioned for an additional indication in the United States. We have another one coming. We have IDE trials ongoing. So we have some natural experiments to see what occurs. We know that the experiment in Korea has worked out well. We're in process in Japan and and how we're in the early experience for broad indications in Europe. That should help us generate data and accelerate additional indications over time in the U.S. And I have to say, I think, it remains a build for SP, but I'm encouraged by the bill.

[Andrew Ranieri, analyst]

And maybe this is more for Jamie. But Jamie, could you talk about the commentary about lower pricing in China for the quarter? Just talk about that a little bit more and maybe put that into context on if this is temporary, if it's permanent or more to come and just the overall competitive situation in China would be great.

[Jamie Samath, executive]

Yes. It's primarily a function of the competitive environment we've described with the domestic robotic players. What we actually have now given last year, we qualified a domestically manufactured Xi is actually some segmentation between the domestically manufactured product and an imported product. And the domestic product gives us the opportunity to both participate in tenders that require a locally produced system, but also allows us to segment on price. But the primary impact on China pricing is really competition. And you kind of see that theme broadly with other med tech players in terms of the impact of [Indiscernible]. It doesn't apply in this case, but kind of the macro theme of pricing pressure does.

[Operator]

And we will go to the next slide. And that will be Matthew Miksic Miksic Barclays.

[Matthew Miksic, analyst]

Congrats on a really strong quarter against tough comps. So a couple of follow-ups, if I could, on a couple of things you mentioned, Gary, in your last answer around around force feedback and sort of the clinical impacts of optimizing and reducing the forest user surgery, which is kind of buzzing around here at stages quite a bit this year in the sessions. And I'm wondering I appreciate always the data that you talked about during the prepared remarks and recent clinical data. I'm wondering how far out are we going to see clinical referenced like that to studies around the use of force feedback versus not? And also maybe efficiency is driven by a lot of the docs you're talking about smoother operating arms and being able to get through cases faster. Is that a year out? Are we 6 months? Are we 2 years out for DV5 research like that?

[Gary Guthart, executive]

Yes. It's a good question. Thank you. This is approximate, not specific, so take it with some error bars. But I think what you're going to see in force feedback study is going to be a progression. You'll see narrow series, single institution studies come out first that are kind of directional. They talk about what they're seeing in their own. And then you'll see a little bit -- and that should be the kind of thing that comes out in the next 12 months. After that over the next couple of years, you'll see multiple center trials that are comparing in a little more structured way. So I think you can predict the path of the journey. But I think this is something that you're going to see from.

narrower input to start to broader input in the next year to prospective studies that start to report over the next year after that. So I think it's a build. But I think it's going to be a powerful build in the end. I think with regard to efficiencies, we're hearing anecdotal reports already that the surgeon autonomy features that are in da Vinci 5, the ability for them to control their own field and to control the equipment, ancillary equipment in the room, has been really positive, and the reporting efficiencies already. I think real-world evidence is going to be powerful on the efficiency side. And I think that's the kind of thing that people can benchmark their own cases, also our data collection capabilities between Intuitive Hub and the my Intuitive app allow them to measure that very quickly. So I think you'll see the real world evidence of that build, and it will be in the coming months and quarters, and that will be exciting for us.

[Operator]

Brandon Vazquez, William Blair.

[Brandon Vazquez, analyst]

I want to focus on Ion real quick. You had a nice rebound in the quarter there after some supply last quarter. Just curious, you see a little bit of catch-up there or not? And then even as these numbers are getting bigger, you're still putting up some really strong growth. So curious where you're seeing growth there, new accounts or existing utilization and how sustainable you think it is?

[Gary Guthart, executive]

Jamie, why don't you take that one?

[Jamie Samath, executive]

Yes, I'd say it was a partial recovery in the quarter. We haven't completely resolved both catheter supply and the vision probe. We still have a little bit of backlog in terms of number of systems that's pending kind of stabilization of that supply. With respect to where are we placing those systems it's actually a blend between existing accounts and new accounts. We still have a number of opportunities, what I call greenfield accounts. And so both are a focus for the sales team.

[Brandon Vazquez, analyst]

Okay. And 1 quick follow-up maybe on the surgical side. The 1% utilization growth, I appreciate off of a tough comp, and we're kind of normalizing, but I think we kind of -- we usually use utilization growth as an indication for system placements and then it implies a certain procedure growth as well. Just talk to us a little bit about what you kind of think a below historical average utilization growth in the quarter might mean for those key moving pieces in the next couple of quarters?

[Jamie Samath, executive]

Start. Go ahead, Gary.

[Gary Guthart, executive]

I'll jump in and then Jamie take it. I think that in the prepared remarks, we had said you had a nice capital placement year and we have bolus of post-COVID come back into Q1. I think the uncertainty part of this is really just going to be with the inpatient volumes look like in the next quarters of 2024. In other words, just the patient census as it comes through. But you're right. I think that it's an indicator of capacity. So depending on what that patient sense is looks like that will determine the high end and the low end of utilization growth in terms of how many procedures people want to put on those systems.

Sorry, Jamie, go ahead, you might discuss the modeling there.

[Jamie Samath, executive]

I would just say that if you look at Q1 utilization over an extended period, look at what the CAGR is versus the year-over-year comparison, you see that start to be in a more normal range of of 3% to 4%. I do think that in the year ago quarter, you had a number of institutions that actually set themselves up to do Sprint with respect to their ability to treat patients. And so I do think that was elevated and at that level of utilization growth of 13%. It wasn't particularly sustainable, so as I look forward to the rest of the year, I'd expect some levels of utilization growth or, let's say, closer to our long-term averages. There's still some patient backlog benefit in the year ago quarters, even in Q2 and Q3. So it's not perfectly match, but I think there's room for normalization over time.

[Operator]

And we will go to the next question from the line of Jayson Bedford, Raymond James.

[Jayson Bedford, analyst]

Just maybe Ion in China. Obviously, a large opportunity there. Just a couple of questions, and I apologize if I missed this. But does Ion fall within the existing robotics quota? And then for Ion, you mentioned clearance is the first step. Can you just talk through the other steps to commercialization and associated timing of those steps?

[Jamie Samath, executive]

Yes, we have some work to put ion at a point where it's actually available to sale -- to sell. So that will take us some time. We're not expecting to have commercialization really until the back half of 2024. And China is a market where, like many cases, when we launch a new product in a market, we do that progressively as we kind of build our infrastructure in terms of training capabilities and engage with customers. So I'd say back up at 24% is when you start to see the potential for ion placements in China.

[Gary Guthart, executive]

On the issue of is it competing for the same quarter, Jamie?

[Jamie Samath, executive]

Sorry. Yes, our understanding is not in the quota given the price.

[Gary Guthart, executive]

And Jason, if you have 1 more follow-up, that will wrap it up for us.

[Jayson Bedford, analyst]

No, that's fine.

[Gary Guthart, executive]

Okay. That was our last question. In closing, we continue to believe there's a substantial and durable opportunity to fundamentally improve surgery and acute interventions. Our teams continue to work closely with hospitals, physicians and care teams in pursuit of what our customers have termed the [Indiscernible], better, more predictable patient outcomes, better experiences for patients, better experiences for their care teams; and ultimately, a lower total cost of care. 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 the future of care that is less invasive and profoundly better, where diseases are identified earlier and treated quickly so patients can get back to what matters most.

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

[Operator]

And thank you, everyone, for joining today's conference call. That does indeed conclude your conference call. You may now disconnect. Have a good day.