Q1 2025 Earnings Call Transcript

Thank you for standing by, and welcome to the Intuitive Surgical, Inc.'s First Quarter 2025 Earnings Release. [Operator Instructions] As a reminder, today's program is being recorded. . And now I'd like to introduce your host for today's program, Dan Connally, Head of Investor Relations at Intuitive Surgical. Please go ahead, sir.

Good afternoon, and welcome to Intuitive's first quarter earnings conference call. With me today, we have Gary Guthart, our CEO; Dave Rosa, our President; 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 Form 10-K filed on January 31, 2025, and Form 10-Q filed on October 18, 2024. 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 introduce the call and provide a business overview. Dave will present the quarter's business, operational and clinical highlights. Jamie will provide a review of our financial results and procedure highlights.

Then I will discuss our updated financial outlook for 2025. And finally, we will host a question-and-answer session. With that, I will turn the call over to Gary.

Thank you for joining us on the call today. Our business performed well in the first quarter of the year with physicians using our products at the high end of our expectations, driven by strong procedure growth in core general surgery in the United States, and strong procedures outside the United States, new system placements in the quarter were solid with particular strength in the U.S. We are pleased with performance of each of our platforms with continued adoption of dV5 and multiport solid results in Ion and acceleration in procedures using our single port platform. Given the dynamic changes in trade policy, I'd like to describe our principles for navigating the current environment, rather than detailing any particular scenario.

Our first priority is to ensure supply of our products to our customers globally. We have spent years becoming a trusted provider of great products and services. And first commitment is to maintaining the status for those who depend upon us. We believe that high-quality minimally invasive care at industrial scale will remain a global need regardless of trade policy and our long-term opportunity remains robust.

We will continue to manage the business for the long-term and invest towards improvement in the quintuple aim. Given potential changes in our costs and our customers' costs across their enterprise, we do not plan reflexive changes to our pricing in the dynamic near-term environment. Our second priority will be to optimize our production costs and rebalance product flows within our existing manufacturing and supply chain footprint as policies begin to stabilize. Finally, we will adjust our supply chain strategy and assess adjustments to our pricing when we see the signs of a durable planning environment for trade.

I'll now turn the call over to Dave to take you through our product, services and operating highlights. Dave?

Thank you, Gary. Intuitive Surgical was founded in 1995. In this, our 30th year of operations, our global da Vinci installed base in Q1 2025 exceeded 10,000 systems and over 50,000 surgeons across 70 countries perform procedures in the quarter. Thank you to our customers, our employees and all our stakeholders for your ongoing collaboration and commitment as we continue to advance minimally invasive care. Starting with procedures.

Da Vinci procedure growth in the quarter was 17%. Areas of strength included general surgery in the U.S. and regional performance in India, Korea distribution markets in the U.K. In the U.S., after-hours procedure growth accelerated to 36% year-over-year. Jamie will describe procedure dynamics later in the call.

Turning to capital. We placed 367 da Vinci systems in the quarter, including 147 da Vinci 5 systems and 19 SP systems. We also installed 49 Ion systems in the quarter. Capital placements were strong in the U.S. with mixed performance outside of the U.S., reflecting stresses in Germany, the U.K. and Japan.

System utilization defined as procedures per installed clinical system per quarter, grew 2% year-over-year for our multiport platforms, 26% for SP and 5% for Ion. Solid procedure growth and capital performance supported strong revenue growth of 19% in the quarter. Product margins were within our expectations, reflecting increased depreciation from new facilities and a higher mix of newer platforms. Operating expenses were within our expectations.

Jamie will take you through our finances in greater detail later in the call. In Q1, our rollout of da Vinci 5 progressed within our expectations with 147 systems placed and over 32,000 procedures performed across a broad set of specialties. We installed our first fully integrated system this month, which now features software to enable the integrated hub and simulator along with a host of other enhancements. Several additional features, including real-time surgical video review, real-time 3D model review and visual force feedback gauges will be enabled upon 510(k) clearance later this year.

We continue to ramp our manufacturing operations and supply chain capabilities to support broad launch of da Vinci 5 midyear. Broad launch means that incorporate the latest fully integrated hardware and software and we're able to meet customer demand, including trade-ins and dual consoles. As we've discussed previously, we remain in the regulatory process in Japan and expect clearance in Europe near the end of 2025. Force Feedback is one of the core features of da Vinci 5. We are starting to see early single institution studies evaluating the impact of Force Feedback on clinical outcomes and proficiency.

In an abstract presented at the North American Robotic Urology Symposium, a team led by Dr. Michael Stifelman, Chair of Urology at Hackensack University Medical Center, studied return of bowel function in a small cohort of patients. Return of bowel function in less than 24 hours is an important metric for certain operations. Of the 28 patients included, 16 patients underwent transparent neo partial nephrectomy or radical nephrectomy where Force Feedback technology was used compared with 12 patients undergoing the same procedure with standard da Vinci Xi instruments.

The authors reported a significantly higher rate of recovery of bowel function within 24 hours, with 83% of the force feedback cohort compared to 25% in the non-force feedback cohort. The authors concluded that force feedback instruments and robotic-assisted kidney surgery are associated with faster bowel function recovery, suggesting potential reductions in colonic trauma. They note, as robotic-assisted surgery advances, integrating force feedback into routine practice could enhance precision and improved recovery across disciplines. Regarding time to proficiency, a second study led by a team, including Dr.

Andrew Hung, Associate Professor of Urology and Computational Biomedicine at Cedars-Sinai Medical Center in Los Angeles, evaluated the impact of force feedback technology on the suturing performance of 29 novice surgeon in a randomized preclinical study. The study showed that force feedback technology has the potential to improve novice surgeon performance by significantly reducing tissue trauma and errors during suturing and time to complete suturing. These results are consistent with the core value hypothesis of force feedback technology, and we expect more of these types of studies to publish in 2025 and beyond.

Force feedback instruments are in limited supply and we expect broad availability near the end of 2025. Use of case insight with da Vinci 5 is growing nicely, with case insights delivered on over 22,000 procedures to date. These data sets include video, kinematic energy and force data and are delivered in the context of surgical procedure steps, enabling surgeons to easily navigate the procedure video and identify meaningful operational and clinical insights. These insights will form the basis of key performance indicators and help of novice and expert surgeons identify objective measures that underpin surgical performance.

As we said before, the long-term opportunity for computational tools is both significant and difficult. Validations at scale will take time and are worthy pursuit. Moving to Ion. Procedures grew 58% to approximately 31,000 in the quarter.

In April, we received clearance of our Ion platform in Australia. And in China, we received our first provincial charge code. In this early phase of launch in China, we are focused on the collection of clinical data to support our broader commercialization strategy. Our priorities for Ion in the near term are supporting utilization growth in the U.S., expansion in international markets and improving product costs.

Turning to SP. Procedure growth accelerated in the quarter to 94%, with solid growth in the U.S. and OUS procedures more than doubling compared to the year ago period, driven by Korea, Japan and early adoption in Europe. In the quarter, we received U.S. 510(k) clearance for da Vinci SP SureForm 45 stapler, which will support the use of SP in thoracic and colorectal indications. Our commercialization efforts in these indications will be measured as we look to establish first access sites and develop key opinion leaders in the coming quarters.

In closing, we are committed to our 2025 priorities. First, focusing on the full launch of da Vinci 5, its regional clearances and follow-on feature releases. Second, we'll pursue increased adoption for our focused procedures by country through training, commercial activities and market access efforts. Third, 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. While periods of rapid change can create inefficiencies, as we adapt to a dynamic environment, we are well positioned operationally and financially to execute against our priorities. I'll now turn the time over to Jamie, who will take you through our finances and procedure highlights in greater detail.

Good afternoon. I will describe the highlights of our performance on a non-GAAP or pro forma basis, and we'll also summarize our GAAP performance later in my prepared remarks. A reconciliation between our pro forma and GAAP results is posted on our website. Given that the current global trade environment is relatively dynamic, before we dive into Q1 results, let me address Tariffs.

To provide some context, the footprint of our manufacturing operations is as follows. In 2024, Intuitive manufactured 98% of our robotic systems in the United States, 70% of our endoscopes in Europe and approximately 80% of our instruments and accessories in Mexico. We source raw materials and other components that go into these finished products from suppliers around the world. The net result of our manufacturing footprint and global customer demand is that Intuitive is both a significant U.S. manufacturer and has become a significant net U.S. exporter.

In terms of the impacts of tariffs to Intuitive, broadly, in order of magnitude, I would characterize tariffs into the following three buckets, first, those tariffs relating to U.S.-China trade. We import into China subassemblies for domestic Xi production and completely finished excise, both of which are expected to incur Chinese tariffs of 125%. We also import components from Chinese-based suppliers into the U.S. to be incorporated into the manufacture of our products, which incur U.S. tariffs of 145%. In addition, our China JV manufactures certain products for our Ion platform that are subject to U.S. tariffs when imported for U.S. procedure demand.

Second, imports into the U.S. of procured components from OUS-based suppliers and imports of endoscopes from our factories in Europe are subject to the 10% baseline tariffs and then increased tariff rates after the current 90-day pause period has elapsed. Third, while most of our products manufactured in Mexico are certified under the requirements of USMCA and therefore, are not subject to current U.S. import tariffs, a small portion do not currently meet the requirements and therefore, incur 25% tariffs upon import to the U.S. Based on the impacts just described, reflecting those tariffs that have been implemented and those that have been announced with both a stated percentage and implementation date and assuming such tariffs remain in place, we currently expect the impact to our income statement for 2025 to be additional cost of sales of approximately 1.7% of revenue, plus or minus 30 basis points.

The impact of tariffs will vary with the volume of capital sales in China, the mix of procured components from OUS suppliers and the proportion of products manufactured in Mexico that are certified under USMCA. Given that tariff costs are capitalized into inventory and then recognized in cost of sales as products are sold, we would expect the impact of tariffs to increase each quarter over the remainder of the year. As a result, we are updating our estimate for pro forma gross margin to be within a range of 65% and 66.5% of revenue. This range does not reflect any potential additional tariffs or any potential inflationary impact on labor cost or the cost of procured components.

To the extent that tariffs and their derivative impact has a durable impact on our cost of sales and/or demand for our products, we will consider implementation over time of a range of mitigating operational actions. However, we do not expect any such measures to have a significant beneficial impact in 2025. Turning to Q1. Core metrics were strong. da Vinci procedures grew 17%, the installed base of da Vinci Systems grew 15% and average system utilization grew 2%. Procedure growth in Q1 was adversely impacted by a lower number of business days compared to the year ago period. On a day-adjusted basis, Q1 procedure growth was 18.5%.

U.S. procedures grew 13%, driven by growth in benign general surgery with relative strength in cholecystectomy, foregut and appendectomy procedures. Consistent with recent trends, bariatric procedures in the U.S. declined in the mid-single-digit range. OUS procedures grew 24%, driven by strength in India, Korea, distributor markets and the U.K. Procedure growth in Korea improved sequentially.

Some portion of that higher growth may be a catch-up in procedures from prior periods as a result of the ongoing precision strike. Procedure growth in China improved from the prior quarter and was a little above the global average, driven primarily by urologic procedures. Looking at OUS performance in aggregate, we see strong procedure growth in colorectal, hysterectomy, benign general surgery, and thoracic categories. Reviewing capital performance, we placed 367 systems in the first quarter, 17% higher than the 313 systems we placed in the same period last year.

First quarter placements included 147 da Vinci 5 systems, taking the total install base to 509 systems. There were 67 trading transactions in Q1 compared to 29 trade-ins last year, driven by some U.S. customers upgrading to da Vinci 5. It is important to note that we expect trade-ins to occur progressively over multiples of years as we build da Vinci 5 evidence and customers evaluate associated returns on such investments. In the U.S., we placed 204 systems in Q1, up from 148 systems last year, reflecting positive customer response to da Vinci 5. Outside the U.S., we placed 163 systems in the first quarter, down from 165 systems placed in quarter one of last year.

In the first quarter of this year, we placed 88 systems in Europe, 16 in China and 10 in Japan compared with 84 in Europe, 10 in China and 20 in Japan in Q1 of last year. OUS placement performance reflects financial pressures and healthcare spending constraints in several key markets including Japan, Germany and the U.K. Customers with existing da Vinci capacity have opportunities to increase utilization, which we actively support. The environment in China continues to reflect the ongoing impact of domestic competition and policy-driven pressure on pricing.

With respect to the previously mentioned tariffs of 125% on imports of excise systems and excise subassemblies into China, these tariffs have a material impact to the product cost of excise systems in China, and may adversely impact our ability to win future tenders. Given the trade environment, financial pressures faced by hospitals and risks to the macro, we may see customers globally reprioritize capital budgets or extend timelines to invest in robotic programs. First quarter revenue was $2.25 billion, a 19% increase over last year. On a constant currency basis, revenue growth was 20% and Systems revenue grew 25% year-over-year, driven by a 17% increase in da Vinci system placements and higher system ASP, reflecting a higher mix of da Vinci 5 placements.

Recurring revenue grew 19% in Q1, representing 85% of total revenue. Additional revenue statistics and trends are as follows leading represented 54% of Q1 placements, compared with 51% last year, driven by a higher mix of U.S. placements where given customer preference the greater proportion of systems are placed under lease arrangements. While leasing may fluctuate quarter-to-quarter, we continue to expect the rate of leasing to increase overtime. Q1 system average selling prices were $1.62 million, as compared to $1.39 million last year, primarily driven by a higher mix of da Vinci 5. Looking forward to the second half of 2025 following broad launch of da Vinci 5, to the extent that we see higher trading volumes, you should expect that such transactions reflect significantly higher trading credits relative to recent periods.

We recognized $39 million of lease buyout revenue in the first quarter, compared with $29 million last year. da Vinci instrument and accessory revenue per procedure was approximately $1,780, flat to last year, reflecting two offsetting dynamics. First, we see I&A per procedure come down due to procedure mix, given a lower mix of bariatric procedures and higher mixed cholecystectomy. Second, we see an offsetting positive mix effect from a higher mix of procedures on our SP Platform and Insufflator Accessory and Force Feedback instrument revenue, coming from da Vinci 5 procedures. Turning to Ion.

There were approximately 31,000 Ion procedures in the first quarter, an increase of 58% as compared to last year. In Q1, we placed 49 Ion systems, compared to 70 in Q1 of 2024. Four of the 49 systems were placed in OUS markets. We estimate the penetration of lung biopsy in the U.S. is approaching the halfway point. And then looking ahead, an increasing proportion of our focus will be helping customers convert Transthoracic needle aspiration biopsies to Ion, while driving increases in utilization of the existing capacity.

Where we have a clearance for Ion in our U.S. markets, we are in the early phase of adoption, where our current focus is on building local ends, engaging societies and healthcare systems to see adoption of our products for the benefit of patients. We expect this to be a multiyear effort. First quarter SP procedures grew 94%, driven by strong growth in Korea and early-stage multispecialty growth in Europe and Japan. We placed 19 SP systems in Q1 compared to 24 systems last year.

Quarter placements included seven in Europe, six in Korea, and five in the U.S. Average system utilization for our SP platform grew 26% in Q1. In absolute terms, SP utilization is the highest of any of our platforms in Korea and Japan. Utilization in Europe is increasing steadily. We expect utilization in the U.S. to increase as we expand indications.

Moving on to the rest of the P&L. Pro forma gross margin for the first quarter of 2025 was 66.4% compared with 67.6% for the first quarter of 2024. The year-over-year decline in pro forma gross margin primarily reflects higher facilities costs, including depreciation as we bring on additional manufacturing capacity and a higher mix of Ion and da Vinci 5 revenue that carry lower gross margins. Our Q1 results did not reflect any significant impact from tariffs. During the quarter, we opened two new facilities at our Sunnyvale, California headquarters that expand our U.S. manufacturing and R&D footprint significantly; a 912,000 square foot facility that will contain da Vinci systems manufacturing and R&D teams; and a 315,000 square foot facility containing our Ion manufacturing and R&D team.

Along with our recently opened factory in Peachtree Corners, Georgia, that manufactures X and Xi Systems, these facilities provide a space to grow over the midterm. Looking ahead to the rest of the year, we continue to expect to open new manufacturing facilities in Germany and Bulgaria and expand instrument manufacturing capacity in Mexico. In addition to supporting our growth plans, we believe, over time, these new manufacturing facilities give us supply availability, quality, and cost advantages from scale and factory automation. First quarter pro forma operating expenses increased 12% compared with last year, driven by increased headcount, higher facilities-related costs, and increased legal fees.

During the quarter, we increased headcount sequentially by just over 500 employees, of which approximately half were in manufacturing roles to support revenue growth. Given long-term opportunities to drive the quintuple aim and grow revenue, our resolve to invest in R&D and innovation remain unchanged. Pro forma other income was $91 million for Q1, up from $88 million in the prior quarter, primarily driven by higher interest income. Our pro forma effective tax rate for the first quarter was 22.3%, in line with our expectations.

First quarter 2025 pro forma net income was $662 million or $1.81 per share compared with $541 million or $1.50 per share for the first quarter of last year. I will now summarize our GAAP results. GAAP net income was $698 million or $1.92 per share for the first quarter of 2025 compared with GAAP net income of $545 million or $1.51 per share for the first quarter of 2024. The adjustments between pro forma and GAAP net income are outlined and quantified on our website. We ended the quarter with cash and investments of $9.1 billion compared with $8.8 billion at the end of last year.

The sequential increase in cash and investments reflected cash generated from operating activities, partially offset by taxes paid related to net share settlement of equity awards and capital expenditures of $117 million. And with that, I would like to turn it over to Dan to discuss our updated outlook.

Thank you, Jamie. I will now turn to our financial outlook for 2025. Starting with procedures. On our last call, we forecasted full year 2025 procedure growth within a range of 13% and 16%. We are now increasing our forecast and expect full year 2025 procedure growth within a range of 15% to 17%.

The low end of the range assumes growth in China is impacted by trade, environmental and competitive dynamics. Governments in key OUS markets continue to constrain hospital CapEx budgets, which limits the expansion of capacity in the field and bariatric procedures continue to decline at rates similar to recent trends. The high end of the range assumes China procedure growth improves relative to 2024, the CapEx environment improves in key OUS markets and procedure declines in bariatrics moderate. The high end of the range also assumes that procedures are not impacted by the current trade environment.

Turning to gross profit. On our last call, we forecast pro forma gross profit margin in 2025 to be within a range of 67% and 68% of revenue, which reflected 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. As Jamie described earlier, we currently expect the impact of recently implemented and announced tariffs globally to impact our cost of sales by approximately 1.7% of revenue, plus or minus 30 basis points. As a result, we are updating our estimate for pro forma gross margin to be within the range of 65% and 66.5% of revenue.

In regards to operating expenses, we now expect pro forma operating expense growth to between 10% and 14%. The projected operating expense growth reflects increased depreciation from new facilities and investments to drive our growth objectives. We now expect our non-cash stock compensation expense to range between $770 million and $790 million in 2025. We continue to expect other income, which is comprised mostly of interest income, to total between $370 million and $400 million in 2025. With regard to capital expenditures, we now estimate a range of $650 million to $750 million, primarily for planned facility construction activity.

With regard to income tax, we continue to estimate our 2025 pro forma income tax rate to be between 22% and 23% of pre-tax income. That concludes our prepared comments. We will now open the call to your questions.

[Operator Instructions] And our first question comes from the line of Travis Steed from Bank of America Securities. Your question, please.

Hi. Thanks for taking the question. First, I’ll ask a question on tariffs. Just the 170 basis point impact in 2025. Just curious how to think about that on an annualized basis, any way to kind of break out how much of that is China versus Mexico and how to think about the cadence over 2025, how much of that impacts in kind of Q4 and in Q3 this year?

Yes. Travis, in terms of the breakout for this year, roughly half-ish of the impact is U.S.-China trade, both directions. And about 40% of the impact is imports into the U.S. ex-China, Mexico, Canada of raw materials and components from U.S.-based suppliers and imports of endoscopes from our factories in Europe. So that kind gives you a sense of what's driving the 1.7% of revenue.

As we said in prepared remarks, the impact of tariffs kind of increases each quarter through year. So the exit rate in Q4 is going to be higher than the 1.7%. There is some variability there with respect to - for example, where Chinese capital sales fall. So we're not going to be precise on the quarterly profile.

Beyond 2025, I think from our perspective at this point, we'd like to see where tariffs stabilize, we'd like to obviously assess what moves can we make over time that we'll assess. So we'll get into what the impact may be in 2026, I think when we get through that process.

Okay. And then a follow-up on the capital environment. Just it sounds like you kind of called out at the risk, but you're not seeing it yet. Just trying to think about how this compares to like 2022 when you saw it in the funnel versus kind of what you're seeing in the capital environment at this point?

Yes. I'd say through Q1, if you look at the U.S., what we've seen is strong customer response to da Vinci 5. I think the capital environment has been relatively strong for U.S. Customers there are using our leasing and user-based arrangements. So that allows them, to some extent, avoid kind of their formal capital budgets, gives them some flexibility to expand their programs.

In OUS markets, as we described in prepared remarks, you see some markets where they're getting constrained by government budgets. That's either to do with kind of the elimination of post COVID funding or it reflects governments reprioritizing funding to other areas. For example, in Europe, you see some funding that moves towards military spending. So some pressures there.

I think our focus in a situation like that is to first help customers increase utilization where they have the existing capacity and can have greater throughput through their assets than we have Genesis resources and other teams that can help them do that. We also have a growing set of economic capabilities, tools that we can help customers understand what the returns of those programs are. That's a growing part of our toolkit internationally. And then we look to expand what we've seen in the U.S. with respect to use of leasing and usage-based arrangements, which are at earlier stages of adoption with our customers there.

In terms of what customers have said to us, we've had questions about tariffs and the environment. I don't think that's shown up yet in terms of core capital demand. But I think we're flagging that could have an impact. And certainly, to the extent that our customers' hospitals see increased pricing as a derivative effect of tariffs, then that creates pressure for them.

Great. Thanks a lot.

Thank you. And our next question comes from the line of Larry Biegelsen from Wells Fargo. Your question, please.

Good afternoon. Thanks for taking the question. Jamie, a follow-up on tariffs. Just on the - did I hear you say that you're including the European reciprocal tariffs, which I think are 20% in 90 days assumed in that 1.7%.

And Jamie, how should we think about your ability to mitigate the tariffs? Just maybe flesh that out a little bit more for us and how quickly you might be able to do that. I had one follow-up.

Yes. We are assuming in the 1.7% estimate for 2025 that the retaliatory tariffs go into effect once the 90-day pause period has elapsed. Obviously, we'll see how that plays out, but we've reflected that in the 1.7%. With respect to the manufacturing operations in our supply chain to the extent that there are low-hanging fruit that isn't disruptive to our partners and our employees, then, of course, we'll pursue those.

But I think our first move is to let things stabilize and evaluate then what's possible. We'll do that concurrently across the year, and we will consider things like, do you have to invest to mitigate what's the time to receive the benefit, what's the economic return of that. And there are complexities in some of the things that you might do from an operational perspective. And so we don't want to move too quickly, given how dynamic the environment is.

That's helpful. And just for my follow-up, Jamie, on da Vinci 5, it looks like da Vinci 5 placements as a percent of U.S. placements actually was lower in Q1 from Q4. Hopefully, I'm not doing the math wrong. Why would da Vinci 5 placements in the U.S. as a percent decline in Q4? And how should we think about the ramp going forward? Thank you.

I believe, Brandon, correct me, I believe dV5 placements as a percent of total in the U.S. was higher in Q1 than Q4. But if I look at Q1 capital performance, supply for da Vinci 5 was where we expected it to be. And with respect to placement performance for all of the models, including da Vinci 5, I'd characterize it as normal seasonality, no concerns there for us.

All right. Thanks so much.

Thank you. And our next question comes from the line of Robbie Marcus from JPMorgan. Your question, please.

Great. Thanks for taking the questions. Maybe on the first one, the procedure volume was excellent in first quarter, and it's rare to see such a big raise after just one quarter. You touched on it in the prepared remarks, but maybe you could spend a little more time walking through what gave you the confidence to raise this early in the year?

Yes, I'll just leave it there, and I have a follow-up question. Thanks.

Yes. We routinely have a process where we obviously, like many companies construct a forecast that reflects customer input. We look at, obviously, our plans and that - that guidance is a function of that routine process. Day adjusted Q1 procedure performance was 18.5%.

I think that gives us a little bit of momentum into the rest of the year. Obviously, we're watching the macro carefully. If you look at the low end of the range of 15%, that would say the rest of the year would have to be 14% procedure growth. And so I think we have a decent range for kind of our bottoms-up process.

Just some anecdotes back from the road, and Dave has been out front of the customer, too. I think we're perceived as part of the solution, not part of the problem. I think that customers continue to adopt I think to see the economic benefits and the patient and outcome benefits. So, so far, so good.

Great. And sorry to harp on it, but tariffs are a big focus, unfortunately, in everybody's world right now. Just to follow-up on Larry's question. It feels like you're taking a worst-case approach here where you're putting all the negatives and there aren't a lot of offsets or any built into the guide.

You talked about maybe evaluating where you are at the end of the year. What are some of the potential levers you have to offset this? And how meaningful can they be? And when do you think we might be able to see some offsets if you do choose to do that?

Thanks.

I'd just say on the philosophy on the tariff guide, from our perspective, we're playing it straight down the middle. It’s tariffs that are in effect all that have been announced. And we felt like that was the most responsible way to go with respect to what we guided. We didn't want to predict what may or may not change.

And so we guided under that kind of a philosophy. In terms of potential mitigating operational activities for which we said we didn't expect a beneficial impact in 2025, maybe I'll let Dave touch on what some of those may be.

Yes, sure. Happy to. Hi Robbie. Some of the mitigations that we're considering on our side, if you look at our supply chain, they are - Jamie mentioned a little bit of it, but it's really two frames of reference that you ought to use.

One is thinking about the parts that are coming into our factories, the ones that we assemble and then the other frame of reference are the parts that are leaving our factories. And so as we look about how do we optimize within those two frames of reference on the parts coming into our factories, our teams have been working to get to industrial scale for years now. And so some of the processes that exist within this framework with inside of Intuitive, really center around assessing risk in all of our supply chain. We procure thousands of parts for our systems and instruments.

And so our teams look through there, assess the risk and then ensure appropriate mitigations are in place. And mitigations there can include dual sourcing. They can include strategic reserves. And so that's for a robust process that runs on a daily basis here for parts coming in.

If you look about our parts, our components and our products going to customers, here, we've done a lot of work to qualify some of our products under USMCA. We've optimized inventory around the globe has some of these tariffs ahead of some of these tariffs taking place. And then if you look in the mid-term, we can use our existing manufacturing footprint that we have around the globe and optimize what products are factored in what area around the globe to help optimize some of the supply for our customers. And then in the long-term, we can build our overall manufacturing footprint against the trade environment that ultimately stabilizes.

And so that's going to be a long-term way in which we help mitigate some of the supply risk, if you will, within our supply chains.

Great. Appreciate it. Thank you very much.

Thank you. And our next question comes from the line of Rick Wise from Stifel. Your question please.

Good afternoon, everybody. I thought maybe just to change the focus briefly. OUS growth was particularly robust at 24%. Maybe you can talk about the drivers there, the sustainability of the drivers, the key markets and just what you've assumed in coming up with your new forecast as well?

Yes. We saw solid procedure growth in the U.S. of 13% and obviously, day adjusted is a little higher than that. I do think that we are seeing a relatively significant benefit from the adoption of da Vinci 5 in the U.S. I think customer response has been quite positive. You're generally seeing higher...

It was - he was asking OUS...

I'm sorry. I'm sorry. I'm sorry, Rick, you're going to have ask your question again, I missed it.

Just the - Jamie, just big - just talking about the OUS growth, the international growth at 24%. It was particularly strong I thought and just drivers there and key drivers and the sustainability of those drivers into the rest of the year and beyond.

Yes. Sorry. Rick, you're talking about the 24% procedure growth for OUS.

Exactly.

Yes. So you see some maybe earlier stage markets for us doing quite well. India, smaller market; Taiwan, those are starting to grow at really nice rates. I think we see our teams making real progress with respect to engagements with - key opinion leaders with surgical societies and adoption across a broader set of procedures.

I think that's going well. Same in Taiwan. We benefited from some incremental reimbursements in Taiwan. Across Europe, you see relatively solid growth that progresses each quarter.

U.K. kind of leads that growth. And in the U.K., they're seeing real value with respect to resource consumption savings addressing waiting list in the U.K. And then we've been actually kind of placing capital in distributor markets a little bit of a higher rate over the last several quarters, and we're seeing that create capacity for procedure growth. So I think that those elements all look good for us.

I think that the watch out for us is to the extent that in Germany, Japan, U.K., ongoing capacity constraints for capital continues then at some point that starts to limit procedure growth. We have room to grow with respect to utilization there. And so that's what we'll pursue to the extent they're constrained. If you look at our long-term OUS procedure growth, it's been in the 20s for a long period of time.

We're at early stages of adoption. And I think we feel quite good about how our teams are performing there. There are particular markets where you have unique dynamics like China.

Got you. And just a follow-up. You've highlighted recently that increased customer interest in two areas. And it went by too quickly, I missed what you said about after hours surgery growth.

I just didn't get the number. But after hours surgery and you recently hired a new leader for the cardiac surgery area, can you update us on these two areas? And where are you in sort of pursuing them? What's next?

And again, maybe just talk about the growth outlook, if you would. Thank you.

Sure. Hi Rick. So, the two areas that you mentioned after hours and cardiac. On the after-hour side, this really is being driven by customers who want to provide equal access to high-quality minimally-invasive surgery to those patients who are so-called after hours and having it be the same as the patients who are entering the hospital during the day.

And so that has been the primary sort of motivation behind it. And the ability for our customers to access capital for our teams to train the after-hours care teams are just parts or components to the equation that enable customers to access systems to have the right trained teams to support the surgeons who are delivering that care after hours. And so, these would be patients who are generally coming in with sort of emergent condition. And oftentimes, those teams for treating those patients, they offer some kind - generally some laparoscopic and minimally-invasive surgery, oftentimes a lot of open surgery.

And so, the ability to have da Vinci as an option there is meaningful to the outcomes of those programs. On the cardiac side, the way that I kind of think about it is, for many years, the interventional side of cardiac intervention, so structural heart and other components from interventional cardiologists have been on the rise and you've seen them offer great outcomes to patients. And we've gone to the point now where I think there's also a set of patients where high-quality, minimally-invasive surgery is great and the best option for them. And so, we're at the point now where we think the technology with DV5 and other parts of our ecosystem, our work with societies, our work with academic institutions and with surgeons who have been doing this around the world, it's the right time for this investment.

It's been growing year-over-year off of a small base and so the need is there. There is patient benefit that is there. And so, we'll line up these investments and continue our journey here for cardiac.

Thanks Dave.

Thank you. And our next question comes from the line of Adam Maeder from Piper Sandler. Your question please.

Hi, good afternoon. Thank you for taking the questions. I'll keep it to one multipart question on force feedback technology. So, I guess the first question is, can you just maybe give us a little bit more color around the percentage of DV5 cases that are using force sensing instruments today?

Remind us the portfolio, how many instruments have this technology, how can that evolve going forward? And then lastly, I saw there was a post-market study. I think it was 200 patients posted to clinicaltrials.gov, evaluating force feedback instruments. So, just maybe flesh out the clinical strategy going forward to validate this exciting technology?

Thank you.

Sure. So, on the force feedback on the number of instruments that currently have the capability enabled that we have six different instruments that were chosen for their - what they do inside the procedure. And so we're looking at components of the procedure that we think would best benefit from force feedback technology. So that's how those instruments were chosen.

In terms of how many today, how many cases are using force feedback. I don't have the number in front of me. There are many thousands of cases that are being done with force feedback, but I don't know the exact number. And when you look forward, I think what you're going to see is like any technology that's being studied you'll see these early single institution studies that we referenced.

And that's where a single surgeon or a group of surgeons can study their results and look at it - look at it within their own institution and against their own data. And then as you look out, you'll start to see cross institute studies. In Intuitive and perhaps other investigators will put together larger studies that will include more patients that could be the one at clinical trials, that you're referencing. But it's a steady progression of data starting from the small and getting to the larger more statistically relevant studies.

And that's when we'll be able to see what force feedback means at scale.

Two comments I'd make here. One is, so far, we're seeing hypothesis that drove the inclusion of force sensing instruments and force feedback technologies start to bear out, better learning for younger surgeons and the right force at the right time during the procedure as being linked to outcome. As you said, those are hypotheses that will be tested over time, but we're going to start seeing those studies progress. On the point of prevalence, how much is being used, just remember, a couple of things.

One is force sensing and non-force sensing instruments can be used on dV5. So Gen 4 instruments can also be used on dV5. And we're supply constrained on force-sensing instruments. So we're not able to meet demand yet. Now we're working hard on that, both from lives in the instrumentation and the manufacturing capacity. So that's coming.

But right now, the answer to what fraction are being used, that's an artificial limitation imposed by our manufacturing constraint.

Next question, please.

Certainly. And our next question comes from the line of Ryan Zimmerman from BTIG. Your question, please.

Thanks for taking the question. I'll stick to one in the interest of time. There's been a lot of discussion on Medicaid cuts and the impact to patients. I don't know, Dave, if you've quantified this or you're willing to put it out there, but I'm going to ask anyway, which is if you were to characterize the payer mix, particularly within the Medicaid population, what you could or could not be exposed to?

And what potentially that impact would be as the government kind of considers this as option? I'd appreciate your thoughts there.

I'd just say it's a healthy mix between private and Medicare depending on the marketplace. I think I'd say it's too early for us to give any specific comments we obviously have discussions with customers. I think much of that is speculation as to how it may play out. But I think it's too early for us to comment, frankly.

Yes. This one on Medicaid, in particular, impact on Medicaid, right, versus Medicare? I think it was...it was...

Yes, that's correct, Gary. Yes. I guess if it were to be amended, what kind of impact would utilization potentially have, particularly for robotics.

Yes. The team has done a little bit of a back of the envelope. I think it's too soon to speculate what that might be. It's not a dominant part of the mix. It's in our procedure mix, Medicaid, but it is not dominant. What that looks like too soon to say.

Thank you.

And our next question comes from the line of David Roman from Goldman Sachs. Your question, please.

Thank you and good afternoon. I wanted just to continue along the thread of potential Medicaid cuts to hospitals. And maybe, Gary, you could expand a little bit on the comment made earlier about Intuitive being potentially part of the solution and not part of the problem. In contrast to kind of the comments that Jamie made or in conjunction with the comments Jamie made about a potentially worsening hospital CapEx environment and some of the factors we need to consider given the external environment?

Yes. Thank you for that. I think it's a great question. Why don't I think we're a part of the solution and just back from the road?

And I think for a well-run program, total cost to treat per patient episode is outstanding, as good as any approach often better, certainly better than open and often better than lap. So I think if hospitals look out at this and say, look, we're going to provide care. This issue - I'm just - one thing they can do is stop giving care. Well, that's a train rank.

So their mission is to provide care. If they have a well-run program, they both get better outcomes, higher physician and surgeon satisfaction and patient satisfaction and lowest total cost to treat in their hands. So of course, there's a whole bunch of different procedures and a whole bunch of different hospitals, but in aggregate, that's a true statement. So they want to do it.

And if they do it, they do better economically. But you have this issue of stress on capital, particularly in some U.S. markets. And the reason that, that stress for them is that the budgets, the operating budgets are not always held by the same budget holder, as the capital budget. So, the operating person is saying, this is going great.

I'm getting really nice returns, but the capital person is being incented by other means. And so Jamie had said in the prepared remarks and he was right, the first thing to do is help them with utilization. And we will. That's what our genesis teams do.

We're happy to help them with analytical tools so they really understand their total cost to treat and what the probability of those programs are. At the same time, if ultimately they need additional capital, that's part the conversation with the other side of the insurance house, which is the one that controls the capital budget. Therein lies some of the stress. So early on, it's go help them with utilization.

Sometimes we can help them with workflow management and also move machines around move systems where they need to. You've seen us do that in our history, back in the day. But in general, I think in many of these economies in many of these countries, high-quality minimally invasive care as provided by da Vinci systems and the like has been fantastic for them. They want to do more or less.

Okay. We are - at our last question, thank you for the questions. 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 it quintuple aims better, more predictable patient outcomes, better experiences for patients, better experiences for their care teams, lower total cost of care; and finally, increased access to 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 in their environment. At Intuitive, we envision a future of care that is less invasive and profoundly better, where diseases are identified earlier and treated quickly, so patients can get back to what matters most. Thank you for your support on this extraordinary journey.

We look forward to talking with you again in three months.

Thank you, ladies and gentlemen, for your participation in today's conference. This does conclude the program. You may now disconnect. Good day.