Intuitive Surgical (NASDAQ:ISRG) held its second-quarter earnings conference call on Thursday. Below is the complete transcript from the call.
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Summary
Intuitive Surgical reported a solid Q2 performance with a 19% increase in revenue to $2.89 billion, driven by a 16% increase in total procedures and a 19% rise in recurring revenue.
The company saw strong global adoption of its Da Vinci and Ion platforms, with Da Vinci procedures growing 15% and Ion procedures growing 36%.
Intuitive Surgical placed 468 Da Vinci systems and 55 Ion systems, reflecting robust customer demand, especially for the Da Vinci 5 systems.
International markets showed strong procedure growth, notably in Europe and Asia, while challenges persisted in China due to increased competition and pricing pressures.
Intuitive Surgical is advancing strategic initiatives, including the Extended Use program to reduce costs and the development of a next-generation flexible robotic endoscope system.
The company expects Da Vinci procedure growth for 2026 to be between 13.5% and 15.5%, maintaining a strong outlook despite challenges in some markets.
Management indicated a focus on R&D and innovation to enhance the capabilities of their platforms and expand access to robotic-assisted surgery globally.
Full Transcript
OPERATOR
Good day and thank you for standing by. Welcome to the Intuitive Surgical Q2 earnings conference call. At this time, all participants are in a listen-only mode. After the speaker's presentation, there will be a question and answer session. To ask a question during the session, you'll need to press star 11 on your telephone. You will then hear an automated message advising your hand is raised to ask a question. Please press star one again. Please be advised that today's conference is being recorded.
I would now like to turn the conference over to your speaker for today, Dan Connolly. Please go ahead.
Dan Connolly
Good afternoon and welcome to Intuitive Surgical's second quarter 2026 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, and Form 10-Q filed on April 22, 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. This conference call will be available for audio replay on our website in the Events section under our Investor Relations page. We have posted today's press release and supplementary financial data tables to our website. 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'll turn it over to Dave.
Dave Rosa, CEO
Good afternoon and thank you for joining us today. If Jamie's and my voices sound a bit different today, we're both recovering from head colds, so I appreciate you bearing with us. Our performance in Q2 was solid. We saw continued global adoption across our multiport, single port, and Ion platforms and steady execution by our teams. In Q2, total procedures increased 16%, driven by 15% growth in Da Vinci procedures and 36% growth in Ion procedures.
The global installed base of Da Vinci and Ion systems increased by 12% and 21% respectively, and we exited the quarter with almost 13,000 systems installed worldwide. In the US, Da Vinci procedure growth was 12%, led by general surgery with after-hours procedures increasing 26%. Growth in the US moderated from recent trends and our expectations at the start of the year, predominantly in procedures that can be deferred. In our customer conversations, some have said that changes in patient coverage and premium dynamics may be affecting when patients seek care and move forward with treatment.
Importantly, the underlying disease burden is unchanged, and deferred conditions typically progress and will ultimately require treatment. As patients return to care, we expect Da Vinci will remain a clear choice for their surgeons and care teams. Outside the US, Da Vinci procedure growth was 20%. Regionally, growth was consistent with Europe and Asia each up 20%, and rest of world markets up 22%. In China, the environment remains challenging. We continue to see lower tender activity, increased domestic robotic competition, and policy-driven pricing pressure.
We continue to operate through a dynamic policy environment, including charge code changes and the 15th Five Year Plan quota process. We are engaging with provincial governments on the charge code policy and are progressing through the green channel process for both SP and Da Vinci 5. When cleared, these platforms will bring additional differentiated capabilities to Chinese customers and their patients. In Japan, new policies supporting robotic surgery went into effect on June 1, including reimbursement for additional procedures and economic incentives for higher utilization programs.
We are encouraged by the direction of the policy environment as well as early response to these initiatives. India had another strong quarter with momentum across a broad set of procedures. This week we received Da Vinci 5 clearance in India and we're excited to bring our latest generation platform to customers in that market. Turning to systems, Q2 was a strong capital quarter reflecting continued customer demand for our newer platforms and confidence in the value of our ecosystem.
We placed 468 Da Vinci Systems and 55 Ion Systems in the quarter. Within multiport placements, reflected strong adoption of Da Vinci 5, including dual consoles and continued demand for our fourth-generation systems where their proven capabilities and value meet customer needs. In the quarter, we rolled out the first phase of more than 100 planned updates to the Da Vinci V platform. These updates are directed at improving telepresence, simulation-based training, and care team workflow.
We have also submitted multiple innovations for FDA 510k clearance that leverage these updates in line with our strategy. We are seeing increased adoption of Da Vinci XIR, particularly in more cost-constrained countries outside the US and in ambulatory surgery centers in the US. XIR expands access to Da Vinci surgery where the customer's procedure mix and economic profile align well with the capabilities and cost profile of our fourth-generation systems.
With more than 13 million procedures completed on Da Vinci Xi globally, customers continue to value the breadth, reliability, clinical capability, and support of the Intuitive ecosystem. Turning to instrumentation, I want to expand further on the Extended Use program we announced in May. This initiative reflects many years of investment in instrument design and manufacturing, consistent with our longstanding approach of strengthening the value of our ecosystem.
In the first half of 2027, we expect to increase the number of uses on a subset of EndoWrist instruments with the benefit targeted to reduce cost in a set of benign procedures. By lowering customer cost per procedure, we expect to support broader adoption of Da Vinci surgery, particularly in those procedures and geographies where cost constraints may be greater. Ultimately, these efforts help reinforce a virtuous cycle where lower costs support broader adoption, which drives utilization and scale and in turn enables continued innovation across our platforms.
Moving to our Da Vinci single port platform, we placed 38 Da Vinci SP systems in the quarter, bringing our global installed base to 445 systems. SP procedures grew 61%, reflecting continued momentum in Korea and the US where expanded indications, new instrumentation, and recent enhancements including extended range instruments, custom remote center software, and reach assist software are supporting broader adoption. In the US, adoption of the SP stapler continues to grow in colorectal and thoracic procedures.
We remain focused on expanding SP adoption through product innovation, training, and geographic expansion. Turning to Ion, lung cancer diagnosis and time to treatment remain major challenges globally. Customers and policymakers are recognizing the value of our Ion platform and we are encouraged by the adoption of the technology as well as the increase in five-year survival rates for lung cancer. Ion procedures increased 36% to 48,000 and now exceed 400,000 cumulatively.
We remain focused on supporting utilization growth in the US and continuing to generate the evidence required internationally to drive adoption. Our commercial teams have now installed Ion systems in 12 countries outside the US, and our development teams are making strong progress on our ROHS and EBUS programs. Aligned with our priority of reaching more patients, we continue to advance multiple early-stage R&D programs exploring the application of robotic-assisted technologies in new disease states.
Recently, we submitted for FDA 510k clearance a foundational non-commercial next-generation flexible robotic endoscope system for use in the gastrointestinal tract. We look forward to updating you on this program and others as they advance through development and regulatory milestones. Stepping back, as robotic-assisted surgery has evolved from an emerging technology to a globally adopted surgical platform, we continue to see increasing segmentation across customer needs.
These needs range from highly complex reconstructive procedures such as coronary artery bypass grafting to high-volume repeatable procedures including cholecystectomy and hernia repair. We have positioned Intuitive to serve customers across this continuum. Our portfolio includes innovative platforms such as SP and Ion, which expand the reach of robotics into new clinical applications, while continued enhancements across our core platforms improve reliability, usability, efficiency, and throughput.
These innovations are designed to help providers advance key healthcare objectives including clinical outcomes, patient experience, provider experience, access, and affordability. We are also innovating across manufacturing and supply chain operations to better serve value-sensitive markets. Programs such as XIR and EUP are intended to expand access to robotic-assisted surgery while maintaining the quality, reliability, and service levels our customers expect.
Supporting these efforts requires sustained investment across multiple technology domains including artificial intelligence and machine learning, robotics, instrumentation, imaging, and advanced materials. Ultimately, we believe customers respond to compelling value regardless of procedure type. In novel and complex applications, value is driven by innovation and clinical capability. In high-volume settings, value focuses on reliability, efficiency, and economics.
With our technology leadership, manufacturing scale, and global infrastructure, we believe Intuitive is uniquely positioned to deliver value across its broad range of customer needs and will continue investing accordingly, including increasing R&D to accelerate those innovations we believe will meaningfully differentiate our solutions, improve durability, and reduce total cost of care. And with that, I'll turn the time over to Jamie to take you through our finances in greater detail.
Jamie Samath, CFO
Good afternoon. I will describe our performance on a non-GAAP basis and summarize our GAAP results later in my remarks. A reconciliation between the two is available on our website. All references to total procedures and their related growth rates encompass both Da Vinci and Ion. Q2 marked another strong financial quarter for Intuitive. Revenue rose 19%, non-GAAP operating margin was 42%, and non-GAAP earnings per share increased 28% from the prior year.
Strength in our financial results continue to reflect robust adoption of Da Vinci 5 and Spring, and in addition, reflected a $36 million pre-tax benefit tied to the refund of previously paid IEIPA tariffs. Total procedures for Q2 grew 16%, reflecting 15% growth in Da Vinci procedures and 36% growth in Ion procedures. Quarter two revenue increased 19% to $2.89 billion, with recurring revenue higher by 19% to $2.47 billion, accounting for 85% of total revenue.
On a constant currency basis, revenue growth was 18%. Overall utilization growth remained healthy with Da Vinci system utilization increasing 3% and Ion system utilization increasing by 11%. Turning to the clinical side of our business in the U.S., total procedures increased 13%, reflecting 12% growth in Da Vinci procedures and 34% growth in Ion procedures. Based on customer feedback, we believe there was a modest adverse impact to Q2 US Da Vinci procedure growth from those...
Patients impacted by the expiration of subsidies for ACA Enhanced premiums. Looking at benign procedures, a subset of which can be deferred, we saw a slight moderation in procedure growth rate that started in Q1. US Da Vinci Bariatric cases continued to feel the impact of rising GLP1 usage, declining high single digits during the quarter. Da Vinci utilization in the US increased 3% in Q2, driven by a growing installed base of higher utilized Da Vinci 5 systems.
Outside the US, total procedures grew 21% with Da Vinci procedure growth of 20%, reflecting strong results in India, Italy, Taiwan, and the UK as well as solid growth in distributor markets and Germany. Da Vinci procedure growth in China and Japan was slightly ahead of the global average but continued to be impacted by the market-specific dynamics we have previously described. We were pleased to see increased system placements in Japan in Q2, partially reflecting recent positive reimbursement decisions by the Japanese Ministry of Health, Labor, and Welfare.
While Da Vinci adoption for benign procedures in OUS markets remains at an early stage, we estimate it represents just over 25% of our international business and volume growth in this category accelerated to 37% in Q2. This will remain an ongoing area of focus. SP procedures grew 61% in the quarter, powered by strength in the US and Korea and encouraging early stage momentum in Europe, Japan, and Taiwan. In the United States, SP average system utilization accelerated from Q1, expanding 25% compared with the second quarter of last year.
Our SPE stapler launch continued to progress well in the US where it is in broad release. It was used in nearly 60% of eligible cases, up from just under 40% last quarter. Internationally, the stapler is now in broad launch across Europe and Korea with positive early adoption, and we expect availability to extend to Japan in Q3. Total INA revenue in quarter two grew 18% to $1.73 billion. Da Vinci INA revenue per procedure increased to approximately $1,830 compared to $1,800 last year, driven by a higher mix of SP and Da Vinci V procedures offset by customer ordering patterns, higher cholecystectomy procedures, and lower bariatric procedures.
The decline in revenue per procedure from last quarter can largely be attributed to customer ordering patterns which were elevated in Q1, especially in OUS markets. Beginning in the first half of 2027, we plan to introduce an updated subset of endo wrist instruments for use with our 4th and 5th generation Da Vinci platforms that feature increased useful lives and lower customer cost per use. The lower cost for customers is targeted towards high volume benign procedures where we see opportunities for incremental growth.
Force feedback instruments and stapling and energy products will not be part of the extended use program. We are still finalizing pricing for this initiative and will provide additional quantification on our next earnings call. Other dynamics shaping Da Vinci INA per procedure include increasing adoption of force feedback instruments, the ongoing mix shift toward Da Vinci 5 and Spring, each of which are accretive, as well as procedure and geographic mix.
Amongst our most anticipated long-term opportunities, cardiac procedures accelerated to 39% growth in Q2 and nipple-sparing mastectomy procedures increased 43%. Although both remain early stage, we continue to advance the ecosystem investments needed to unlock broader adoption including development of cardiac-specific instruments and the accumulation of clinical evidence supporting NSM. Turning to capital performance and starting with our Da Vinci business, we placed 468 Da Vinci systems in quarter two, an 18% increase from the 395 systems placed in the same quarter last year. 246 of the 468 placements were Da Vinci 5 placements, including 114 dual consoles. The install base of Da Vinci 5 is just over 1,700 systems used by over 15,000 surgeons since launch. Customers acquired 64 refurbished Xi systems and 58 X systems in Q2 compared to 10 and 49 in the year-ago period, reflecting investments into robotic programs by more cost-constrained customers that want access to our broad Gen 4 ecosystem.
There were 144 trade-in transactions in quarter two, up from 83 a year ago, driven primarily by U.S. customers upgrading to Da Vinci 5. Capital performance was strong in the U.S. where we placed 267 systems, up 24% from the 216 systems placed last year driven by adoption of and upgrades to Da Vinci 5. We also placed 27 systems at ASCs, significantly higher than our history, reflecting our recent focus on this customer segment. 20 of the 27 placements at ASC were XIR systems.
Outside the US, we placed 201 systems, an increase of 12% compared to the 179 systems placed last year. OUS placements included 75 systems in Asia, 79 in Europe, and 47 in Rest of World markets compared to 69, 73, and 37 respectively last year. Higher placements in Asia were driven by Japan where we placed 25 systems as compared to 15 systems last year. In China, we continue to face competitive dynamics, placing two systems including our first Da Vinci 5 system in Hong Kong.
Da Vinci 5 is not cleared in mainland China at this time. We continue to see relative strength in distributor markets despite a number of these markets being targeted by competitors. The strength of our segmented system portfolio in combination with the competitive advantage of our broad Gen 4 ecosystem is core to our success. During the quarter, we placed 71 systems in these markets as compared to 46 systems last quarter and 65 systems last year. 42 of the 71 placements were X or XIR systems. We will continue to pursue accelerated growth in these markets. Within the 468 Da Vinci placements, we placed 38 SP systems in Q2, higher than the 23 systems last year, primarily driven by increased placements in the US and Japan. For our ION platform, we placed 55 systems in Q2 compared to 54 systems last year. Given our capital performance, quarter two systems revenue grew 19% to $685 million for our Da Vinci business.
Leasing represented 54% of Da Vinci placements as compared to 56% last quarter and 49% last year. Da Vinci leasing revenue increased 22% reflecting a 15% expansion of the installed base under operating lease arrangements and a 7% increase in lease revenue per system driven by a higher mix of Da Vinci 5 systems. The average selling price for purchased Da Vinci systems was $1.6 million in Q2 as compared to $1.5 million last year driven by a higher mix of Da Vinci 5 and dual console systems, partially offset by higher trade-ins and a higher mix of lower ASPX and XIR systems.
Lease buyout revenue was $56 million as compared to $51 million last quarter and $30 million last year. Quarter two service revenue increased 21% to $472 million reflecting an increase of the Da Vinci install base of 12% and the ION install base of 21%. Service revenue per system for our Da Vinci install base increased 8% year over year, also reflecting a higher mix of Da Vinci 5 systems. During the quarter, we executed our first wave of my Intuitive plus renewals, our integrated Da Vinci 5 offering of telepresence, simulation, and AI-driven case insights.
While the initial renewal cohort was small, no customer chose to opt out of their MI arrangement. Turning now to the rest of the P and L, non-GAAP gross margin for the quarter was 70% and increased from 67.9% in Q2 of last year. Excluding the $36 million benefit from IEEPA tariff refunds, Q2 non-GAAP gross margin would have been 68.7%. The year-over-year improvement reflects product cost reductions, fixed overhead leverage, and the tariff refund.
Quarter two non-GAAP operating expenses increased 13% year over year, driven by higher headcount, increased variable compensation, and higher facility costs. We added 215 employees during the quarter, of which about half were in manufacturing to support increased customer demand. We are intentionally growing R&D at a higher rate than SGNA as we prioritize innovation investments that allow us to reach more patients in new diseases, drive long-term growth, and advance the quintuple aims.
Non-GAAP Other income was $83 million for the quarter as compared to $85 million last quarter. Our non-GAAP effective tax rate for quarter two was 22.6%, consistent with our expectations. Non-GAAP net income for the second quarter was $1 billion compared with $798 million last year. Non-GAAP earnings per share was $2.80 per share compared to $2.19 per share in quarter two of last year. Now turning to our GAAP results, GAAP net income for the quarter was $818 million, or $2.29 per share, compared to $658 million, or $1.81 per share, in Q2 of last year.
We ended the quarter with $8.6 billion in cash and investments, up from $8 billion last quarter, driven by cash flow from operating activities offset by stock repurchases of $379 million at an average price of $430 and capital expenditures of $112 million. Free cash flow in the first half of 2026 was $1.8 billion, an increase of 71% compared to the first six months of 2025. With that, I'll turn it over to Dan to discuss recent clinical publications and our updated outlook for 2026.
Dan Connolly
Thank you, Jamie. Turning to the clinical side of our business, I'd like to share with you data from recent studies that we found to be notable. In addition to the specific data highlighted on this call, we encourage you to consider the wide body of evidence detailing these topics and others in published scientific studies over the years. In November, Emily Thomas and Dr. Andrew Schneider of the University of South Carolina School of Medicine, Greenville and Prisma Health in Greenville, South Carolina, along with co-authors, published a comparative analysis of laparoscopic and robotic appendectomy, a multi-hospital retrospective cohort study in the Journal Surgical Endoscopy. In this study across a regional multi-hospital health system that ran from August 2021 through February 2024, the authors compared outcomes for robotic-assisted and laparoscopic appendectomy in 1,431 patients, including 352 treated with Da Vinci and 1,079 treated laparoscopically. The results demonstrated that robotic-assisted surgery was associated with significantly lower rates of conversion to open surgery at 0% for the robotic cohort versus 3.2% for laparoscopy.
The results also demonstrated that robotic-assisted surgery was associated with significantly lower rates of unexpected extended bowel resection at 0% for the robotic cohort versus 1.7% for laparoscopy. After adjusting for differences between the two groups through multivariable regression, the robotic-assisted approach was associated with a 66% decreased risk of any complication relative to the laparoscopic approach. The authors attributed this difference to improved three-dimensional visualization and dexterity of wristed instruments in managing intraoperative complications such as a necrotic appendiceal base, extensive adhesions, or bleeding.
The authors concluded that robotic-assisted appendectomy is safe and may be associated with significantly lower complication rates compared to the laparoscopic approach, and that these findings support broader adoption of robotic assistance in general surgery. In May, at the American Urological Association annual meeting, Dr. Jacob O'Hara and Dr. Michael Stifelman of Hackensack Meridian Health in New Jersey, along with co-authors, presented use of force feedback is associated with faster return of bowel function after partial and radical nephrectomy in a supplement of the Journal of Urology.
In this prospective cohort study, the authors evaluated 73 patients who underwent multiport transperitoneal partial or radical nephrectomy with Da Vinci performed by three high-volume robotic surgeons. Their work compared 48 patients in whom force feedback was used against 25 in whom it was not. The results demonstrated that 63% of patients in the force feedback cohort achieved return of bowel function within one day compared to 28% in the cohort without force feedback.
The authors hypothesized that force feedback improved
Jamie Samath, CFO
Return of bowel function by decreasing trauma to the colon and duodenum during mobilization, and they concluded that its use in robotic-assisted, partial and radical nephrectomy is associated with significantly faster return of bowel function. I will now turn to our updated financial outlook for 2026, starting with Da Vinci procedures. In April, we forecast full-year 2026 Da Vinci procedure growth to be within a range of 13.5% to 15.5%. We are maintaining our forecast to be within this range with an expectation to be closer to the midpoint.
We continue to expect the primary growth drivers to be general surgery in the US, including after-hours and procedures outside of urology. Internationally, our range considers the impact of changes to ACA premium subsidies and patient behavior in the US, China tender volumes, and competitive intensity in that market, capital pressure in parts of Europe related to macroeconomic impact and shifting governmental priorities, prior 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 67.5% and 68.5% of revenue, which reflected 100 basis points of impact from tariff. We are updating our estimate for non-GAAP gross profit margin to be within a range of 68% and 69% of revenue. We continue to expect higher input costs in certain areas, including freight and semiconductor memory. Other factors for the year include faster growth of newer products in Da Vinci 5 and ION, modest incremental depreciation from recent facility expansion, and the impact from higher Da Vinci system upgrades partially offset by product 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 13%. In recent periods, R&D has grown faster than SG&A. We expect that trend to continue over the remainder of 2026. Additionally, in Q4 2025, we made a $70 million multi-year contribution to the Intuitive Foundation.
We do not expect to make a contribution to the foundation in 2026. We now estimate non-cash stock compensation expense between $880 million and $900 million. We continue to forecast other income, which is comprised mostly of interest income, to total between $315 million and $335 million. With regard to income tax, we continue to expect our non-GAAP income tax rate to be between 22% and 23% of pre-tax income.
OPERATOR
This concludes our prepared remarks as we open the line to questions. We ask that you limit yourselves to one question so that we may reach as many analysts as possible. Thank you. As a reminder, if you would like to ask a question, please press star 11 on your telephone. You'll hear an automated message advising your hand is raised. We also ask that you wait for your name and company to be announced before proceeding with your question. One moment while we compile the Q and A roster.
The first question today is coming from the line of Travis Steed of Bank of America. Please go ahead.
Travis Steed (Equity Analyst at Bank of America)
Hey, thanks for taking the question. I'll start with the US procedure growth. First question is how do you know how much of this is ACA versus just the market maturing or something else? Other medtech companies aren't calling it out or seeing it, especially when ACA is such a small percent of the total covered lives. And do you expect any of these delayed procedures to come back in the second half of the guide?
Jamie Samath, CFO
Hey Travis, it's Jamie. Two things actually that we're looking at. First and most importantly is just feedback from our customers as we look at their procedure trends with us and engage with them in terms of what they're seeing. If you look at those procedure types where we know that a subset of them can be deferred, we see a difference in terms of what's happening in the procedure trends, particularly in Q2, relative to those procedures where they're less deferrable or not deferrable.
So it's just a combination of those two things. If you look at what we saw in Q2, US procedure growth overall for Da Vinci was 12% versus the 14% we saw in Q1. There's likely some combination there of the impact from ACA, but also you're just seeing a little bit of the lure of large numbers as well.
Travis Steed (Equity Analyst at Bank of America)
Okay, thank you. And then on the INA revenue impact and extended use, realize not wanting to put a fine point on it yet, but we'd estimated it as kind of a five-point total impact over a couple of years, a little less than the seven points in 2020. I don't know if you can kind of if that's in the ballpark or put some sort of framework around it for investors. And then also maybe talk about how this can open up maybe ASCs and international procedures.
Jamie Samath, CFO
Yeah, not ready to quantify it yet, Travis. As we said in the prepared remarks, we'll do that on the next earnings call. I'd just say a couple of things. The improvements that allow us to extend the lives have been years in the work by our engineering teams. It is intended to lower cost where we see cost constraints in both certain procedures and geographies. Think of benign outpatient procedures and those markets that just generally have healthcare systems with lower reimbursements.
In terms of how it starts to impact as we release those in the first half of next year, think of it as being a progressive impact over 2027 versus some step function just in terms of how it will adopt and how it will be rolled out by the various countries. We looked back at what we did in the first extended use program back in 2020 and obviously we've had the time to assess the impact of that both in our own data trends and in feedback from customers.
And I think we have confidence that as you make innovations that allow you to lower cost for customers when there's opportunity to grow, that's a good strategic thing to do.
Travis Steed (Equity Analyst at Bank of America)
Great. Thanks a lot.
OPERATOR
Thank you. One moment for the next question. And our next question will be coming from the line of Robert Marcus of JP Morgan. Please go ahead.
Robert Marcus (Equity Analyst at JP Morgan)
Oh great. Thanks for taking the questions. So one for me. You know the CapEx environment is one of the most important catalysts and background items for Intuitive. You know there is obviously concern amongst investors as bad debt might build at hospitals as people fall off ACA and Medicaid. What are you seeing today in terms of the capital environment in the US and outside the US and the willingness to invest in capital? And I think more importantly is the go forward.
So what are you expecting? What's assumed in guidance both US and OUS for the future health of the CapEx cycle? Thanks a lot.
Jamie Samath, CFO
The US capital environment, at least in our experience, has been stable for some time now and you see that I think in the healthy system placements in Q2 in the US up 24%. I do think that we have a relative advantage in around 70-ish percent of the systems acquired in the US are under leasing arrangements and so that gives customers I think greater flexibility relative to when they have capital budget constraints. But I think we feel good about how capital has performed in the US in recent periods and our pipeline at least up until this point has been healthy.
Much of that has been driven by interest in Da Vinci 5. So to some extent there's some uniqueness relative to customers wanting to get access to the latest technology to differentiate themselves in the marketplace and take advantage of the feature set embedded. If you look at the US placements in Q2, 267 systems relative to the 216 in the year-ago period, almost the entirety of that increase is in trades and so it shows the extent to which customers are interested in upgrading embedded in that.
Given how we designed Da Vinci 5 structurally it does give customers incremental capacity and that's reflected in how we've described the higher utilization of Da Vinci 5 versus Xi. We also saw Greenfields up in Q2 and that was mostly the 27 systems that we placed at ASCs. So we feel pretty good about the US environment to this point. Of course, there are some customers that express caution over ACA enrollment trends, but we haven't seen that impact our pipeline, at least to this point in international markets.
It's basically what we've described on the call. China is competitive and challenging from a pricing perspective. Japan has been impacted by government funding. We think the reimbursement decisions that went into effect in June are positive and we have a kind of cautious tone of optimism for as we look forward. In Japan, the distributor markets have responded well, particularly to our portfolio of systems. Europe, it depends on the market. There are some that are stressed by government budgets and some that look pretty healthy.
Robert Marcus (Equity Analyst at JP Morgan)
Appreciate it. Thanks a lot.
OPERATOR
Thank you. One moment for the next question. And our next question will be coming from the line of Rick Wise of Stifel. Please go ahead.
Rick Wise (Equity Analyst at Stifel)
Good afternoon everybody. Could you talk Dave, a little bit more about the May 21 press release you highlighted and you highlighted it went quickly. I think you said over 100 such Da Vinci 5 upgrades and enhancements ahead, if I heard that correctly. Correct me please if I'm wrong, but at what rate are these going to unfold and happen and rollout? I know subject to FDA approval. But how do we think about these incremental ads? Are there one or two or five that are likely to be more impactful and impactful on growth or procedure volumes or new procedures than others?
Dave Rosa, CEO
Hey Rick, I appreciate the question. So the way to think about this cadence that we've committed to as we take Da Vinci 5 as a platform and its compute power, the 10,000 times we're able to add capabilities and features to that on a regular basis. And so the press release that you're referring to has 100 updates and some of those updates will be not visible to the customer. They're kind of under the hood, so to speak. And many will be visible to the customer.
And they're focused in the areas that we talked about, three of them in particular that take advantage of these updates we submitted for 510 clearance. And so those updates center two of them center on really I would say kind of usability and efficiency features where the care team and the surgeon may be able to minimize some communication back and forth on the surgeon tool eject feature, for example, where they can indicate exactly which tool is going to be needing to be changed.
The other one on as we are able to adjust multiple arms either preoperatively or during the case will help efficiency of the case. And now we're finally adding this digital ruler too. And that's another one that requires clearance. And that one you can imagine in a variety of cases where it can be used by the surgeon to measure a particular part of the anatomy and what they're trying to ensure meets the needs of the patient. And so those are the three that are submitted for clearance.
Others will be kind of circling around some of the efficiencies and effectiveness of the system. And then that's what you'll see going forward too. As we look at next year and years beyond is a set of updates, many of which will be kind of standout features that improve the capability of the system.
Rick Wise (Equity Analyst at Stifel)
And Dave, I hoped you'd expand on your comments about this new GI robot. Why this area, why now? And maybe you can give us a flavor for the potential incremental TAM and impact on Intuitive's outlook. Thank you.
Dave Rosa, CEO
Yeah, sure. So the way I would frame GI is basically a natural extension of our mission to bring better, minimally invasive care to more patients. You know, I would say that ION has demonstrated we can develop and commercialize platforms beyond core soft tissue surgery. And I'm excited we're in a good place to bring the learnings from Da Vinci and the learnings from ION, bring those together and form our work in the GI tract. And so we have spent time with GI physicians and care teams to understand where a robotic approach could improve therapeutic outcomes.
The CARE team experiences really all aspects of the quintuple aim and we're excited about what's possible. And I just want to reinforce this remains early. The 510 submission is for a non-commercial and a liminal system. And we'll build clinical evidence and work through the regulatory review processes and we'll provide updates along the way. Just not ready today to describe kind of timing or size of the opportunity, but encouraged by what we're learning and the potential for GI to become another area where minimally invasive robotics can create real value over time.
OPERATOR
Thank you. And one moment for the next question. Our next question is coming from the line of Lawrence Biggleson of Wells Fargo. Please go ahead.
Lawrence Biggleson (Equity Analyst at Wells Fargo)
Good afternoon. Thanks for taking the question. I just wanted to ask about China. We recently saw that the government is creating a centralized VBP for imaging and other surgical equipment. Are surgical robotics a part of that VBP program? And how might that impact Intuitive in China?
Dave Rosa, CEO
Hey, Larry. So to the best of our knowledge, I wouldn't compare this tender centralization necessarily with VBP. What we think the government is really trying to do here is manage some of the duplication and waste that they see in the tender process when it's individualized to hospitals in all the provinces. And so we think actually, in a way, what they're going to do is more structurally develop the tenders to take advantage or to basically reinforce the need for strong robotic programs and not just bespoke features that are system by system, kind of tailored by depending on who's writing the tender.
And so we do believe that robotics will be part of it. Again, I wouldn't compare it to VBP, and we'll see how it starts to kind of phase in now over the next quarters.
Lawrence Biggleson (Equity Analyst at Wells Fargo)
That's helpful, Dave. One follow-up, the recent press release that Rick asked about also talked about instrument security and how Intuitive is enhancing instrument encryption technology to improve the security and monitoring of its products. So my question is, what's the tangible benefit of that? And do you think this will incentivize hospitals to stick with your instruments as opposed to remanufactured instruments? Thank you.
Dave Rosa, CEO
Yeah. Here's what I'd say about that, is it's clear that cybersecurity is front and center when you talk to our customers and across the globe. And so really, the introduction of this new encryption technology is just part of our continued investment to strengthen the security of our products, the quality of our products, the availability of our products. And really, that's what it is centered on in this case.
Lawrence Biggleson (Equity Analyst at Wells Fargo)
All right, thanks so much for taking the question.
OPERATOR
Thank you. One moment for the next question, please. And our next question is coming from the line of Ryan Zimmerman of BTIG. Please go ahead.
Ryan Zimmerman (Equity Analyst at BTIG)
Good afternoon. Thanks for taking the question. First question for me is going back to the capital demand and the environment. I mean, there's a bit of a dichotomy, I think, between capital demand and procedure growth. And I'm wondering, Dave, when you think about the capital cycle that you're seeing, particularly what you saw this quarter, does it reflect assumptions of increasing demand ahead? Because I think if I think about what Gary has said in the past in terms of system growth, typically hospitals are buying systems ahead of increasing demand. And so just maybe speak to the differences between the system placements versus what you saw with procedures this quarter, please.
Jamie Samath, CFO
Ryan, it's Jamie. Maybe I'll take that if I should take the US. A couple of things just to consider. About half of the placements in the US in Q2 were trades. So while you can get incremental capacity in the field, if you're upgrading to DaVinci5, obviously then half of those placements are not expanding the installed base. And you have seen the US installed base expansion kind of moderate slightly over the last several quarters. If you look at system utilization, which I think is an important metric relative to your question in the US, that grew 3% in Q2, which is a healthy level and a metric that we'll watch carefully.
Again, I would just say we have heard from some customers some caution on ACA enrollment trends, but again, it hasn't affected the capital pipeline so far. Obviously, we're going to watch the procedure trends across the US in the coming quarters.
Ryan Zimmerman (Equity Analyst at BTIG)
Okay. And then just second question for me is on DB5 upgrade cycle durability. You know, we did a recent survey. The bulk of respondents in our survey, about 77% or so, were already upgrading the DB5 or were actively pursuing an upgrade. But when I step back and I think about the DV5 install base relative to the broader install base, how do you think about the ability to upgrade to DV5 in the existing install base relative to Greenfield? And where would you characterize what inning you're in, if you will, with the DV5 upgrade cycle, given the broader install base that is out in the field today?
Jamie Samath, CFO
I don't think we have a perfect prediction. I would just say if you look at the when we introduced Xi, it took about seven years before we got to the peak trade-in volumes going from SI to Xi. I just give that as a historical reference, nothing more. I think that as with Xi, the DaVinci 5 capability and its ecosystem increases over time with the software updates and the ability to improve other elements of the ecosystem. And each time we do those updates, that then makes the system more attractive.
Of course, there'll be some segmentation in the US that's likely along the lines of what ASCs and HOPDs want to use given the procedure mix in those settings versus in the hospital. But we said for some time now we think the upgrade cycle is progressive and occurs over multiples of years.
Ryan Zimmerman (Equity Analyst at BTIG)
Thank you. Appreciate it.
OPERATOR
Thank you. One moment for the next question. And our next question will be coming from the line of Matt Taylor of Jefferies. Please go ahead.
Matt Taylor (Equity Analyst at Jefferies)
Hi, thanks for taking the question. I guess I wanted to ask you a little bit more about XIR. You mentioned there's momentum in those programs, especially in ASCs and kind of cost-sensitive areas. I was wondering if you could give us more color on how many of those you're placing and maybe kind of an outlook about how you think that will evolve and what percentage of the mix those could represent in the future.
Dave Rosa, CEO
Yeah, I might just start and Jamie, please follow up. If you look across the globe and you just, you mentioned, you know, we have segments and we're seeing segmentation across our customer base through in the US ASCs and smaller hospitals outside the US certainly in those geographies where kind of the healthcare system is more cost constrained. And XIR is just a fantastic option for them as it takes advantage of our entire 4th gen ecosystem and it has just great capability across a broad set of procedures.
And so, you know, I'm, I think I'm, I'm excited about where that's positioned and what it's offering customers because we've seen it be able to meet their economic needs. That's why I think you've seen the placements come up this quarter. Our teams are focused in working with customers to understand their needs and we think XIR is going to be a, just a strong option for them. And so I would expect it to be a significant part of our placements over the coming quarters.
What's exciting about XIR is it gives us the opportunity to access customers that have not yet invested in robotics, allows them to have their first program, start to get through the learning, see the benefits of it and becomes then customer that we can bring to more advanced technology over time. We've had XIR for about a year now. I think the installed base is something like 130 XIRs in the field. About 50 of those are in the US that's concentrated with the 27 ASCs placements. 20 of the 27 were XIR and some other customers in the US but a large portion of them are in international markets. And again it gives us the opportunity to go to customers that are new to robotics. And so there's 11 or 12 customers in that year period, 11 or 12 countries rather in that year period that have taken an XIR. And so I think there's diverse interest in those places where it's cost sensitive and it's advantaged by the breadth of the Gen4 ecosystem.
Matt Taylor (Equity Analyst at Jefferies)
Got it. Thank you so much guys.
OPERATOR
Thank you. One moment for the next question. And our next question is coming from the line of Vic Koptra of BMO. Please go ahead.
Vic Koptra (Equity Analyst at BMO)
Hey, good afternoon and thanks for taking the questions. I'll just keep it at one. So given the favorable reimbursement changes that took effect in Japan on June 1st. I'm just curious how significant the contribution from Japan could become over the next few years if adoption trends develop as you expect. Thank you.
Dave Rosa, CEO
Yeah, I think we expect procedure adoption to take some time given their newer categories and in some cases you need to work through surgeon training and so forth. And despite the new reimbursements, I think we're balanced about the continuing financial challenges along with some of the financial incentives that now exist. So I think that will be progressive over some time. What have we said about the size of the market opportunity, Dan? I think incrementally relative to prior increases, it's somewhat smaller and will take time to develop.
And the TAM of the new opportunity, have we described that? I have not specifically described it. Inguinal hernia is the largest of the procedures with the newer reimbursement. So we'll see how that progresses over time and we'll keep you updated.
OPERATOR
Thank you. One moment for the next question. And our next question is coming from the line of Michael Pollack of Wolf Research. Please go ahead.
Michael Pollack (Equity Analyst at Wolf Research)
Good afternoon. Thank you for taking the question. I want to take another crack at extended use impact in 2027. So you know, Travis alluded to the last cycle was a 7% impact. The adjustments that were made were described as 9 to 15%. You have some good things going through the INA per case line right now. DB5 generally, force feedback, SP mix, all good guys. Is it fair to think that you're investing kind of away that upside with extended use and the INA per case line would be flat or, or is that not a great assumption and there is risk that INA per case as we roll through 27 and 28 year on year could be down a little bit.
Jamie Samath, CFO
Thank you, Mike. I totally understand the question from a modeling perspective for next year. I'm not going to provide the quantification until we've been through the analysis and made our decisions. I think that in the way that we think about managing the company, where we're balancing two objectives, growth and profitability, and where we see opportunities to have incremental growth in these lower acuity procedures, then we're willing to pursue those.
I think that you're right. What you called out is there is the opportunity for mix on those products that have incremental innovation embedded in them that is manifested in higher pricing or higher INA per procedure, then you have some dynamics that can offset. And that's what we try to describe in the script. But I'm not going to go through the kind of quantification until we've been through our process internally.
Michael Pollack (Equity Analyst at Wolf Research)
Thank you.
OPERATOR
Thank you. One moment, please, for the next question. Our next question is coming from the line of Vijay Kumar of Evercore. Please go ahead.
Vijay Kumar (Equity Analyst at Evercore)
Hi, guys. Thank you for taking my question. Maybe just one from my side. I know there's nervousness around the utilization metric. Can you talk about your exposure to Medicaid or exchanges, if you will?
Jamie Samath, CFO
I'm sorry, Vijay, do you mind just repeating the question?
Vijay Kumar (Equity Analyst at Evercore)
What is your procedure exposure to healthcare exchanges and Medicaid?
Jamie Samath, CFO
Oh, we don't have a precise estimate. A significant portion of the business is private pay insurance or commercial insurance. Medicare is a lower proportion of our business and Medicaid is lower yet again. But we don't have a precise estimate of what portion of our procedure business is under ACA.
Dan Connolly
Understood. And Jamie, I know you gave the procedure guidance for the annual third quarter. Comps get tougher. Is that something we need to be cognizant of?
Jamie Samath, CFO
Yeah. Just thinking about the second half of the year. Obviously, the first half of the year, closer to 15% on da Vinci procedure growth guiding more towards the midpoint for the rest of the year. There is a little bit of a tougher comp in the US in Q3, I think we noted at the time last year. Additionally, Q3 internationally had some seasonal holiday movements that moved from Q4 to Q3. So a little bit of an impact in Q3 and Q4 on the international side as well.
Dan Connolly
Thank you, Jamie.
OPERATOR
Okay, that was 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 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 an 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 three months.
This concludes today's programming. Thank you so much. You may now disconnect.
Disclaimer: This transcript is provided for informational purposes only. While we strive for accuracy, there may be errors or omissions in this automated transcription. For official company statements and financial information, please refer to the company's SEC filings and official press releases. Corporate participants' and analysts' statements reflect their views as of the date of this call and are subject to change without notice.
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