Intuitive (ISRG) Q3 2026 Earnings Call: Revenue Up 22%, Procedure Outlook Narrowed

Key Takeaways

• Q3 2026 revenue increased 22% year over year to just over $3 billion, with recurring revenue representing 84% of the total.
• Combined da Vinci and Ion procedures grew 15%. Da Vinci procedures rose 14%, including 10% growth in the U.S. and 20% outside the U.S., while Ion procedures increased 31%.
• Intuitive placed 546 da Vinci systems, up 28%, including 315 da Vinci 5 systems. Net da Vinci placements, which expand the installed base, grew 40%.
• Non-GAAP operating margin was 42%, or 41% excluding a one-time $28 million pretax tariff refund. Non-GAAP EPS increased 25% to $3.00.
• Management narrowed its 2026 da Vinci procedure growth outlook to 14%-15%, with growth expected near the midpoint, and raised the non-GAAP gross margin range to 68.7%-69.3%.
• Instrument pricing actions and a China price reduction are expected to lower da Vinci instruments and accessories revenue per procedure by approximately 3%-5% on a constant-mix basis once fully implemented.

Core Financial Data

Business and Operating Performance

Total procedures across da Vinci and Ion increased 15%, supported by a 13% expansion in the installed system base and a 2% increase in average utilization. Intuitive ended the quarter with more than 13,200 da Vinci and Ion systems installed worldwide.

Da Vinci procedures grew 14%. U.S. growth was 10%, against 16% growth in the prior-year quarter, while procedures outside the U.S. increased 20%. International growth included Europe at 20%, Asia at 19% and other markets at 22%.

International benign procedures grew 41%, accelerating from 37% in Q2 and 34% in Q1. Hernia repair and cholecystectomy were the strongest contributors. Management said benign procedures now represent more than one-quarter of international da Vinci volume and account for a significant portion of the gap between current volumes and the addressable opportunity.

SP procedures increased 55%, including 50% growth in the U.S. and 40% in Korea. Intuitive had 487 SP systems installed across 27 countries, up 42% year over year. Procedures in SP markets other than the U.S. and Korea nearly doubled.

Ion procedures grew 31%, including 29% growth in the U.S. The company placed 56 Ion systems, compared with 50 a year earlier. Intuitive also received reimbursement for Ion in Korea during the quarter.

System placements and portfolio mix

Intuitive placed 546 da Vinci systems, up 28% from 427 a year earlier. Placements included 315 da Vinci 5 systems, 87 Xi systems, 65 XiR systems, 42 SP systems and 37 X systems.

U.S. placements rose 27% to 335 systems, driven by more multi-system transactions as customers converted to da Vinci 5. Outside the U.S., placements increased 29% to 211 systems. Europe placements rose 83% to 115, while Asia placements increased 30% to 78.

The company installed 18 systems at U.S. ambulatory surgery centers, including 15 XiR systems. Management estimated that slightly less than 10% of the U.S. soft-tissue surgery market is currently performed in ASCs and that about 70% of those volumes are associated with existing integrated delivery networks.

More than 2,000 da Vinci 5 systems were installed worldwide at quarter-end, and over 18,000 surgeons had used the platform since launch. Da Vinci 5 accounted for more than one-quarter of U.S. procedures, up from 13% a year earlier.

Pricing and recurring revenue

Da Vinci instruments and accessories revenue per procedure was approximately $1,860, compared with $1,800 a year earlier. The increase primarily reflected a higher mix of SP procedures and da Vinci 5-specific products, partly offset by procedure mix.

Beginning in the first half of 2027, Intuitive plans to extend the useful lives of selected core EndoWrist instruments on fourth- and fifth-generation platforms and introduce volume-based pricing. The measures are focused on high-volume benign procedures where costs may constrain adoption.

A separate policy-driven price reduction in China begins in November 2026. Combined, the China changes and broader pricing program are expected to reduce da Vinci instruments and accessories revenue per procedure by approximately 3%-5% on a constant product and geographic mix basis once fully implemented.

Management identified several potential offsets, including greater Force Feedback adoption, higher SP procedure mix and da Vinci 5 integrated insufflation. Force Feedback instruments were used in about 8% of da Vinci 5 procedures during Q3. Integrated insufflation was used in approximately 85% of applicable da Vinci 5 procedures and generated about $100 of additional revenue per procedure from tube sets.

Management Guidance

The company expects the extended-use instrument program to begin in the U.S. later in Q1 2027, subject to FDA clearance. Europe is expected to follow in the second half of 2027, with other markets around that period. Management does not expect the full 3%-5% pricing impact until the end of 2027.

Intuitive said the gross-margin effect should be modest and that it will seek to offset the pressure through product cost reductions. Management also reiterated a long-term non-GAAP operating margin framework of 35%-40% and indicated that margins above that range provide capacity for additional investment in research and development and growth initiatives.

Risks and Areas to Watch

• Management’s procedure outlook accounts for possible effects from changes to Affordable Care Act premium subsidies, lower ACA enrollment, Medicaid eligibility changes and potential changes to the 340B program.
• China remains challenging because of lower recent capital placements, pricing policy changes, tender volumes and competitive intensity.
• Newer products, including da Vinci 5 and Ion, are growing faster and can pressure gross margin, although management cited product cost reductions as a partial offset.
• The pricing program is designed to stimulate procedure adoption, but management said the expected volume elasticity will develop over time rather than immediately in 2027.
• The $450 million no-fault settlement related to third-party instrument remanufacturing and system servicing remains subject to court approval, which the company does not expect until 2027.
• Cardiac and breast surgery are growing rapidly but remain small relative to total procedure volume. Their near-term adoption depends on surgeon training and the accumulation of clinical evidence.

Analyst Q&A Highlights

Management addressed concerns about U.S. procedure growth by emphasizing capacity expansion, benign general surgery, ASC adoption and longer-term indications such as cardiac and breast surgery. U.S. net placements grew 41% during the quarter, supporting additional procedure capacity.

On pricing elasticity, management said data from the first extended-use program launched in 2020 supports the view that lower customer costs can expand adoption. The price reductions will be concentrated in cost-sensitive, high-volume benign procedures, where the benefit to customers will be greater than the blended 3%-5% revenue-per-procedure effect.

Regarding the product pipeline, Intuitive highlighted on-site cytology and integrated endobronchial ultrasound for Ion. The company also cited hyperspectral imaging, fluorescent molecules and AI-enabled visualization for da Vinci as potential sources of additional clinical value and revenue per procedure.

Management maintained that a cart-based robotic architecture offers the best balance of capability and usability in both hospital operating rooms and ASCs. It said customers prioritize reliability, ease of use, repeatability, suitable economics and a supporting clinical and service ecosystem rather than a specific modular architecture.

The company also discussed early clinical use of Force Feedback. Management cited surgeon experience suggesting the technology may support gentler tissue handling, while noting that broader adoption will require further evidence and customer understanding of its value.

Full Earnings Call Transcript

Complete Earnings Call Transcript

Management Remarks

Operator

Hello, and welcome to Intuitive Third Quarter 2026 Earnings Release.

[Operator Instructions]

I would now like to turn the call over to Dan Connally, Head of Investor Relations. You may begin.

Daniel Connally

Good afternoon, and welcome to Intuitive's Q3 2026 Earnings Conference Call. Joining me today are Dave Rosa, our CEO; Jamie Samath, our CFO; Dr. Jamie Wang, our Chief Medical Officer; and Gary Lowe, our Chief Legal and Compliance Officer.

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 10-K filed on February 3, 2026, and 10-Q filed on July 21, 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 conference call is as follows: Dave will review our business and operational highlights. Jamie will review our financial results and procedure highlights. Jamie Wong will review clinical highlights. I will review 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.

David Rosa

Good afternoon, and thank you for joining us today. Q3 was a strong quarter for Intuitive, with broad-based adoption across our multiport, single-port and Ion platforms. In Q3, total procedures increased 15%, driven by 14% growth in da Vinci procedures and 31% growth in Ion procedures. In the U.S., da Vinci procedure growth was 10% and outside the U.S., da Vinci procedure growth was 20%. We exited the quarter with more than 13,200 da Vinci and Ion systems installed worldwide. Over time, our customers have adopted operationalized and standardized on the da Vinci ecosystem to provide their patients with improved care. That adoption has been driven by our commitment to innovation robust training and clinical evidence, and it is apparent in how customers use da Vinci today.

In the quarter, almost 7,000 customers in more than 70 countries performed da Vinci procedures at a rate of over 10,000 procedures per day. On the clinical evidence front, more than 48,000 peer-reviewed publications have evaluated the effectiveness of da Vinci surgery, including the recent benign COMPARE study which Jamie Wong will discuss in more detail shortly.

As I described last quarter, we continue to see increasing segmentation across our customer base, need to vary by procedure, site of care, geography and health care system. We have been investing to support this segmentation, and we have positioned Intuitive to serve current and future customers with both our existing technologies and those in development. Meeting those needs also requires that we evolve our commercial approach to tailor how we engage, price and provide solutions for customers in each segment. In Q3, global customer demand across our da Vinci portfolio remains strong. Da Vinci system placements increased 28% worldwide, with da Vinci 5 in SP accounting for 65% of global placements.

Installations of Xi RNX more than doubled in the quarter. Customers continue to adopt da Vinci 5 and its growing capabilities with demand for both capacity expansion and system upgrades. We exited the quarter with more than 2,000 da Vinci 5 systems installed worldwide, used by over 18,000 surgeons since launch. We continue to see strong interest in XiR both in the U.S. and internationally, where customers are leveraging its familiarity, capabilities and cost profile to build programs around a focused set of procedures.

Our da Vinci single port platform is playing an increasingly important role for our customers and their patients. Our investments in additional clearances and instrumentation are yielding results as SP procedures expand in the U.S. and internationally. Adoption of the new SP stapler continues to broaden and in Q4, we plan to make a U.S. submission for the SP vessel sealer, which we believe is a key enabler for wider adoption of our SP platform. Increasingly, customers that adopt both multiport and single port describe benefits to their overall da Vinci programs, with SP opening new approaches for the surgeon, while existing procedure demand fills their multiport capacity.

In Q3, we finalized a set of pricing actions for a subset of high-volume benign procedures where costs may be a constraint to broader access to da Vinci surgery. We believe these actions, in conjunction with increased availability of XiR will expand our addressable opportunity and enable da Vinci technology to reach more patients around the world. Jamie will describe the anticipated impact shortly.

Outside the U.S., we are elevating our focus and increasing our investments to help customers establish and expand their da Vinci programs. As of Q3, nearly 4,000 international customers have a da Vinci program and nearly 25% operate 2 or more systems. These customers are moving beyond urology and cancer procedures into benign hysterectomy in Germany, cholecystectomy in the U.K. and India and inguinal hernia repair in Japan. To support this growth, we are continuing to build the foundation of market access country by country through regulatory clearances, reimbursement, training and clinical and economic validation. Da Vinci placements outside the U.S. increased 29% in the quarter, with broad-based global demand.

In Europe, Germany led the region with 20 system installations. We also placed systems in more than 20 other European countries in benign procedures led procedure growth. In Asia, Japan improved on both system placements and procedure growth for the second consecutive quarter while India had another strong quarter with 42% procedure growth, surpassing 200,000 cumulative da Vinci procedures.

In China, the operating environment remains challenging. To support expected long-term growth in Asia, we recently announced plans for a significant new INA manufacturing facility in Penang, Malaysia. We expect this facility to begin operations in 2028. Beyond da Vinci, we are investing in Ion outside the U.S. through multiyear country-by-country work that is foundational to broadening access and shortening the time between detection and treatment of lung cancer. During Q3, we received reimbursement for Ion in Korea, and we expect further reimbursement actions in other geographies in the coming quarters. This quarter, we received several CE marks including Force Feedback instrumentation and cardiac procedures on da Vinci 5 as well as transvaginal gynecological procedures on SP. We now have da Vinci 5 cleared for cardiac procedures in the U.S. Europe, India, Japan and Korea.

During Q3, we received FDA 510(k) clearance on da Vinci 5 for a surgeon initiated tool eject and multi-arm targeting, both of which bring incremental efficiency in surgeon autonomy to procedures. Surgeons have reported that these innovations support extending access to da Vinci surgery beyond traditional work days and hours. Recently, we submitted a capitational ultrasonic aspirator instrument for FDA 510(k) clearance for use in liver and pancreas procedures. And last week, we received FDA 510(k) clearance for an integrated version of the da Vinci 5 handheld endoscope.

In August, we received FDA 510(k) clearance for our foundational noncommercial next-generation flexible robotic endoscope system for use in the gastrointestinal tract. This program is early in its development, but we are encouraged by our progress and look forward to updating you as we advance. Adoption of Intuitive telepresence continues to increase with surgeons using these sessions, the share techniques and to scale training in ways that were not previously practical. Telepresent on da Vinci 5 serves as a foundation for our efforts in telesurgery where we expect several regulatory clearances in the first half of 2028. Our teams continue to develop additional digital and AI capabilities on da Vinci 5, including a voice-activated user interface and automated fourth arm control to further enhance efficiency and the user experience.

AI controlled motion and surgery has the potential to improve efficiency and outcomes, but it is early and must earn the confidence of regulators, surgeons, care teams and patients before we deploy it at scale.

Looking ahead, our objective at Intuitive is to reach more patients with the best care available by combining robotics, human expertise, data and artificial intelligence so that minimally invasive care becomes more accessible and less variable.

The problems we are working to address are significant and specific. Minimally invasive surgery access and adoption remain uneven around the world. Patients wait too long between detection and treatment, and the care a patient receives still varies more than it should, depending on the hospital they enter and the surgeon available that day. Over time, we are focused on significantly advancing Quintuple Aim to ensure that the broader patient journey can become more predictable, more connected and less disruptive to a patient's life.

Before I pass the time to Jamie, today, we announced that we have reached an agreement, subject to court approval, with U.S. customers who participated in the class action lawsuit on third-party remanufacturing of da Vinci instruments and third-party servicing of da Vinci systems. We believe that this no-fault settlement provides certainty for both our customers and Intuitive and maintains our ability to advance the safety, quality and security of our products. And with that, I'll turn the time over to Jamie to take you through our finances in greater detail.

Jamie Samath

Good afternoon. I'll 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. The strength of our financial performance this quarter reflects the durability of our business model, driven by an expanding portfolio of differentiated products that provide clear clinical and economic value for our customers and their patients. Increasingly, our da Vinci and Ion systems and the Intuitive ecosystem are being integrated into customers' core infrastructure across a variety of procedures, sites of care and geographies, driving value for hospitals and health care providers and recurring revenue for Intuitive.

Today, we are also quantifying the instrument pricing actions we discussed in July, which we expect to reduce da Vinci I&A revenue per procedure by approximately 3% to 5% on a mixed constant basis once fully implemented. This is a deliberate choice to broaden adoption in high-volume benign procedures, and I will describe these actions in more detail shortly.

Key financial highlights for the quarter are as follows: Revenue grew 22% to just over $3 billion, of which 84% was recurring revenue. Net da Vinci placements, that is placements that expand the installed base grew 40%. Non-GAAP operating margin was 42% of revenue or 41%, excluding a onetime pretax tariff refund of $28 million. Non-GAAP earnings per share grew 25% to $3 per share. Core metrics were solid in Q3. Taking da Vinci and Ion together, total procedures grew 15%. The installed base of systems grew 13% and average system utilization increased 2%. Revenue growth of 22% against total procedure growth of 15% reflects our innovation-led strategy and growth in system placements. As da Vinci 5, SP and Ion become a greater proportion of our business, revenue growth benefits from a richer product mix higher levels of integration and incremental upgrade volumes.

Additionally, the scale and cost advantages we have built allows us to broaden our platform portfolio, which customers in more geographies and expand access by lowering the cost of da Vinci surgery. The price reductions are concentrated in high-volume benign procedures where costs may be a barrier to adoption. Those procedures particularly outside the U.S. and in ambulatory settings where we see the largest opportunity to serve incremental patients. This is a strategic decision to reinvest a portion of the value our innovation creates in lower customer costs where they will have the greatest impact on adoption. We believe broader adoption creates more long-term value than near-term revenue per procedure.

Turning to the clinical side of our business. In the U.S., total procedures increased 11%, reflecting 10% growth in da Vinci procedures and 29% growth in Ion procedures. U.S. da Vinci growth of 10% was consistent with the expectations we described in July and reflects in part a 16% growth in the prior year quarter, our most difficult comparison of the year -- after hours procedures and benign gynecology procedures other than hysterectomy continued to lead growth. Da Vinci 5 accounted for more than 1/4 of U.S. procedures in Q3, up from 13% a year ago and da Vinci 5 systems continue to run a utilization above our Xi base.

Looking ahead, we believe the breadth of surgeon adoption, the continued expansion of benign general surgery and a growing da Vinci 5 an SP installed base, together with procedures early in adoption, including emergent general surgery, cardiac and nipple sparing mastectomy positions us for durable U.S. procedure growth over the long term. In the short term, we continue to monitor the impacts from lower ACA enrollment, changes to Medicaid eligibility and potential changes to 340(b). Outside the U.S., total and da Vinci procedures grew 20% with Europe up 20%; Asia, up 19% and rest of world geographies up 22%. In Europe, growth was led by the U.K., Germany and Italy. In Asia, India and Taiwan led growth and Japan procedure growth accelerated, reflecting early signs of a response to the June reimbursement changes.

Procedure growth in China was roughly in line with the corporate average, reflecting lower recent capital placements. In Rest of World markets, growth was led by Canada, Australia and Brazil. Within OUS results, da Vinci adoption for benign procedures continued to accelerate, growing 41% in Q3 up from 37% in Q2 and 34% in Q1 with the strongest growth in hernia repair and cholecystectomy.

Benign procedures represent over 1/4 of our international volume today and a significant majority of the gap between our current international volumes and the addressable opportunity, which is why they are a focus of our investments.

As we build local clinical and economic evidence, a growing number of customers in OUS markets are recognizing the clinical benefits of da Vinci for these procedures and our tiered system portfolio, including XiR together with the pricing actions I will describe shortly, provides customers the flexibility to rightsize their programs relative to local reimbursement. Third quarter SP procedure growth was 55%, reflecting accelerated growth in the U.S. of 50% and growth of 40% in Korea, our largest SP market. We now have 487 SP systems installed across 27 countries and procedures in the 25 markets other than the U.S. and Korea nearly doubled from Q3 last year. Total I&A revenue in quarter 3 grew 18% to $1.8 billion. Da Vinci I&A revenue per procedure was approximately $1,860 compared to $1,800 last year, primarily driven by higher SP procedures and da Vinci 5 specific I&A, partially offset by procedure mix.

With respect to instrument pricing, there are 2 developments to describe. The first is a set of pricing actions we will implement beginning in the first half of 2027 including the expansion of our extended use program announced in May. The second is a policy-driven price reduction in China that starts to take effect next month. As Dave described earlier, customer needs are increasingly segmented and complex procedures, value comes from innovation and clinical capability in high-volume benign procedures such as cholecystectomy, and inguinal hernia repair it comes from a reliability, efficiency and economics, and that's where our pricing actions are focused.

Beginning in the first half of 2027, we will extend the useful lives of a subset of core endorse instruments on our fourth and fifth generation platforms and introduce volume-based pricing, both lower our customers' cost per procedure, years of investment in instrument design and manufacturing scale enable us to preserve the quality and reliability customers count on.

In the U.S., the extended use instruments require a 510(k) clearance, which is in process. In China, the charge curve policy changes we described last quarter will result in a significant reduction in our I&A prices in that market beginning in November. We continue to engage with provincial governments on implementation and to progress through the green channel process for SP and da Vinci 5.

Taken together, we expect these pricing actions in the China price reduction to lower da Vinci I&A revenue per procedure by approximately 3% to 5% on a mixed constant basis once fully implemented, meaning holding procedure product and geographic mix constant to isolate the pricing changes themselves. For reference, that is less than the 7% we estimated when we launched our first extended use program in 2020. The accretive dynamics we described last quarter, including Force Feedback adoption, and the mix shift towards da Vinci 5 and SP are not included and will be positive contributors to I&A revenue per procedure.

In terms of timing, the China reduction takes effect in the fourth quarter while the extended life instruments as part of our broader I&A pricing actions will roll out by country beginning in the first half of 2027. So the remaining impact will build progressively over 2027 rather than as a step function. Turning to clear procedure categories that we expect to be future growth drivers. Cardiac procedures grew 40% in Q3. And during the quarter, we received CE Mark for use of da Vinci 5 in cardiac procedures in Europe.

We now estimate that the line of sight cardiac opportunity is between 300,000 and 400,000 procedures a year in the regions we are cleared. Separately, breast surgery grew 42%. Both remain early-stage opportunities whose near-term pace is linked to the training of surgeons and the accumulation of clinical evidence, and we are investing in both. Today, these procedure volumes are still small relative to our total volume. Turning to capital performance and starting with our da Vinci business. We placed 546 da Vinci systems in quarter 3, an increase of 28% compared to 427 systems in Q3 last year. Demand was broad-based across our platform portfolio, 315 da Vinci 5 systems, 87Xi,65XiR, 42 SP and 37x systems. Da Vinci 5 placements included 41 in OUS markets, up from 12 last year as da Vinci 5 becomes available in more countries. In the U.S., we placed 335 systems up 27% from the 263 systems placed last year, driven by an increased number of multi-system deals as customers continue to convert to da Vinci 5.

Building on our focus on ambulatory surgery centers, we installed 18 systems at U.S. ASCs in Q3, including 15 XiR systems. This is an early-stage multiyear effort and placements will be uneven quarter-to-quarter, but our pipeline of ASC opportunities continues to build informed by customer familiarity with XiR's capabilities and reliability and its favorable cost profile. Outside the U.S., we placed 211 systems, an increase of 29% compared to the 164 systems placed last year. By region, we placed 115 systems in Europe, up 83% from 63 last year, 78 in Asia, up 30% from 60 and 18 in rest of world countries compared to 41 last year. Rest of World placements tend to be uneven quarter-to-quarter. Europe's performance reflected our broadening focus with record partly placements in Portugal, Turkey and Austria and solid growth in Poland, Croatia and Romania. Across all geographies, we placed 37 X systems and 65 XiR systems with purchased ASPs of approximately $0.5 million and $1.2 million, respectively, demonstrating our ability and willingness to compete effectively across the broad spectrum of customers and their economic objectives.

Over the last 3 years, we have entered new geographies and including Croatia, Peru, Morocco and Lithuania. And in 2027, we plan to accelerate our expansion into additional countries we do not serve today. Given increasing investments in OUS markets and planned expansion into new geographies, in January, we plan to update our estimate of the long-term opportunity in soft tissue surgery. We placed a record 42 SP systems in Q3 including 21 in the U.S. and 12 in Korea, and the installed base of SP systems increased 42% from the year ago period to 487 systems. For our Ion platform, we placed 56 systems in Q3 compared to 50 systems last year. Given our capital performance, Quarter 3 systems revenue grew 30% to $769 million. The average selling price for purchased da Vinci Systems was approximately $1.6 million, flat to last year as a higher mix of Da Vinci 5 was primarily offset by a higher mix of XiRs. Quarter 3 service revenue increased 22% to $482 million, reflecting the increased installed base of da Vinci and Ion systems and a higher mix of da Vinci 5.

Turning now to the rest of the P&L. Non-GAAP gross margin for the quarter was 69.9%, an increase from 68% in Q3 of last year. Q3 results included a onetime benefit of $28 million from the refund of previously paid IEEPA tariffs. Excluding this benefit, non-GAAP gross margin would have been 68.9%, an improvement of 90 basis points year-over-year. The underlying improvement primarily reflects product cost reductions and fixed overhead leverage and our engineering and operations teams continue to execute on cost reduction programs across each of our platforms.

Quarter 3 non-GAAP operating expenses increased 18% year-over-year, driven by increased variable compensation, reflecting our results, higher head count and higher prototype expenses as several programs advanced in development, R&D, again, grew faster than SG&A, a portion of the increase reflects the timing of expenses between quarters. Given the progress our R&D teams are making and the opportunities in front of us, we will continue to prioritize incremental investment in our existing and new platform and in advancing our AI capabilities, which we believe will meaningfully differentiate our solutions and expand the number of patients we can serve. Non-GAAP other income was $75 million for the quarter compared to $83 million last quarter, reflecting lower average cash balances following our share repurchases.

Our non-GAAP effective tax rate for the quarter -- for quarter 3 was 21.4%, consistent with our expectations. Now turning to our GAAP results. GAAP net income for the quarter was $523 million or $1.49 per share compared to $704 million or $1.95 per share in Q3 of last year. Our GAAP results reflect the $450 million litigation settlement that Dave described earlier. This settlement is subject to court approval, and we do not expect that decision until next year.

We ended the quarter with $6.8 billion in cash and investments, down from $8.6 billion last quarter. Cash generated from operating activities was more than offset by stock repurchases of $2.9 billion at an average price of $377 per share and capital expenditures of $113 million. With that, I'll turn it over to Jamie to discuss recent clinical publications.

Unknown Executive

Thank you, Jamie. It's a pleasure to speak with you this afternoon. As we routinely do on these calls, I'd like to share with you recently published peer review literature that we found to be notable. In addition to the specific data highlighted on this call, we encourage you to consider this data alongside the wider body of evidence detailing these topics and others and published scientific studies over the years. On our Q4 2024 earnings call, we described the landmark COMPARE study a med analysis where the authors reported multiple benefits for the da Vinci approach when compared to alternative minimally invasive or open approaches in commonly performed oncologic procedures. Last month, Dr. Thomas Shen and colleagues from the Massachusetts General Brigham and the University of Virginia School of Medicine in collaboration with researchers from Intuitive published the benign COMPARE study, comparing perioperative outcomes of benign minimally invasive, laparoscopic, da Vinci robotic and open procedures, a systematic review and meta-analysis of evidence in [indiscernible] of surgery open. This benign COMPARE study looked primarily at standard perioperative and 30-day clinical outcomes of 13 high-volume benign procedures across general surgery, gynecology, urology and bariatrics, including, but not limited to, benign hysterectomy, cholecystectomy, benign colon and various hernia repairs.

In many of these procedures, conventional laparoscopy has long been the standard of care. This met analysis included data from 366 studies across 32 countries, published between 2010 and 2024 and included randomized controlled trials, prospective and retrospective cohort studies and large real-world database studies. In total, the analysis covered roughly 1.5 million da Vinci patients, 10.7 million laparoscopic patients and 1.7 million open patients. Results identified lower conversions to open surgery as the most clinically important and consistent finding. Compared with laparoscopy, da Vinci procedures were associated with 54% lower odds of conversion with significant reductions observed in benign hysterectomy, [ ventral ] inguinal hernia repair, myomectomy, cholecystectomy and benign colon surgery. As the authors noted, conversion of open surgery is an important intraoperative event associated with increased morbidity and prolonged hospitalization, which is negative implications for patients and health care systems. Da Vinci patients also had 13% lower odds of blood transfusion and a shorter length of stay than laparoscopic patients, with the largest reductions in benign colon surgery, adrenalectomy and benign hysterectomy.

Rates of 30-day complications, readmissions and mortality were comparable between da Vinci and laparoscopy, while average da Vinci operative time were about 24 minutes longer. Compared with open surgery, Da Vinci is associated with larger differences across nearly every studied measure, including 46% lower odds of postoperative complications and hospital stays that were nearly 2 days shorter. These differences are positive implications for patients and health care systems.

The authors concluded that da Vinci was associated with fewer conversions, less pain and faster recovery compared with open and laparoscopic surgery supporting its effectiveness for benign indications. From my perspective as a surgeon, this large-scale analysis of millions of patients provides meaningful data on the expanding use of da Vinci surgery beyond oncology. These clinical correlations point toward a compelling value proposition for the use of da Vinci in these commonly performed high-volume benign procedures. With that, I'll pass the time over to Dan.

Daniel Connally

Thank you, Jamie. Our updated financial outlook for 2026 is as follows: Starting with da Vinci procedures. In July, we forecast full year 2026 procedure growth to be within a range of 13.5% to 15.5%. And with an expectation to be closer to the midpoint. We are narrowing our forecast to be within a range of 14% to 15%, with an expectation to be closer to the midpoint. Our range continues to consider the impact of changes to ACA premium subsidies on patient behavior in the U.S. as well as tender volumes and competitive intensity in China among other factors.

Turning to gross profit. On our last call, we forecast non-GAAP gross profit margin to be within a range of 68% and 69% of revenue, including an estimated 100 basis point impact from tariffs as well as related refunds. We are updating our estimate to be within a range of 68.7% and 69.3% of revenue, including an estimated 90 basis points impact from tariffs as well as related refunds. Factors impacting the range include faster growth of newer products in da Vinci 5 and Ion, partially offset by product cost reductions. We continue to forecast higher input costs in certain areas like freight and semiconductor memory. Our actual non-GAAP gross profit margin will vary depending largely on product, regional and trade-in mix and pricing. For operating expenses, we continue to expect 2026 non-GAAP operating expense growth of 11% to 13%.

As a reminder, in Q4 2025, we made a $70 million multiyear contribution to the Intuitive Foundation. We do not expect to make a contribution to the foundation in 2026. Throughout the year and in Q3, in particular, we grew R&D at a rate above SG&A. We expect that trend to continue over the remainder of the year. We now estimate noncash stock compensation expense between $860 million and $870 million. We now forecast non-GAAP other income, which is comprised mostly of interest income, of between $300 million and $310 million, due primarily to the impact of share repurchase activity in Q3.

With regard to income tax, we expect our non-GAAP effective tax rate in Q4 to be 22%, plus or minus 50 basis points. That concludes our prepared remarks. As we open the line to your questions, we ask that you limit yourselves to 1 question so that we may reach as many analysts as possible.

Operator

[Operator Instructions]

Our first question comes from the line of Lawrence Biegelsen with Wells Fargo.

Question-and-Answer Session

Larry Biegelsen

I'll just keep it at one here, focused on U.S. procedure growth. So Jamie or Dave, U.S. da Vinci procedure growth was stable on a stack 2-year basis. But the 10% growth in the quarter was the lowest we've seen since COVID. Shipments were strong and it sounds like you have a ton of innovation and the extended use program is coming. So are we seeing a temporary lull in U.S. da Vinci procedure growth and the innovations and the pricing actions will help accelerate U.S. da Vinci procedures as soon as next year? I'd love any color on that.

David Rosa

Larry, this is Dave, and I appreciate the question. Let me frame up the U.S. opportunity a bit and then Jamie can dive in with some specifics. So for me, the U.S. opportunity really breaks down into 2 areas. The first is about the addressable opportunity right in front of us that we're going after on a daily basis and the second is a longer-term opportunity to expand the indications that da Vinci can have an impact in. And so if we look at the first part, for the procedures that we know where the U.S. procedure opportunity is significant, particularly in benign general surgery. When I'm talking to customers, in order for them to adopt robotics across the benign general surgery areas as well as other benign indications. They really want to see how it compares to the alternatives where laparoscopy as well in trends like Jamie described and against open surgery sometimes. They want to see how they're doing clinically, how is it doing economically and that is something we've invested in for a long time. We've worked hard to provide customers the data that they need from Intuitive, combine it with their data so they can understand how those modalities are doing against each other.

In Q3, I had the opportunity actually to meet with about 5 large IDN customers. And when I was meeting with them, what I'm seeing is now they are developing their own real-time dashboards, looking at the economics and the clinical outcomes relative of da Vinci relative to laparoscopy and open. And I think that's a shift that I believe is worth noting because it's moving from anecdotes and sort of episodic data that they may look at once a year, and they're looking at it on a routine basis.

And so when I saw those data and talk to those customers, robotics is comparing favorably as compared to the other modalities. And so you take that, that sort of foundation of data. You get directional data from studies like COMPARE but you get the actual data in our customers' hands through these interactions like I'm describing. Combine that with our portfolio, the rest of our ecosystem with the commercial performance of our capital expanding capacity with the focus of our commercial teams broadly, clinical service, training and in the pricing actions that Jamie described. And I think that's the foundation of durable U.S. procedure growth into that significant opportunity.

Jamie Samath

Larry, I might just add. The way we think about it, the unit opportunity in front of us in the U.S. is significant. I understand investor attention on the U.S. kind of growth over the last several quarters. There's 4 things that we're focused on that we're driving, maybe just to add some color. First is adding capacity, particularly to support the benign general surgery growth. And what you saw in this quarter was U.S. net placements increased 41% and that's a little bit of a change from what we've seen in more recent quarters. Second thing is, as we've talked about, we've more recently added a focus on the ASC opportunity. If you look at the number of systems we've placed in ASCs last 2 quarters combined, that's more than we've placed in ASCs in almost the last 3 years and we think that continues to be an attractive opportunity for us.

And those first 2 areas are supported by both the I&A pricing actions that we've described and our tiered portfolio if you want to invest in da Vinci 5 in the hospital with its capability with the capability that will only grow every year as we do software updates and extend the ecosystem, that's a good investment. But our tier portfolio offers those customers an XiR in HOPD or an ASC. The other 2 areas that we're driving, we're focused on over longer horizons, 3 is to kind of progressed cardiac and breast along the early-stage adoption curve it's in, and that requires both investment and execution.

And then the fourth is what Dave described. We have programs today in R&D that have the potential to add new indications in the U.S. and elsewhere, and those are moving along and progressing and those are quite interesting. Again, they're on longer-term horizons.

Operator

Our next question comes from the line of Robert Marcus with JPMorgan.

Robert Marcus

Great. I want to follow up on the extended use, and it's great. I appreciate the 3% to 5% headwind over the total enactment period both between that and the China pricing. How do we think about necessarily the time lines? Will there be any stocking ahead of the implementation of this? And how do we think about it down the P&L both from a gross and operating margin. if I could add 1 more there. Last program, you did have a price elasticity benefit on volumes. How are you thinking about volumes in response to the pricing actions.

Jamie Samath

You'll probably have to remind me of your questions, Robbie, as I go along. But there may well be a little bit of stocking kind of customer ordering patent volatility across the period in which we launch. I wouldn't expect that at this point to be significant, and obviously, we'll call that out as that occurs. In terms of the impact on gross margin, I would say that it would be a modest impact on gross margin that will look across '27 to offset with the cost reduction programs that we have in play. And therefore, whatever impact there is on gross margin can fall through to operating margin, but I expect that to be smaller and offset at some point in the year.

With respect to elasticity, I would just say we believe that these actions will drive elasticity. That's the underlying intention because where we're applying them to the greatest extent is where there are cost sensitivity or cost as a barrier to adoption. And the benefit for those high-volume benign procedures is quite a bit greater than the blended 3% to 5%. Obviously, that's our intention. We have looked back at the first EUP program that we did in 2020 on our data supports the existence of elasticity, and we have confidence that, that implementation was was successful.

That, of course, is looking at our own data, but also gaining feedback from our customers. And so over time, as we address economics, when you think about how we frame our line of sight opportunities. As we address economics and bring costs down, we expect to increase the addressable market for Intuitive. And so those are the underlying intents. But I think we have relative confidence in the elasticity. That doesn't obviously turn on immediately in 2027, but over time.

David Rosa

I know that pricing is a focus of the question as it relates to benign procedures and addressable opportunity, but I also -- I want to make sure that we are recognizing the value of our entire portfolio. And so da Vinci 5 and its innovation, we're pricing such that innovation is correlated to the value it creates. And so we have that thrust and that focus in our portfolio while actively doing the lowering of costs that Jamie described because that's where broader access matters. And so it's not a trade-off. It's our strategy to really expand our addressable market and serve more patients around the globe, and we're confident that it's going to make a difference as we look forward.

Operator

Our next question comes from the line of Travis Steed with Bank of America.

Travis Steed

Maybe just a pipeline question, especially with this quarter being probably the biggest quarterly buyback you've ever done. So congrats on that. There's a lot of focus on U.S. procedures. And one of the things I've thought about is there are things that -- in the pipeline that can add revenue for procedure. And as we're looking at the pipeline, I know there's anything you'd like to point to or what could be coming on AI use cases or imaging things or even anything that's interesting on the GI robot or lung cancer that could be helpful for investors at this point.

David Rosa

Yes. Thanks, Travis. It's a great point and one that we've described a couple of times in previous quarters. Starting maybe with Ion actually, the 2 active development programs that we have that are progressing strongly. One is around a Rose system, and that's on-site cytology so that the physician and the care team can understand if they the cells may be cancer or not real time. And so they can get better answers than they do today and do it more quickly. And the second program there is endobronchial ultrasound integrated into the ION platform. And so that allows us to do staging. Both of those should be in bring value to the Ion program, speed up at the time, we think from detection to diagnosis and ultimately treatment, but will be accretive to the revenue per case on the Ion platform.

You mentioned Vision is another area that we're very excited about when it comes to da Vinci. And so we have multiple programs going there with advanced visualization technology around hyperspectral imaging, fluorescent molecules and some AI features that we do think will bring that incremental value, and we're going to be able to add some revenue per procedure as a result. And so it is exactly my point of this is where innovation can bring outsized value to the customer and then bring some accretive revenue on a per procedure basis to Intuitive and we have that across our portfolio.

Operator

Our next question comes from the line of Rick Wise with Stifel.

Frederick Wise

Another question about the ASC opportunity. Can you talk about your progress and what's next? And maybe frame the contribution to future growth and how these next-generation extended use approach maybe impacts the opportunity. But related to that, maybe you can touch on now just with the Stryker CMR news, we have 2 competitors likely offering modular systems in the ASC. How are the competitive dynamics play in there? Does Intuitive need a modular offering of some kind? And just help us think through those various points.

David Rosa

I appreciate the question, Rick. And maybe I'll break it down into kind of 2 parts because one is around the ASCs. And again, we've described this before. If you talk to ASC customers, what they're asking for is not a particular architecture. What they're asking for is something that can be repeatable, easy to learn, easy to use, reliable and serve the procedures that they're targeting for the ASCs in a very consistent away because it's about volume and it's about getting patients out in a repeatable noble way. So if you use that as the problem to be solved in the ASC environment, now you can start saying, what kind of technology matches that invest serves that problem or solve the problem to be solved. And so if you look at how might customers look at robotic competitors and make a choice. And for me, it comes down to basically 3 areas.

One is it's got to be the right architecture for the ASC. It's got to be -- have the right portfolio of systems so that it can be priced in a manner that fits their economics. You got to have that broader ecosystem because we know that's what leads to good outcomes. And then you have to have the supporting infrastructure. All the teams and capabilities that are required to make sure a program runs at pace. And so customers understand this.

They're now looking across potentially multiple solutions, and they're they understand that it takes more than a robot. It does take an ecosystem, but the robot is front and center. And so you asked about the architectures. And if I look back over our 30 years, we have engineered and tested just about every form of architecture there is out there.

And that includes modular, table-mounted and other types of robots. We brought in customers to assess them and to evaluate them side-by-side with us. And we continue to believe that a cart-based architecture consistent with da Vinci is the best option. It's the best balance of capability and usability no matter where you look, and it might be in the main OR or in the ASC environment. And so if you we believe that it is not required to have a modular type of architecture to serve the needs of the customer in these segments where they are doing benign procedures and maybe increasingly complex procedures over time. And so I think we are well positioned with our portfolio, the pricing that Jamie described to serve the needs of our customers there, and we look forward to earning their first choice.

Jamie Samath

And Rick, maybe just some framing in terms of numbers. These are a bit lagged, but we think a little under 10% of the U.S. soft tissue surgery business is in ASCs today that's growing. About 70% of those volumes are ASCs associated with or affiliated with existing IDNs. So they are customers and surgeons that we know. That's our initial focus our penetration of kind of all of the ASC opportunity is low in the first quarter. And that's why now that we have XiR and we have the supply XiR, it's a focus of ours.

Operator

Our next question comes from the line of Adam Maeder with Piper Sandler.

Adam Maeder

I wanted to ask about UP 2.0 and specifically one of the offsets -- the potential offsets for sensing instruments. And if I heard directly, it doesn't sound like there's any offset assumed in the 300 to 500 basis point headwind for these. So I would love just any update on for sensing instrumentation, where is adoption today? What percentage of procedures are being done with for sensing? And how do you think it could evolve over time? And would also just appreciate any color in terms of kind of primary use cases for the for sensing technology.

David Rosa

Adam, I appreciate the question. Maybe I'll start with a quick story that just happened. And so a few weeks ago, we hosted the surgeon event here where the early surgeons that were involved with da Vinci came to our campus and we had a nice event. I had the opportunity to meet with a very well-versed prostatectomy surgeon who has done over 10,000 cases, and he showed me his results that were a comparator between Xi and da Vinci 5 and he was showing the return of potency in this case from time 0 through 12 months. And so -- and you watch it gradually increase from about 50% or so out of the gate to above about 80%. And he has very good data, he's one of the world's surgeons. And then he laid his recent da Vinci 5 experience on top of it and have moved the entire curve up by about 10 points.

And so -- and I asked him why, and he has attributed to that to Force Feedback and the ability to sense those forces and be that much gentler around the nurse sparing portion of the prostatectomy, which led to those results. And so that's maybe a little bit of color about how Force Feedback can make a difference in outcomes and even with surgeons who are very, very high up in their use of da Vinci.

Jamie Samath

In terms of adoption this quarter, about 8% of da Vinci 5 cases involve Force Feedback that's kind of been kind of a slow increase from where we've started. We only got full full supply later in the quarter. So that affected the 8%. I would say this, our ambitions for that number to be -- that penetration number to be quite a bit higher. Obviously, to some extent, that requires us to create the evidence that supports the value propositions. The teams are working hard on that, and we have our eye very close in terms of how that gets adopted and the actual value of using the force feedback instruments is well understood. I would just say there are other offsets as we described. The SP I&A per procedure is quite a bit higher than multiple. And obviously, those procedures are growing at a much higher rate. And on da Vinci 5, because of the integrated insufflation, when integrated insulation is used, which is about 85% of the time, there's an additional about $100 per procedure for the tube sets that connect to the [ insulator ]. So those 3 can drive offsets in terms of the 3% to 5% and they generally would be expected to grow at a faster pace than the base INA.

Operator

Our next question comes from the line of Jayson Bedford with Raymond James & Associates.

Jayson Bedford

Maybe just for Jamie. On the EUP, how long will it take you to fully implement the program, meaning when do you expect to see the 3% to 5% gross impact on revenue per procedure? And is there any way to kind of frame the expected impact in '27?

Jamie Samath

Yes. It will be country by country. The first is the U.S. As I said, that submission is in process. So we'd expect to start to roll that out sometime later in Q1 depending on obviously when we get clearance. Europe, it would be next, and that's not until the second half of '27 and then some of the other markets just before or just after that. So I don't think we get to the full impact until the end of the year, frankly.

Operator

Our next question comes from the line of Matt Taylor with Jefferies.

Matthew Taylor

I did want to follow up on the settlement that you talked about today. You mentioned one time, no fault and just provide some certainty for your customers. I guess -- just wondering what this practically means for your customers and how they move on from that? And if you could just talk about remanufacturing in general and whether there's been any kind of real headwind.

David Rosa

Yes, sure. Maybe I'll start, and [indiscernible] will please weigh in. So this settlement really is an agreement with our customers, specifically regarding third-party instrument marine manufacturers and third-party service providers. And I think the important part here is that it provides a clear framework and how we'll continue to work together in those 2 specific areas and it lets us focus on really the things that are important. So advancing the safety, quality and security of our products for surgeons, care teams in their patients.

And so we believe that this certainty that it provides allows us to move forward and really focus on building value with our customers.

Jamie Samath

Just to add briefly, I think the resolution really strengthens our customer relationships and it just provides a defined framework for how we work together on instruments and servicing.

Operator

Our next question comes from the line of Chris Pasquale with Barclays.

Unknown Analyst

I wanted to ask about margins. You guys have done a great job improving profitability over the past few years. This quarter was better than expected. Street's modeling operating margin flat next year. So while I appreciate you don't really want to get into '27 in detail right now. You talked about offsetting the gross margin headwind from extended use. Are there any other considerations that we should take into account as we think about profitability and your ability to continue to expand margins here going forward?

Jamie Samath

Yes. I think what we've said for some time now is kind of the range of where we'd expect to be on operating margin is between 35% and 40%. And I think that's, frankly, best-in-class in med tech. As we think about it from a strategy perspective, our lean is to invest, invest in areas where we can innovate and bring differentiated capability to our customers and their patients, but also to support investments that allow us to grow at accelerated rates so that we can, again, serve more patients. And where we are right now, 41%, 42%, we have the capacity to invest. And so as we finish our planning process, then want to evaluate that carefully. I'm not ready to say what we'll do on operating expenses, but certainly, if there are opportunities for us to do what I just described, then we'll use that capacity to invest. We'll provide that guidance, obviously, in January.

Daniel Connally

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 turned to 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 in their environment.

At Intuitive, we envision a future of care that is less invasive and profoundly better where diseases are identified earlier and treated quickly so patients can get back to what matters most. Thank you for your support on this extraordinary journey. We look forward to talking with you again in 3 months.

Operator

Ladies and gentlemen, that concludes today's conference call. Thank you for your participation. You may now disconnect.