Intuitive Surgical, Inc. (ISRG) Q1 2026 Earnings Report, Transcript and Summary

Good day, and thank you for standing by. Welcome to the Intuitive First Quarter 2026 Earnings Conference Call. [Operator Instructions] Please be advised that today's conference is being recorded. I would now like to hand the conference over to your speaker today, Daniel Connally, Vice President, Investor Relations. Sir, please go ahead.

Good afternoon, and welcome to Intuitive's First Quarter Earnings Conference Call. Joining me today are Dave Rosa, our CEO; and Jamie Samath, our CFO. Before we begin, I would like to remind you that comments made on today's call may 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 our Securities and Exchange Commission filings, including our most recent Form 10-K filed on February 3, 2026. Our SEC filings can be found through our website at intuitive.com 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 in the Events section under our Investor Relations page. We are experiencing technical difficulties with distribution of today's press release. Note, you can find today's 8-K, including our press release, on our website or at the SEC's website. The Q1 2026 financial data tables have been posted to our website as well. Our format for this afternoon's earnings conference call is as follows: Dave will review business and operational highlights. Jamie will provide a review of our financial results and procedure highlights. I will review clinical highlights and discuss our updated financial outlook for 2026. And finally, we will host a question-and-answer session. With that, I will turn it over to Dave.

Good afternoon, and thank you for joining us. Q1 was a solid start to the year for Intuitive, driven by 17% total procedure growth and broad-based adoption across da Vinci and Ion as customers continue to advance minimally invasive care. In Q1, da Vinci procedures grew 16% to 847,000, and Ion procedures increased 39% to 43,000. Performance was strong in the U.S. and Europe, with mixed results in Asia. In the United States, da Vinci procedures grew 14% year-over-year, led by strength in general surgery. Growth was supported by a 31% increase in after-hours procedures and higher overall utilization. da Vinci 5 utilization continues to exceed that of da Vinci Xi, driving U.S. utilization growth to 4%. Outside the U.S., da Vinci procedures grew 19%, led by continued strength in general surgery and gynecology as adoption expands beyond urology. The lower growth rate relative to prior quarters reflects ongoing challenges in China and Japan. In China, the environment remains largely consistent with recent quarters reflecting relatively low tender activity across the category, domestic competition and policy-driven pricing pressure. Given our belief in the long-term opportunity, we continue to make investments to improve procedure growth, establish favorable patient charge codes and support other market access activities. In Japan, procedure growth improved sequentially, but remained below historical levels following fewer system placements in 2025. We are encouraged by recent policy developments, including incremental financial support for higher-volume robotic programs and new reimbursement for 7 additional procedures. Both policies to be effective starting in June 2026. Jamie will describe these changes in more detail shortly. I have confidence in our ability to execute our international strategy. Investments in our organizational capabilities, clinical trials and research, and market access efforts are yielding supportive robotic surgery policies and reimbursements in many of the countries we serve. The arc of progress is evident with OUS procedures now representing 38% of total da Vinci volume, up from 25% a decade ago. We are well positioned to expand access and drive deeper adoption in these countries with the addition of XiR to our system portfolio, and our overall ecosystem of technologies, training and services. Turning to capital. We placed 431 da Vinci systems in Q1, including 232 da Vinci 5 systems, 34 SP systems and 34 XiR systems. We also placed 52 Ion systems in the quarter. As da Vinci 5 moves into broader clinical use globally, customer adoption and feedback remain very encouraging. Customers are building experience with the da Vinci 5 ecosystem, resulting in increased clinical throughput and expanded access to da Vinci surgery. At the recent annual SAGES conference, several clinical abstracts demonstrated objectively lower tissue forces using da Vinci Force Feedback instrumentation across multiple procedure types. We continue to believe that objective knowledge of applied forces in surgery will lead to improved surgical outcomes and are investing to demonstrate this at scale. In March, we received FDA 510(k) clearance for additional uses of our Force Feedback instruments. Five of 6 instruments are now cleared for 15 uses, while our Mega SutureCut Needle Driver is cleared for 10 uses. Combined with multiyear investments in supply chain and manufacturing, this clearance supports broader availability in Q2 that will increase over the rest of the year. We expect adoption of Force Feedback instrumentation to progress steadily through 2026 and beyond. Turning to our digital ecosystem. We continue to invest in the data and digital infrastructure that underpins our longer-term innovation road map. da Vinci 5 captures real-world surgical data at greater scale and fidelity, enabling deeper insight into how procedures are performed in practice. That insight paired with clinical context from connected electronic medical records, provides better understanding of variation, workflow and outcomes, and informs current and planned digital and AI-enabled capabilities. My Intuitive+ continues to play an expanding role in training and program support, with growing adoption of Intuitive Telepresence capabilities that enable proctoring, mentoring and collaboration across surgeons and sites. Collectively, these efforts are foundational to our long-term digital and AI road map where we expect to add telesurgery, deeper decision support and augmented dexterity, including aspects of future automation, all in pursuit of advancing the Quintuple Aim. I'm excited by the progress our development teams are making. Turning to our Single Port Platform. SP momentum continued in the quarter with procedures growing 68% year-over-year. Growth was driven by expansion in Korea and the U.S. and ongoing early adoption across select international markets. Recently, U.S. surgeons performed the first non-IDE nipple sparing mastectomy cases as we advance our measured rollout focused on training and support of our customers. We also moved our single-port stapler into broad launch, which will support deeper penetration in thoracic and colorectal procedures as customers expand their programs. Our teams are focused on new product and procedure launches, expanding our customer base and securing new geographic clearances. Over the midterm, SP will incorporate much of the da Vinci 5 ecosystem, including current and future digital and AI capabilities. We're excited about the potential of SP to drive meaningful improvement in the Quintuple Aim. Moving to Ion. We're pleased with the results and progress this quarter. Ion's North Star is to help physicians improve lung cancer patient survival. Clinical publications continue to reinforce progress here, including a recent Mayo Clinic publication of approximately 2,000 patients, which demonstrated that use of Ion supports earlier identification of malignancy with the potential to improve patient survival. Dan will walk through the study in more detail later in the call. Our teams are making progress on our rapid on-site tissue evaluation technology, or ROSE, and endobronchial ultrasound integration as we look to further streamline the time from detection to diagnosis. Looking ahead, our company priorities for 2026 are unchanged. First, the global expansion of our platforms, digital feature releases and ecosystem enhancements. Second, increased adoption for focused procedures by country through training, commercial activities and market access efforts. Third, building industrial scale, enhancing product quality and achieving manufacturing optimization. And finally, advancing innovation to reach more patients in current and new disease states. Before I turn the call over to Jamie, I want to recognize an important leadership transition at Intuitive. Dr. Myriam Curet is retiring this quarter after more than 20 years as Intuitive's Chief Medical Officer. I'd like to thank Myriam for all her efforts in advancing our mission as a physician, a patient advocate and a business leader. I'm also pleased to announce Dr. Jamie Wong's promotion to Chief Medical Officer and member of our executive leadership team. Jamie provides -- combines a deep clinical background as a practicing da Vinci urologist with his experience of more than a decade at Intuitive, leading a variety of functions. As CMO, he will lead our global medical office, overseeing customer training, clinical evidence generation and research, and reimbursement and market access efforts. And with that, I'll turn the time over to Jamie to take you through our finances in greater detail.

Good afternoon. I will describe our performance on a non-GAAP basis, and I'll summarize our GAAP results later in my remarks. A reconciliation between our non-GAAP and GAAP results is available on our website. All references to total procedures and their related growth rates include both da Vinci and Ion procedures. Before detailing our quarterly results, I would like to briefly address the cyber incident that occurred during the first quarter, which resulted in unauthorized access to some customer business and contact information as well as certain Intuitive employee and corporate data contained in certain of our IT business applications. The incident did not disrupt our business or manufacturing operations and did not affect our products. It also did not have a significant impact on our first quarter financial results. We have contained the incident, notified customers and informed appropriate data privacy regulators. We are also taking additional steps to further strengthen our cybersecurity protocols. In Q1, total procedures grew 17%, reflecting 16% growth in da Vinci procedures and 39% growth in Ion procedures. Quarter 1 revenue increased 23% to $2.77 billion, with recurring revenue also higher by 23% to $2.4 billion, accounting for 86% of total revenue. On a constant currency basis, revenue growth was 22%. Non-GAAP operating margin was strong at 39%, primarily reflecting leverage of fixed costs. The strength of our financial results reflect the continuing global expansion and procedure adoption of our da Vinci 5, Ion and SP platforms. Turning to the clinical side of our business. In the U.S., total procedures increased 15%, reflecting 14% growth in da Vinci procedures and 37% growth in Ion procedures. For our da Vinci platforms, we continue to see strong growth in cholecystectomy and appendectomy procedures, which combined grew by 31%, driven in part by continued expansion of use of da Vinci during after-hours and on weekends. We are starting to see emerging evidence that a broad set of clinical outcomes for appendectomy are improved with da Vinci surgery as compared to laparoscopy. Over the last year, in the U.S. we've invested in incremental clinical support for surgeons performing benign gynecology procedures given the opportunity to improve patient outcomes. While total U.S. gynecology procedures grew 10% in Q1, investments in this area drove a 19% increase in non-hysterectomy benign procedures, including sacrocolpopexy, endometriosis, oophorectomy and myomectomy during the quarter. da Vinci bariatrics procedures in the U.S. continue to be impacted by the growth in use of GLP-1s and declined approximately 10%. da Vinci utilization in the U.S. increased 4% in Q1, higher than recent quarters, driven by a growing installed base of da Vinci 5 systems, where utilization is approximately 11% higher than Xi. With respect to the expiration of subsidies for enhanced premiums under ACA, while we did not see any significant impact on procedure volumes in Q1, at this time, we remain cautious as to what the potential impact, if any, might be. Outside the U.S., total procedures grew 20% with da Vinci procedure growth of 19%, reflecting strong results in India, Canada, the U.K., Korea and Taiwan, and solid growth in distributor markets, Italy and Germany. The market in China continued to be challenging. In Q1, procedure growth was below the corporate average, reflecting lower tenders and competitive and pricing pressures. There are ongoing discussions with provinces regarding potential new charge code and reimbursement policies in China for robotic procedures. We are actively engaged with policymakers but do not expect clarity on the outcome of these matters until 2027. Procedure growth in Japan was also below the corporate average, reflecting lower capital placements over the last several quarters. In Q1, the Japanese Ministry of Health, Labor and Welfare, or MHLW, recently introduced incremental reimbursement for hospitals that exceed robotic procedure volumes of 200 qualifying cases per year. In addition, 7 new procedures have been granted robotic reimbursements starting in June of 2026. Furthermore, rectal resection has been granted premium reimbursement when performed robotically. While we are encouraged by these steps, we remain cautious in our outlook for the Japanese market in the short term given the financial position of public hospitals in recent periods. Globally, we continue to see healthy procedure growth for our SP platform at 68% for Q1 with strength in Korea and continuing robust early-stage growth in Europe, Japan and Taiwan. In the U.S., SP's average system utilization continued to accelerate following recent additional clearances, growing 22% as compared to quarter 1 of last year. During the quarter, we moved our new SP stapler into broad launch in the U.S., where it was used in almost 40% of cases where we would expect a stapler to be used. We are planning to move the SP stapler into measured launch in Korea and Europe in Q2 as we expand manufacturing capacity. As a result of our clinical performance, total I&A revenue in quarter 1 grew 23% to $1.7 billion. da Vinci I&A revenue per procedure was approximately $1,880 compared to $1,780 last year, driven by customer ordering patterns, a higher mix of SP and da Vinci 5 procedures and FX, partially offset by lower bariatric and high cholecystectomy procedures. Turning to capital performance and starting with our da Vinci business. We placed 431 da Vinci systems in quarter 1, a 17% increase from the 367 systems placed in the same quarter last year. 232 of the 431 placements were da Vinci 5, including 40 in OUS markets. The installed base of da Vinci 5 is now almost 1,500 systems used by almost 13,000 surgeons since launch. Customers acquired 34 refurbished Xi systems in Q1 compared to 2 in the year ago period. 26 of the 34 placements were in OUS markets in segments where we see greater cost sensitivity. There were 119 trade-in transactions in quarter 1, up from 67 a year ago, primarily driven by U.S. customers upgrading to da Vinci 5. In the U.S., we placed 226 systems, up from 204 last year, driven by adoption of da Vinci 5. Outside the U.S., we placed 205 systems, an increase of 26% compared to the 163 systems placed last year. OUS placements included 117 systems in Europe, 62 in Asia and 26 in the rest of the world compared to 88, 52 and 23, respectively, last year. Relative strength in Europe was driven primarily by the U.K., where we placed 34 systems as the NHS closed out its budgetary year. We placed 13 systems in Japan and 4 systems in China, reflecting lower overall tender volumes. Within the 431 da Vinci placements, we placed 34 SP systems in Q1, higher than the 19 systems last year, driven primarily by increased placements in the U.S. and Taiwan. For our Ion platform, we placed 52 systems in Q1 compared to 49 systems last year. Q1 Ion placements included 13 systems in OUS markets. Given our capital performance, quarter 1 systems revenue grew 24% to $651 million. For our da Vinci business, leasing represented 56% of da Vinci placements as compared to 47% last quarter and 54% last year, driven primarily by customer preference. da Vinci leasing revenue increased 28%, reflecting a 14% expansion of the installed base under operating lease arrangements and a 12% increase in lease revenue per system, driven by a higher mix of da Vinci 5 systems and higher utilization for usage-based arrangements. The average selling price for purchased da Vinci 5 systems was $1.7 million in Q1 as compared to $1.6 million last year, driven both by a higher mix of da Vinci 5 systems and dual-console systems, partially offset by higher trade-ins. Lease buyout revenue was $51 million as compared to $39 million last quarter and last year. Quarter 1 service revenue increased 19% to $434 million, reflecting an increase of the da Vinci installed base of 12% and the Ion installed base of 22%. Service revenue per system for our da Vinci installed base increased 6% year-over-year, primarily reflecting a higher mix of da Vinci 5 systems. Turning now to the rest of the P&L. Non-GAAP gross margin for the quarter was 67.8%, an increase from 66.4% in Q1 of last year. The year-over-year increase reflects product cost reductions and fixed overhead leverage, partly offset by the impact of tariffs. While Q1 results were not significantly impacted by higher oil and memory prices, we do expect those to have a greater unfavorable impact in the remainder of the year. During the quarter, our da Vinci 5 system achieved contribution margins comparable with our Xi system, and our Ion platform achieved contribution margins that are close to the corporate average, reflecting significant efforts by our engineering and operations teams. Continuing initiatives to further improve gross margins, excluding the impact of tariffs, are focused on leverage of fixed overhead, improving product and service margins for da Vinci 5 and additional reductions to product costs for our SP and Ion platforms. Future gross margins will reflect our execution on these initiatives, competitive pricing dynamics, global tariff rates and product, regional and trade-in mix. Quarter 1 non-GAAP operating expenses increased 10% year-over-year, a little lower than our expectations due to the timing of certain expenses. The year-over-year increase was driven by higher headcount, increased variable compensation and higher facility costs, partially offset by lower legal expenses. We added 425 employees during the quarter, of which 230 were related to the acquisition of our distribution business in Italy, Spain and Portugal. Non-GAAP other income was $85 million for the quarter as compared to $86 million last quarter, reflecting lower interest income. Our non-GAAP effective tax rate for quarter 1 was 22%, consistent with our expectations. Non-GAAP net income for the first quarter was $901 million compared with $662 million last year. Non-GAAP earnings per share was $2.50 per share as compared to $1.81 per share in quarter 1 of last year. Now turning to our GAAP results. GAAP net income for the quarter was $822 million or $2.28 per share compared to $698 million or $1.92 per share in Q1 of last year. We ended the quarter with $8 billion in cash and investments, down from $9 billion last quarter, driven by stock repurchases of $1.1 billion, the acquisition of our distributor business in Italy, Spain and Portugal, and capital expenditures of $103 million, partially offset by cash generated from operating activities and proceeds from employee equity activity. Taking a moment to recap our recent financial performance, a core element of our strategy focuses on excellence in product innovation to launch highly differentiated products that drive the Quintuple Aim for the benefit of customers and patients. Revenue growth ahead of total procedure growth reflects, in large part, the differentiated value of da Vinci 5. As that new platform becomes a greater proportion of our business, revenue growth benefits from accretive pricing, higher levels of integration and incremental trade-in volumes. We see opportunities to continue to drive innovation-led revenue performance with our SP stapler, planned SP vessel sealer and growth in use of existing and planned AI and digital capabilities. We also have plans to increase the value of our Ion platform in the lung through our pursuit of a staging indication and the integration of AI-based ROSE technology. With that, I'll turn it over to Dan to discuss recent clinical publications and our updated outlook for 2026.

Thank you, Jamie. Earlier this month, Dr. Sebastian Fernandez-Bussy from Mayo Clinic in Jacksonville, along with co-authors across Mayo Clinic sites in Jacksonville, Phoenix and Rochester, published a study in Mayo Clinic Proceedings titled 2000 Peripheral Pulmonary Lesions Sampled by Shape-Sensing Robotic-Assisted Bronchoscopy and Mobile Cone-Beam Computed Tomography: The Mayo Clinic Experience. In the study, which ran from July 2019 through August 2024, 12 proceduralists used Ion to biopsy 2,115 peripheral pulmonary lesions from 1,904 patients. Lesions biopsied were an average size of just under 18 millimeters, with more than half located in the upper lobes at a median distance of 17 millimeters from the chest wall. Diagnostic yield according to the recently published strict ATS/ACCP Consensus Statement definition was 79% with sensitivity of malignancy reported at 85%. Further, 74% of patients had concurrent endobronchial ultrasound lymph node staging with the authors noting, "The ability to perform diagnosis and staging within the same anesthetic event reduces the risk of repeated interventions, facilitating lung cancer diagnosis and advanced disease management." Additionally, results demonstrated a strong safety profile with a pneumothorax requiring intervention rate of 1.4% and severe bleeding defined as Nashville Grade 3 or higher of 0.3%. Notably, the rate of early-stage primary lung cancer diagnosis in the study increased by 23 percentage points from 46% in 2019 to 69% in 2024. The authors concluded, "In this high-volume multi-center 5-year study, shape-sensing robotic-assisted bronchoscopy has shown a consistently optimal diagnostic yield with low complication rates. To our knowledge, this is the largest cohort assessing shape-sensing robotic-assisted bronchoscopy following the recent strict consensus on diagnostic yield. The ability to sample multiple peripheral pulmonary lesions and include hilar and mediastinal staging within the same anesthetic event positions shape-sensing robotic-assisted bronchoscopy as the preferred method of choice over CT-guided thoracic biopsy for assessing suspicious peripheral pulmonary lesions." I will now turn to our updated financial outlook for 2026, starting with da Vinci procedures. In January, we forecast full year 2026 da Vinci procedure growth to be within a range of 13% to 15%. We are increasing our forecast and now expect full year da Vinci procedure growth within a range of 13.5% to 15.5%. We continue to expect primary growth drivers in 2026 to be generally consistent with those in 2025, including general surgery in the U.S. and procedures outside of urology internationally. Our updated range continues to consider the potential impact of changes to ACA premium subsidies and patient behavior in the U.S., capital pressure in parts of Europe related to macroeconomic impact and shifting governmental priorities, China's tender volumes and competitive intensity in that market, recent capital challenges in Japan and how long those persist in 2026, and pharmaceutical products for obesity management. Turning to gross profit. On our last call, we forecast non-GAAP gross profit margin to be within a range of 67% and 68% of revenue, which reflected 120 basis points of impact from tariffs. We are updating our estimate for non-GAAP gross profit margin to be within a range of 67.5% and 68.5% of revenue, which now reflects 100 basis points of impact from tariffs as well as higher input costs in other areas, including freight and semiconductor memory. Other factors for the year include faster growth of newer products in daVinci 5 and Ion, modest incremental depreciation from recent facility expansion and the impact from higher da Vinci system upgrades, partially offset by cost reductions. Our actual non-GAAP gross profit margin will vary quarter-to-quarter depending largely on product, regional and trade-in mix and pricing. In regard to operating expenses, we now expect non-GAAP operating expense growth to be between 11% and 14%. We continue to estimate noncash stock compensation expense between $890 million and $920 million. We now forecast other income, which is comprised mostly of interest income, to total between $315 million and $335 million due primarily to lower average cash balances following share repurchase activity in Q1. With regard to income tax, we continue to expect our non-GAAP income tax rate to be between 22% and 23% of pretax income. That concludes our prepared remarks. We will now open the call to your questions.

[Operator Instructions] Our first question will come from the line of Travis Steed with Bank of America.

Congrats on a good quarter. Maybe to start, I kind of want to talk a little bit about some of the future. You talked a lot about data and digital infrastructure, augmented dexterity. Just kind of curious how you see the digital and data road map for Intuitive. And there's also some hints on biopsy and the ROSE acquisition. So I'd love to kind of hear your big picture view of how that kind of plays out and anything you can say on timing?

Yes. Happy to do it, Travis. Thank you for the question. So I'll start with AI. And I'm really -- and you asked the question, but I'm going to speak specifically about AI as it shows up in our products and with our customers and not so much AI on the corporate side. And so if -- when we look at AI, it's like any other product, and it's really through the lens of the Quintuple Aim and will it advance outcomes and reduce variation, improve certain patient experiences, lower total cost, advance access for patients around the globe. And we believe, yes, that AI will be a contributor to moving the Quintuple Aim forward. And our approach here is what we've described in the past. And it's really to build kind of this layered capabilities. And it starts with high-quality data, and that data will exist in video data from surgeries. It will exist in robotic data streams like kinematic data and force data. It will exist in connected electronic medical records, where we're working with customers to do so. And once we have that high-quality data set, then the job of our AI and our data scientists is to turn that into meaningful insights. And once we have those, I think the critical part here is how do we deliver those to the customer and it has to be in a consumable fashion, it has to be at the right time in the moment that matters to the customer. So there are, I think, ways in which this will show up to the customer. Some will be as operational guidance and assistance as they look at their hospital robotic program and want to increase efficiencies or understand costs. Some of it may show up in the learning of a surgeon and/or a care team. But a lot of it will show up in the operating room and I think show up in the surgery itself. And an example of this kind of first phase might be AI-enabled anatomy identification where you can see AI showing critical structures in the surgical field, showing tissue planes to help assist the surgeon. Then, over time, what we expect is that many of those same foundations that are being established and built in kind of that first phase, if you will, will support more advanced assistance around augmented dexterity and it will include -- likely include aspects of automation. There, an example might be helping to control the camera as the surgeon is focused on the procedure. And so throughout this, every step, it's about clinical value, of course, and it's about safety and reliability, and not just doing this in a one-off but doing this in a scaled fashion. And so if I look at that as the layer that we're progressing through and I look to see where -- how do we sit, how do we exist within the AI ecosystem and how are we differentiated? I think part of that differentiation is around the installed base of systems that we have out there, including about the 1,500 da Vinci 5 systems, the 3 million and more procedures that are being done on an annual basis. And I believe that gives us the foundation to strengthen the differentiation over the next 3 to 5 years. If you look at the industry and you say, what is broadly available, broadly available to everyone, it's things like edge and cloud compute, the math that underscores much of this, some of the training algorithms. Our advantage, we believe, lies is in the unique data sets that are available to us today through something like Force Feedback and will be increasingly available to us as we add capability to da Vinci 5. And so all of that together creates this flywheel. It's a flywheel that starts with data, insights, actions. Advancing the Quintuple Aim, the flywheel spins, it becomes that virtuous cycle. And we have the teams focused on it, and we are investing to advance this in the future and look forward to updating you along the journey.

That's exciting. Can't wait. Maybe my follow-up question, Jamie, on margin. You highlighted some macro stuff, but still raised gross margin 50 basis points and tariffs only came down 20 basis points. So I guess the contribution margin of dV5 comparable to Xi, a nice positive for margins. But kind of curious kind of what you saw in the macro and what you kind of baked in on that front? And any color on kind of what percent of COGS you'd call chips and exposure to oil and resin?

Yes. I'd just say for oil prices and the derivative impact that has on input prices and logistics costs and memory, based on what we know today, in the gross margin guidance, it has an impact, but it's relatively small. I think what you see in Q1, in particular, is relatively significant leverage from the 23% revenue growth and a really nice contribution from the product cost reductions that we've described. So the macro is having an impact. And obviously, we're watching it carefully and you also have to watch the potential supply constraints. But the macro is baked in and relatively small, just given the components of our product costs.

So Travis, real quick, you had asked about ROSE and EBUS and just some color there. So both are known technologies. And the time lines are more short term, but they won't be this year. We do believe that they are bringing a truly significant differentiated value to the lung cancer diagnosis -- detection and diagnosis journey and expect to share that value with customers. And so as that gets closer, we'll let you know more about it.

[Operator Instructions] Our next question will come from the line of Larry Biegelsen with Wells Fargo.

Congrats on a good start to the year here. I had one on procedures, and then I had one follow-up for Jamie. So I'd love to hear you talk about the appendectomy opportunity. It looks like about 300,000 per year. It's one of the first times I've heard you call that out on an earnings call, 300,000 per year in the U.S. And if you could size the incremental Japan opportunity from those new procedures, that would be great. And I had one follow-up.

Yes. We haven't sized appendectomy yet. I think there's a question of what makes sense in terms of the robotic portion of that overall TAM because we're so early in appendectomy, we're still kind of working through internally on what we think is the right opportunity. We called out the kind of emerging evidence on clinical outcomes just because over the quarter, actually, we've had a couple of engagements with surgeons that have kind of done work in their own institutions. And we saw several of those come together. And across the set of functional outcomes in the work that they did, da Vinci was better on all comparison points, which we thought was encouraging. We'd like to see that show up in clinical studies that have larger data sets in terms of number of patients, but we think that's super interesting for what is typically a relatively quick procedure with relatively low reimbursements.

And Japan?

On Japan, I think we noted MHLW added reimbursement coverage for 7 procedures across a couple of different categories. The largest of those is bilateral inguinal hernia repair. Reimbursement there is roughly $1,500 per procedure. I think in aggregate, it's too early for us to size the incremental procedure opportunity in Japan. But the impact is relatively modest, and like in prior periods where we've had incremental reimbursement, it will take time to develop.

Jamie, I'd love to maybe flesh out more what you meant by innovation-led revenue growth. This is the first time I've heard you talk about that. Is there any way to frame how much faster revenues will grow versus procedures. In Q1, it was obviously 23% versus -- 17%, I'm sorry. Do you expect that delta to increase going forward? Maybe just talk about the implications of this innovation-led revenue growth.

Yes. I really felt like it was worth describing because if we look back at last year, even revenue growth was 21%. And obviously, procedure growth was also lower than that last year. And then you see the numbers in Q1. The business framing we have is kind of what I described as a push and pull. We're very conscious about deploying our R&D to places where we can be differentiated and make a difference on the Quintuple Aim that's integrated in how we make R&D deployment decisions. And so where you can be differentiated and make a resale difference for customers, then -- and create value for them, then you get to sharing that value in the form of on the Intuitive side, accretive pricing or incremental pricing. And we see that in da Vinci 5, you see that actually in SP I&A and there are other areas where we have that opportunity. On the other side of it, if you look at the totality of our business, there, of course, are procedures and geographies that are more cost sensitive. And so we also then look for -- as we work on bringing our costs down, particularly our manufacturing and product costs, we also look for opportunities to then share that cost savings with our customers because they have economical cost sensitivity. And we do that particularly in mind with what can be the elasticity response when it's cost sensitive. And so we work on both of those. And therefore, that creates a mix dynamic between the 2. In terms of like how long does it sustain? I don't think I want to get into that just because we don't guide revenue, it's really our attempt to just describe what's happened in recent periods with respect to the difference between revenue growth and procedure growth. And I think we're just reemphasizing the fact that innovation is critical to our success.

[Operator Instructions] Our next question comes from the line of Robbie Marcus with JPMorgan.

I'll add my congratulations on a really nice quarter as well. Two for me. First, the utilization continues to just be really impressive, especially with the after-hours metrics and the utilization improvement on da Vinci 5, which is now becoming a pretty substantial part of the installed base. I was hoping you could just add a little more color there in terms of how much more is there to go? Because I think everyone knows that utilization and procedure volume growth ultimately is what drives placements. So how much more is there to go? And how do you think about that translating into unit growth down the road? How much and when, if you're willing to quantify?

That's -- in some regards, that's the impossible question to answer in the following sense, Robbie. It really -- you have to be aware of the averages, and you have to look at it by market in terms of where is the distribution of utilization within any given market, what's the mix of systems they have in any given market. From a macro perspective, we are strategically aligned with customers that we want to increase robotic throughput because we think that serves them well economically and is good for Intuitive long term. So it's a difficult question to answer. There are markets where there's obviously room to improve utilization such as Japan and some of the European markets. In the U.S., I think utilization growth will mostly be driven by the rate by which the entire installed base in the U.S. switches over to da Vinci 5, which we think structurally has the ability given its feature set to run higher levels of utilization in Xi. For us, we'd like to keep utilization growth going because we think it's supercritical and differentiates us, I think, from competitors also. But I don't think we have the ability to call how long it goes and what the derivative impact is.

I know it's a hard question. That's why I'm asking you. I'm hoping you could do my job for me a little bit. Maybe just a follow-up. We have more and more competitors trying to enter the market here, some in the U.S. from big surgical competitors, some in China, others in Europe, you now have the opportunity to offer a tiered pricing strategy with refurbished Xis. It'd be great just to get a refresh on how you're thinking about global competition at different price points in different markets and how you're feeling about your positioning there?

Yes, Robbie. So I think we've -- competition is about, I think, meeting the needs of the customer at the right price point. And so it's really about the value that they're going to obtain for getting a robotic program established and treating patients and getting to great outcomes. And so what we know is that the basis of competition, we are wanting to make sure that people look at it not as the kind of the price you pay for the robot and the fact that now you have it in one of your ORs, but it's really the value of your program. How are patients being treated? Are you seeing the outcome improvements? Are you seeing a shift in the mix of open surgery to minimally invasive robotic procedures that you expected in any of the other strategic initiatives that a given customer might have? And so that's where and how we want to ensure that we are entering the conversations with customers and helping educate them around the globe about the questions they should be asking, what kind of data should they be looking for as they engage one or more robotic competitors from around the globe. And when it comes to those conversations and the data that are shared, I expect with our portfolio and now with XiR added, that will be a strong choice to lead in those value because of the demonstrated clinical output, the reliability of our systems, our ecosystem of services and training that can support them on their journey. And so that is, I think, the high-level picture of how we compete globally. Jamie, anything else you may want to add to that.

I would just say we're still selling X, and actually, we sold 41 X systems in the quarter, 34 refurbished Xis. And then, of course, we have dV5, I think the segmentation there is really appealing. And in some sense, is a competitive advantage for us to be able to tier feature the capability and economics for various segments of our customers. The refurbished Xi like Dave said, if I'd just say it again, that is a very capable product. It has the full complete suite in the ecosystem and the economics for customers are really attractive. And so I think that's been a great kind of addition to the system portfolio.

[Operator Instructions] Our next question will come from the line of Rick Wise with Stifel.

Sorry for my scratchy voice here. One, a specific question for Jamie and then a bigger picture question for you, Dave. Jamie, just help us, if you could, better understand what dynamics internationally drove I&A at double the rate of procedure growth. I mean it's -- obviously, it's a big delta of 40% OUS I&A versus 19% OUS procedure growth. Was there anything onetime there or country specific? And is this dynamic -- should we imagine this dynamic continues?

I have not looked at that deeply for OUS specifically, Rick. I do think the customer ordering pattern is likely a good chunk of that because all of our distributors obviously are international, and they can be pretty lumpy in terms of their kind of ordering patterns. They can place orders for several quarters. So I'd imagine that the greatest impact is that. And I think given the strong capital placements, we probably had a bunch of stocking orders that also benefited Q1. And finally, there is a benefit from FX.

Got you. All right, Jamie. Dave, for you, just as we get ready for some upcoming robotic meetings and I reflect on some of the topics that are going to be discussed and presented. I was hoping you maybe would sort of step back and looking longer term, talk about a couple of initiatives that others are focused on. And to what degree is this important to Intuitive Surgical? Like telesurgery robotics. We saw the first promote procedure done recently. The value of robotics to stroke or a minimally invasive cardiovascular disease. And just again, at the highest level, your interest or passion or focus on areas like that, that might be future drivers of growth for Intuitive.

I really appreciate the question, Rick. If I stand back and I think about adding incremental capabilities to our ecosystem, it is about where, one, number 1, we can drive the Quintuple Aim. Number 2, whatever it is, we think will be better in our hands. And so to -- for example, some of the things that you called out on telesurgery, I actually -- I really believe deeply in the collaboration capabilities of these telestration, telecollaboration tools. And we are seeing some pretty rapid utilization of our current platform with My Intuitive+, and we're seeing thousands of use cases a month. And so that is, I think, demonstrating stickiness and value with our customers. As we expand those capabilities and it will include telesurgery in the future, that is on our road map. We expect that to be a subset of those use cases. And I -- just yesterday, I was with a customer here and we were speaking to their expectation of how telesurgery will be deployed within their IDN, within their small set of hospitals, and I think there's real value there, though we do believe that a majority of the use cases when telecollaboration is warranted will likely be served by existing tools with telestration and audio/video interactions. And it will, if you will, kind of escalate to telesurgery in certain use cases. So I do think that's an important part of our future in what customers will find value in. Recently -- semi-recently, we've announced kind of our investment into cardiac and cardiac surgery. And there, again, I believe that there's going to be a set of patients who can benefit from minimally invasive cardiac surgery and a set of patients who will benefit from percutaneous transcatheter approaches. And the evidence shows that, in some cases, surgery is better, and in some cases, an interventional approach is better. And when surgery is warranted, then I think the investments we're making, capabilities of da Vinci 5 and our investments in training, in particular, will pay dividends and have an opportunity for surgeons to treat patients with a very minimally invasive cardiac approach to their disease. And there are others, you mentioned stroke. That is an interesting area. But there are plenty of areas that I think about in terms of adding capability and procedures and value to Intuitive and to the patients that our customers serve. One of the trends over the year that I've been just kind of fascinated by is how surgeons take the core capabilities of a platform like da Vinci and apply them into areas that we didn't envision that it wasn't an area that we investigated and that's been repeated over and over. And that -- and I believe, with da Vinci 5 capabilities that exist today and as we add more in the future, we're going to see that cycle continue. And we're going to see surgeons and we're seeing it already, say, hey, we think there is value in these areas that aren't currently served. And so I'm excited by some of those opportunities. We'll do the work to see if indeed there's true value there, and it can be scaled and repeatable and teachable. But it's an area that I look forward to updating you along the way.

[Operator Instructions] Our next question will come from the line of David Roman with Goldman Sachs.

Maybe you could start on SP. And it looks like a lot of pieces are coming together here to support further adoption of that technology, whether that's additional clearances from a procedure standpoint or additional instrumentation. Maybe just give us a sense of kind of where we are in bringing SP to a point where that adoption curve can accelerate, whereby that becomes a more just meaningful percentage of places? And I guess, if you could also contextualize that, is that additive to the overall addressable procedure market? Or does it become a choice of a typical dV5 procedure or SP?

Yes. I guess I would say, if you look at the kind of procedure growth over the last year or so, it's been strong, 68% this last quarter. And that strength has been in part driven by additional geographical clearances and additional procedure clearances, particularly in the U.S. And so I think that, that then continues over some period. It's not that it suddenly inflects and accelerates from where it is. I think we continue that kind of progression on some reasonable pace. If you look at the question of long term, what are the incremental opportunities that are different from multi-port? That multi-port is not going to serve and therefore, in effect are TAM expanding. I think those opportunities exist. Nipple-sparing mastectomy is a good example of that. And obviously, that's in an early stage. You have some work being done to see if SP is better than alternatives, including multi-port. And of course, that's been largely in exchange between one stream or one set of procedures that we have to another. There's work in our labs that's super interesting for additional disease states that aren't served today that TAM expanding. It's too early for us to discuss because our current focus is on the opportunity we have. We have still a long way to go in each of the markets where we're cleared and for the new indications that we've added. And so like the next year or 2 is -- that's where our focus is. But I think the long-term opportunity for SP is perhaps a little underestimated.

That's helpful. And I appreciate. It's hard to get into all the detail on a call like this regarding just your OUS strategy given the number of different geographies and moving pieces. But maybe just at a high level, you could help us think about the number of actions you've taken here. You acquired distributors in Europe. You have the XiR opportunity. You have a joint venture in China to go after that market. But how are you prioritizing markets outside the U.S.? And what is, broadly speaking, the strategy here just to ensure competitiveness as new lower-cost entrants approach the market, but also contrasted with things like favorable reimbursement clearances in the U.K., which occurred last year. Maybe just help think about how OUS evolves here a little bit over the course of '26 and how that contributes to your forward outlook here.

David, for me, you sort of answered your own question, I think. It is all of the above, right? Our investments start with the people we have in the region and to ensure that they understand deeply, are well trained, of course. The investments we have in our products, including an expanding system portfolio, ensuring that the procedures that are being served in that geography have the right rest of the ecosystem cleared in that geography. That's another piece of the puzzle as we continue to innovate and bring new products to the market, we want to ensure those are available as well. So there are regulatory pathways. And so we have the portfolio of products that are required in a given geography. Then, what we want to do is ensure to the very best of our ability that they are priced appropriately for the value they bring. And so we have broad economic programs and pricing that we're able to tailor to the market. But what we want to do, and I mentioned this briefly before, is we want to ensure that the value that's being realized is able to be articulated and substantiated in a given geography. That is not just all about price. And so that's a piece of the market access effort that goes into ensuring our customers themselves understand the value, but also that the reimbursement in government agencies that drive the overall economics of a given country also understand the value. And that's a multiyear journey. So you get it from both sides, kind of the products and pricing, but also the value being realized by both customers and the government. And that is a geography-by-geography amount of work and that's years in the making around the globe.

Maybe I'd just add. In each of the markets, we take a localized approach to how we engage, what our strategy is there. And each of those markets has a strict strategic plan, and that results in us investing differentially in each of those markets. For OUS, as you've seen, we'll go direct in markets already where we think the opportunity makes sense for us. And there may be instances where we start to look in large markets, some localized manufacturing, which is becoming increasingly important for some of those markets. I think the final thing I'd say is, we have ambitions internationally, just given we're earlier in penetration. And over time, there may be additional markets that we franchise with distributors that we don't do business in today.

Okay. That was our last question. Thank you for all 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 the Quintuple Aim, better and 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 and their needs and their environment. At Intuitive, we envision a future of care that is less invasive and profoundly better, where diseases are identified earlier and treated quickly so patients can get back to what matters most. Thank you for your support on this extraordinary journey. We look forward to talking with you again in 3 months.

This concludes today's conference call. Thank you for participating, and you may now disconnect. Everyone, have a great day.