PROCEPT BioRobotics CorporationPRCTNASDAQ
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Operator: Good afternoon, and welcome to the PROCEPT BioRobotics Fourth Quarter 2025 Earnings Conference Call. [Operator Instructions] As a reminder, this call is being recorded for replay purposes. I would now like to turn the conference over to Matt Bacso, Vice President, Investor Relations, for a few introductory comments. Please go ahead.
Matthew Bacso: Good afternoon, and thank you for joining PROCEPT BioRobotics Fourth Quarter 2025 Earnings Conference Call. Presenting on today's call are Larry Wood, Chief Executive Officer; and Kevin Waters, Chief Financial Officer. Before we begin, I'd like to remind listeners that statements made on this conference call that relate to future plans, events or performance are forward-looking statements as defined in the Private Securities Litigation Reform Act of 1995. While these forward-looking statements are based on management's current expectations and beliefs, these statements are subject to several risks, uncertainties, assumptions and other factors that could cause results to differ materially from the expectations expressed on this conference call. These risks and uncertainties are disclosed in more detail in PROCEPT BioRobotics filings with the Securities and Exchange Commission, all of which are available online at www.sec.gov. Listeners are cautioned not to place undue reliance on these forward-looking statements, which speak only as of today's date, February 24, 2026. Except as required by law, PROCEPT BioRobotics undertakes no obligation to update or revise any forward-looking statements to reflect new information, circumstances or unanticipated events that may arise. During the call, we will also reference certain financial measures that are not prepared in accordance with GAAP. More information about how we use these non-GAAP financial measures as well as reconciliations of these measures to their nearest GAAP equivalent are included in our earnings release. With that, I'd like to turn the call over to Larry.
Larry Wood: Thanks, Matt. Before discussing our fourth quarter results, I want to share context on progress since joining the company as CEO. When I joined PROCEPT, I outlined an immediate near-term plan for the organization that I believe was critical to positioning the company for its next chapter. It was essential to move with a clear vision, a strong sense of urgency and a culture grounded in discipline and accountability. Historically, PROCEPT executed effectively in its first chapter of growth. That work created the foundation the company benefits from today. However, as the company evolves, so do the requirements for success. The next stage of PROCEPT's development requires shifting the operational focus towards increasing procedure volume, expanding margins and achieving profitability and gaining market share. At the same time, we must deliberately build an organization that supports both near-term performance and long-term sustainable growth. We recently made two changes to our commercial organization that we believe are strategically important for long-term performance. First, we have realigned our commercial team into an integrated regional structure where our clinical and sales functions now report to a common regional leader. The new structure creates a single point of accountability at the regional level to ensure clinical and commercial activities are coordinated around customer success and procedure growth. Second, we formed a dedicated launch team by reassigning a small number of our top performers to focus specifically on new system placements. The intent is to drive more consistent launches, reduce variability in activation and accelerate time to value for customers because we see launches as a key lever to improving downstream utilization and performance. In the near term, the sales realignment and formulation of the launch team creates some short-term disruption. Certain account coverage has changed and temporarily, we have fewer tenured resources in the field as we stand up the launch team. We view this as a normal transition period as teams ramp, establish account relationships and standardize new operating processes. Importantly, we believe these changes better position us for sustained high growth through clear leadership, better alignment and more repeatable launches. We will continue to manage through this transition thoughtfully, and we expect the benefits to build as the organization settles into the new model. Now turning to fourth quarter results. In the fourth quarter, we completed 12,200 procedures, reflecting approximately 69% annual growth. On the third quarter earnings call, we reduced our previously issued Q4 guidance by 1,000 handpiece units as we reestablish customer inventory targets that we felt were appropriate based on usage volume. Separate from establishing inventory targets, it became clear as the quarter progressed that accounts have become accustomed to purchasing large quantities of handpieces and receiving bulk discounts in the final weeks of the quarter. I've always believed pricing discipline is foundational for long-term success. At PROCEPT, I have been focused on implementation of handpiece price discipline. And as part of that, we eliminated the historical practice of providing discounts on bulk purchases, particularly at the end of the quarter. Despite customer requests, we remain disciplined and did not allow bulk purchases at a discount. As a result, handpiece unit sales were approximately 80% of procedures in the fourth quarter and for the first time, procedures exceeded handpieces sold. While this resulted in lower-than-expected revenue, it delivered a significant improvement in handpiece selling price. Average fourth quarter selling price was $3,340 or up $140 or approximately 5% sequentially from the third quarter. Historically, handpiece unit sales exceeded procedure volumes by approximately 8% to 16%. Based on the last several months, we now expect handpiece unit sales and procedure volumes to be in close alignment on a go-forward basis with sustained improvement in handpiece average selling prices. These business practice changes resulted in a reduction of our projected 2026 handpiece revenue. The revenue impact is meaningfully offset by the increase in handpiece average selling prices. Based on the combination of these factors with the short-term disruption associated with the sales force realignment, we are now resetting 2026 guidance to $390 million to $410 million, representing annual growth of 27% to 33%. Before I turn it over to Kevin to walk through the financials, I want to close by previewing what to expect at our Investor Day tomorrow morning. For the first time since the IPO nearly 5 years ago, we will provide a more detailed multiyear look at our financial guidance, including more details on '26 and '27, our path to profitability and an update on the Water IV Prostate Cancer trial as well as a vision for our future. I hope to see everyone there. With that, I'll hand it over to Kevin to walk through the financials for the quarter. Kevin?
Kevin Waters: Thanks, Larry. Total revenue for the fourth quarter of 2025 was $76.4 million, representing 12% year-over-year growth. U.S. revenue for the quarter was $66.6 million, reflecting 10% growth compared to the prior year period. Turning to U.S. procedures. As noted by Larry, we completed approximately 12,200 U.S. procedures in the fourth quarter of 2025, representing approximately 69% year-over-year growth. Handpieces sold totaled 9,400 units at an average selling price of approximately $3,340 during the quarter, reflecting a 5% price increase compared to the third quarter of 2025. Other consumable revenue totaled $2.3 million in the fourth quarter. As a result, total U.S. handpiece and other consumable revenue was $34 million in the fourth quarter of 2025, representing 16% growth compared to the fourth quarter of 2024. Turning to U.S. robot placements. In the fourth quarter, we sold 65 new HYDRO systems. At the end of 2025, we had an installed base of 718 systems, representing a 42% increase compared to year-end 2024. Total U.S. system revenue was $27.6 million in the fourth quarter comparable to the prior year period with systems sold at an average selling price of approximately $425,000. International revenue in the fourth quarter of 2025 was $9.8 million, representing year-over-year growth of 25%. Moving down the income statement. Gross margin for the fourth quarter of 2025 was 60.6% compared to 64% in the fourth quarter of 2024. The approximate 450 basis point shortfall compared to fourth quarter guidance was driven primarily by lower-than-expected U.S. consumable revenue as well as a onetime voluntary field action that contributed approximately 240 basis points of pressure. On a full year basis, 2025 gross margin was 63.7% compared to 61.1% in 2024. Total operating expenses for the fourth quarter of 2025 were $77.4 million compared to $63.4 million in the prior year period. The increase reflects continued investment to support commercial expansion, continued innovation across our BPH platform technology and increased funding for our Water IV Prostate Cancer trial, positioning us to drive long-term growth and expand our clinical and technology leadership. Net loss for the fourth quarter of 2025 was $29.8 million compared to a net loss of $18.9 million in the fourth quarter of 2024. Adjusted EBITDA was a loss of $19 million in the fourth quarter of 2025 compared to a loss of $10.3 million in the prior year period. Cash, cash equivalents and restricted cash totaled $285 million as of December 31, 2025, providing a strong balance sheet to support our strategic priorities. Moving to our 2026 financial guidance. We now expect full year 2026 total revenue to be in the range of approximately $390 million to $410 million, representing growth of approximately 27% to 33% compared to 2025. This guidance range assumes international revenue to be in the range of $50 million to $51 million. Additionally, we now expect 2026 total U.S. procedures to be in the range of 60,000 to 64,000, representing growth of approximately 39% to 48%. As Larry noted, the adjustment to our 2026 revenue guidance is driven by a few factors. As a result of our business practice changes, we now expect handpiece unit sales to be closely aligned with procedure volumes, which results in a reduction in 2026 handpiece revenue. This revenue reduction is meaningfully offset by the increase in U.S. handpiece average selling prices, which we now estimate to be $3,500 in 2026. Our updated guidance incorporates both factors above in addition to the short-term disruption of our sales organization, as discussed by Larry. Importantly, our 2026 outlook does not change our confidence in the company's long-term growth and profitability trajectory through 2026 and 2027. Turning to gross margins. We expect full year 2026 gross margin to be approximately 65%, which includes $5 million to $6 million of tariff expense compared to $1.3 million in fiscal 2025, which is an approximate 100 basis point headwind to 2026. Turning to operating expenses. We expect full year 2026 operating expenses to total $350 million, representing a 17% increase compared to 2025. After considering all relevant factors, we expect full year 2026 adjusted EBITDA loss to be in the range of $30 million to $17. Our revised revenue guidance reflects positive EBITDA in the fourth quarter of 2026 at both the low and high end of the revenue range. For the first quarter, we expect total U.S. procedures to be in the range of 12,000 to 12,800, representing growth of 29% to 37%. This anticipates the implementation of multiple commercial initiatives designed to drive more durable and sustainable procedure growth. As these initiatives take hold, we expect procedures to accelerate, reaching growth of over 50% in the second half of the year compared to fiscal 2025. We expect total revenues for the first quarter of 2026 of $79 million to $82 million, representing growth of 14% to 19%. Included in our total first quarter revenue guidance is U.S. system revenue of approximately $20 million and $10 million of international revenue. I would now like to pass it back to Larry for closing comments.
Operator: Thanks, Kevin. While financial performance in the fourth quarter was lower than anticipated, the changes we have made are critical to driving sustainable high growth and paving a clear path to profitability. We are very excited to share more details on 2026 and beyond at our investor conference tomorrow morning at 8:00 a.m. Eastern. With that, we are happy to take questions. Operator?
Operator: [Operator Instructions] Our first question comes from Matthew O'Brien with Piper Sandler.
Matthew O'Brien: I think we can ask two. But the first one upfront here is just -- I think, Larry, everybody knew that the quarter was going to be soft on the handpiece side, but the level of softness here just wasn't anticipated. So maybe just talk a little bit more about what unfolded in Q4? And specifically, did you flush -- just looking at some of the math, did you flush about 4,000 handpieces in Q4 on the inventory side? And then I do have a follow-up.
Larry Wood: Yes. Thanks, Matt. Well, first, I'd just say we're dealing with two distinctly different dynamics. The first was we had signaled on the Q3 call that we expect there to be some destocking, but that was really about establishing part levels for accounts based on their usage. And I think directionally, that number was still pretty sound. The thing that came to light later in the quarter was how much our business practices of allowing bulk purchases at a discount was influencing customer purchase behavior. And when we did a deep review of that, I just didn't think it made sense for us on a go forward to be running that practice and discounting that way. I think without that incentive, customers no longer did the bulk purchasing, and that's obviously what contributed to the revenue mix. I think the big thing is it had two positive structural effects for us. The first one was the obvious one of ASP. We saw our ASP increase to about $3,340 in the quarter. But the other thing is it's going to improve our quality and predictability of revenue by aligning shipments more closely with underlying procedure volumes. And the health of our business was never going to be defined on customer stocking patterns or bulk purchases. It's always going to be about our procedure growth. And so that's really what we focused on. And so yes, there was a lot more reduction in inventory. I think our handpiece sales were about, I think, I don't know, 77% of procedure volume. So I think you can do the math on that and get to the number of units that came out. But I think the big thing for us is, as we look at 2026, we're now modeling those being at about a 1:1 ratio, and we're modeling an ASP of about $3,500, which is about a 9% improvement over where we were in 2025. And these are the structural foundational fundamental things that I just feel we have to do to really to ensure our path to profitability in the time frames that we want to be.
Matthew O'Brien: Okay. I appreciate that. And then as far as the guide goes for '26, it's obviously back-end loaded. I'm looking at the Q1 commentary, it's just, it's still -- it's the toughest comp of the year as far as handpieces go, but it's pretty modest. So it just seem like the impact from the commercial reorg is still going to be influenced in Q1. I guess, why such confidence that you're going to see this benefit towards the back half of the year? Because I just don't -- I'm just hoping we don't have to cut the expectation for the full year again?
Larry Wood: Yes. No, thanks, Matt. And I understand your question completely. We put a range and try to give guidance on where we think we're going to be in Q1. And I think Q1 always starts a little bit slow coming out of the holidays. That's always something that we have. And I think I've seen that in previous companies as well. I think the other thing, though, is we did just signal that as the as the sales force matures into the new alignment as they rebuild relationships with customers, we have people covering different accounts. We just wanted to signal that there's -- that's going to take a little bit of time for it to mature. But we do think these are going to pay dividends to us. We do think having people that are just dedicated solely on procedure growth in their territories and they're no longer distracted by launches and then having dedicated launch teams, we do feel that, that's going to pay benefits. But those are going to show up more in the back half of the year rather than the front half of the year. And we're going to provide a lot more detail tomorrow. We're going to walk across the procedure walk. And you're -- we're going to be completely transparent about it. I know we've talked before about really procedure volumes. We focus on handpiece revenue. But tomorrow, we're going to walk through all of that in detail and I think give you all the components of it. And I think you'll be able to make informed decisions about how confident you could be in our plan.
Kevin Waters: I just want to follow on to Larry here, Matt, this is Kevin. And we're going to go through this, as Larry mentioned tomorrow, to give a full cohort analysis. And to your concern or question around the low end of the range, we're going to provide everybody with comfort that at the low end of the range, we are only expecting very modest utilization growth in our legacy installed base. We're actually going to show you that tomorrow to directly answer your concern that you just brought up.
Operator: Our next question comes from the line of Chris Pasquale from Nephron Research.
Christopher Pasquale: It looks like handpiece sales exceeded procedure volumes by a little over 10,000 units over the past 3 years, including this quarter's drawdown. So what gives you confidence that the ratio is going to be 1:1 in '26? Why shouldn't the rest of that gap need to be closed?
Larry Wood: Yes. Thanks for your question. I think there's a couple of things here. When we look at the history here, handpiece sales have been about 108% to 115% of procedure volume, and now we're modeling that at 1:1. But we're modeling it 1:1 even though that we're going to increase our installed base by a couple of hundred systems that are all going to have to take inventory and take stocking orders and do all those things as we expand our installed base. So even with that, we're modeling at a 1:1. Based on all of our analysis and assessments, I think there's probably more upside to that number than downside. But I think 1:1 is where we're modeling it at. And that's a significant change from how we've done all of our previous modeling. And that actually is probably the biggest impact to the reduction in guidance. If we would have modeled handpiece sales at 110% even of procedures like we historically had, then that would have been worth a little over $20 million, probably $20 million, $22 million. And we're able to offset a lot of that with the price increase. But again, I think the long-term health of our business is going to be focusing on procedure growth and having steady, stable revenue. The other thing I can say is we made this change in the fourth quarter of pretty much the last month. So we have about 8 or 9 weeks of runway under this new business practice. And we continue to see now handpiece sales and procedures pretty much flying in formation. And I think that's what gives us confidence that that's that the 1:1 ratio is going to be appropriate for 2026.
Christopher Pasquale: Okay. And then, Kevin, you talked about the gross margin impact of a field action in the quarter. Could you just give us some details around what that was and if that impact is contained to the fourth quarter?
Larry Wood: Yes. I'll start with the field action. And here's what it was. It was a onetime nonrecurring field action. There were no patient safety issues. There were no concerns. It had to do with compatibility between the handpiece and between the system itself. And what we did was we were just able to go to a field upgrade that just took that issue off the table for us. And so we've upgraded our systems and made the appropriate changes. So that was contained in the fourth quarter. Kevin, if you can walk through the math on it.
Kevin Waters: Yes. It was approximately $1.5 million, which was 240 basis points of pressure is the math. But as Larry said, onetime, and it will not impact us moving forward.
Operator: Our next question comes from Josh Jennings of TD Cowen.
Joshua Jennings: I was hoping to just get a better understanding of the fourth quarter dynamics and the go-forward outlook just on ending the bulk -- end-of-quarter bulk purchase deals that were offered previously. Are you seeing any customer dissatisfaction? And do you anticipate that some high-volume or medium volume and low-volume centers will decrease their utilization at least in the short term until these higher handpiece prices are digested?
Larry Wood: Yes. Thanks, Josh. We don't anticipate that, and we haven't seen that. I think there were some customers, frankly, in December that were waiting us out to see if we would bring back these incentives before the end of the quarter, and we didn't. But we've seen the ordering patterns and certainly in Q1 and even late last year, people were having to reorder to support the cases that we're doing. And I don't think it impacted utilization or our case volume, and we haven't heard anything about that. We're just, again, really focused on being disciplined about this. And again, we're fairly deep in Q1, and I just don't think that's impacted us. I think there was a little bit of a mindset in the company that if we -- if people took these orders and we -- and the idea of bulk discounts isn't unique to PROCEPT or anything else. I think people thought like if they have much more handpieces, maybe that would be an incentive for utilization. And I just don't think the two are related at all. So we're going to continue to drive our procedure growth, and that's going to be our key area of focus. That's why we made the changes to the sales force. But we're going to be very disciplined about handpiece pricing. And we're going to be disciplined about system pricing as well.
Joshua Jennings: Understood. And you took -- you made some comments, Larry, just on the -- some disruption just in the commercial work or the commercial restructuring. Just wanted to hear about just the stability of the sales force and some of your all-star clinical specialists and reps on the capital side as well. I mean, is it relatively stable? Are you seeing any attrition? And are you planning on adding to the team as you move forward in 2026 and beyond?
Larry Wood: Thanks, Josh. Yes. No, I think our team has been stable. We haven't seen any higher attrition. When I talk about the disruption, it's not about losing people. And I'll just provide a little bit more color on this, and we'll talk about it more tomorrow as well. But what we did to create the launch teams is we took some of our most tenured people, some of our most seasoned people, and we moved them over to the launch team because we really want launches to go well. And I learned this in my time at Edwards. When we launched TAVR site and they launched -- and they launched well with steady rhythm and steady volume, they just became healthy programs for us. If somebody launched and they launched poorly, it took a long time for them to get up to the projected volumes of where we thought they should be. So we really want to focus on these launches and make sure they go well, make sure teams have all the support and they deliver spectacular outcomes for their patients, especially in those first early procedures. In creating those launch teams, though, we took some of our best people out of the utilization team, plotting at procedure support team. And in doing that, we backfill those positions. We have people in place on those, but they have to rebuild relationships with those customers. You don't have somebody that maybe has a long-standing relationship. And we also realigned territories that we think allow us to better service our customers and drive the growth. But whenever you do that, people have to reestablish relationships and do all those things, and that's just what we're going through now. But this isn't anything that's unique to us when out of the network, and we used to split territories and hire new reps. You have new people calling on established accounts, and it takes time for them to build those relationships. So I see this as being very transient, been very normal. We just did a lot more of it all in one fell swoop rather than the normal course of business where you're splitting territories periodically. But I think we have great people. I think we have people in the right places. It's just going to be a matter of people maturing and selling into their new accounts that they cover.
Operator: Our next question comes from the line of Richard Newitter of Truist Securities.
Richard Newitter: I have two. The first one, just on systems. I think you had said a $425,000 ASP or blended ASP. You did 65 systems. So can you just tell us what the kind of the greenfields were? Were there any operating leases in there and trade-ins, et cetera? And then for 2026 on systems, I don't think you gave an explicit placement number. I think the Street at around 220 something for the year. Doing the math, it would suggest you're basically kind of -- or I think that's what you're backing into. Can you confirm that? And then I have a follow-up.
Larry Wood: Yes. I'll start with the pricing. Our capital pricing varies a little bit quarter-to-quarter, and it really has to do with our customer mix, whether we're selling into some of the big IDNs or whether their individual systems are being placed. So the $425,000 doesn't reflect any softness in the capital. I think what we're modeling next year is we expect ASP for systems to be flat to up compared to what we saw this year. And so that's kind of where we are. And I think in terms of systems, I think we're modeling Greenfields to be very similar to this year. We're going to shed more light on that tomorrow. But Kevin, do you have anything to add?
Kevin Waters: No, we're going to walk through the different components, Rich, of guidance tomorrow, but your observation around roughly flat system sales with a slight increase in ASP is a fair assumption.
Richard Newitter: Okay. And then Larry, just starting from the first quarter or fourth quarter of last year even, I know this predates you, there were some seemingly transient or was explained to us was transient externalities, things like the hurricane, the impact on solution, et cetera. And then there were some onetime factors as we move through the year. And then you -- on your last call, obviously prepared us for this destocking or the stocking component and trying to get that right now. It seems like there was some discounting. I guess with respect to kind of where we are today and what you see in the business going forward, what can you tell us about the health of the actual underlying demand for procedures? Is there anything with the reimbursement changes, doctor usage patterns? Is it all, in fact, self-inflicted type items that are leading to the drawdown here or the lower consumables forecasting? I think there's just been a lot of consecutive kind of noise around procedures, and now we're entering a period where there's some internal self-help factors. So how can you get people confident in your visibility, the ability to execute on this new seemingly reset level and that there's nothing underlying on demand side or the penetration curve that's just -- you're bumping up against the wall?
Larry Wood: Yes. Thanks for the question. And I understand where you're going with this. And again, one of the things that we never reported on before with actual procedures, we always report on handpiece revenue. And to provide a new level of transparency, we -- externally, we're going to talk about procedures. And if you look at our procedure growth, it was almost 70% in the quarter. And so compared to year-over-year. So I think the procedure demand -- and I'll tell you even at that number, we're trying to accelerate well past that and drive further growth beyond that. But it was pretty healthy procedure growth. The revenue shortfall wasn't really driven on the procedure side. It really was about the customer ordering behavior. And it was being driven much more than probably we appreciated by these discounts that people have become accustomed to, and we were living in the cycle of people stocking up at the end of the quarter and then depleting going into the next quarter, which is leading to very lumpy sales. And again, I reviewed that practice with the team, and we just looked at it hard and said, I don't think this makes any sense for us. And if you look at the ASP that we're modeling for next year, I think that's where we're going to get the benefits from it. And to some degree, I traded off continuous this ordering cycling at discounts for having more ASP and steady revenue that's going to mirror procedures. And I just think these are foundational fundamental things that needed to happen. But I feel very strongly that these things are behind us. We've talked about the sales force reorganization that I expect to improve our execution around procedure growth. And we're going to talk tomorrow about what our value proposition is for Aquablation in the clinical community. And I think we have a compelling story to tell. And so if you make the investor conference tomorrow or watch online, we're going to provide a lot of detail on that, that we've never provided before. But I think we have a solid strategy, but it all starts with these fundamental pieces. And price is just something that's always a huge part of that. And our margins and our path to profitability, those are key areas of focus for us. And the steps that we've taken are the things that I believe are going to drive us to the success and profitability that I think we all want.
Operator: Our next question comes from Brandon Vazquez from William Blair.
Brandon Vazquez: Larry, in a story like this, I mean, ideally, we're trying to put this behind us and use the analogy of ripping the Band-Aid off in one quarter. I think what investors often try to grapple with here is that meaningful changes to the commercial side or big inventory changes like this typically aren't a one quarter 1 and done, but it feels like you guys have some of the confidence that, in fact, you're going to just continue growing through the year despite some of the noise going on and even some of the externalities that Rich was talking about that have been impacting the business for a little bit. Maybe you could spend another like couple of minutes on -- you said it's been a couple of weeks that you guys have been doing some of these new initiatives. Any metrics you can give us on what's already being done in the early days that's kind of giving you confidence that this is done, that there's not going to be another thing that we need to change on a go-forward basis?
Larry Wood: Sure. Thanks for the question. Well, I'll start with the procedure matching to handpiece revenue. We made those changes in the last month -- in December of last year. So we have pretty many weeks of run rate now where we're seeing those 2 numbers pretty much aligned. And so that's one of the things that gives us confidence that that's behind us. But again, we're going to increase our installed base by a couple of hundred instruments this year, and all of those are going to need inventory to drive. So even if there was a little bit more destocking in our installed base, which I don't have any evidence that there is, we're still going to have all these new systems coming in that are going to need inventory, which is why I said there's probably a little more upside than downside. But again, I think our focus is going to just be strictly on procedure growth because the health of our business is never going to be impacted by customer ordering or stocking patterns. It's going to be driven by our execution in the field and by growing procedure volumes. And that's why we made the changes to the sales organization, and we made them all at one time, so we can get it behind us. We can get the team moving forward and they can go execute. And we've aligned the team under our common regional leader now to where we have the focus and we have the accountability and aligned incentives to go drive our growth on the things that matter the most, which, again, is going to be procedure growth. So I understand the question and I understand the comments, but we had to make these changes to drive the organization the way that we need to drive it. And I'm building this thing with a multiyear plan in place, not an individual quarter. And so we just had to stop some of these things that I think we're hurting our margins, and I think we're encouraging the wrong customer behavior. And that's what we've done. And I feel very confident that the inventory issue, I feel very confident that is behind us. And on the sales organization, I'm confident that this will pay dividends to us down the road. But again, it's a big organization change. It does take time for those things to settle in as people will reestablish those relationships, but all of that is factored into our 2026 guidance.
Brandon Vazquez: Okay. And switching gears a little bit, just because this will probably start to come up a lot in investor conversations going into the quarter, of course, I'm sure you guys have heard that a lot of noise around PAE given the reimbursement there and a lot of experts doing or a lot of urologists doing more PAE cases these days. You gave the procedure numbers, which is super helpful. But maybe talk to us a little bit what you're seeing in the field and help us bridge like you called 10 urologists and 9 out of 10 of them are doing more PAE, your procedures are still growing. Kind of give us the lay of the land of how you're seeing Aquablation and PAE playing out in the field.
Larry Wood: Yes. No, thank you. We're going to provide more detail on procedure trends at the investor conference tomorrow, but we're still very early in penetrating a market with more than 400,000 surgical BPH procedures annually. So our primary opportunity improving commercial execution is going to be consistently taking share. From a competitive standpoint, we continue to think that we offer a very strong value proposition, particularly related to term. Specific to with respect to PAE, while the site and service economics can be attractive, we're seeing continued variability in clinical durability. And we've also seen more variability in payer coverage. And our current market intelligence suggests that coverage may be more selective over time rather than broader. And as a result, we don't see changing the long-term competitive dynamic for patients who are appropriate for resective therapy. But we're going to show some data tomorrow, and we're going to walk through what we think our value proposition is and why we think we're going to be successful making inroads from a share perspective in this patient population.
Operator: Our next question comes from Suraj Kalia from Oppenheimer & Co.
Suraj Kalia: Larry, can you hear me all right?
Larry Wood: I can hear you fine.
Suraj Kalia: So Larry, I want to follow up on Chris' question. Obviously, the math is the math in terms of inventory in the field. I guess if I could comment it from a different angle, Larry, look, the Board signed off, the Audit Committee had to sign off on the previous sales process, right? Now a completely new process has been instituted. My question, Larry, would be, why now? Why couldn't this be staged? And what specific thing has triggered the Audit Committee, everyone to say, okay, we bless this. This is the path to go and now is the time to do this?
Larry Wood: Well, look, one of the things that we've talked about, and we'll show more detail on it tomorrow is the -- if we look over the last 4 or 5 years, the handpiece revenue was always higher than our procedure volume. And if we look at what was happening with pricing, pricing was pretty stable during that period of time. But I signaled last year that I thought inventory levels in the field were higher than they needed to be, and that's why we signaled that we thought we would take some of that inventory level down. It wasn't until we were deep in the quarter that I think we started to get an appreciation for just how much these incentives were really driving the customer stocking behavior. And I think -- when I look at that, price is such a hard thing to do and improving margins is such a challenge. And I just thought there's a huge opportunity here. To be at a $3,500 price point in our 2026 plan is a really meaningful upside, but that's not going to pay dividends just for us in the short term. That's going to pay dividends over the next several years as we think about our path to profitability and improving our margins. And so the idea that you would try to like whittle these things down and bleed this thing off over many quarters, it was just going to be a headwind that we frankly would have to keep talking about and just gradually do it. And I think we would not have seen the ASP benefit if we would have tried to bleed this off over a long period of time. So we just made the decision. And look, we understand completely why it created a revenue shortfall, but the impact that it has to ASP next year is so significant. To me, again, building these foundational pieces for the long term, it's just critical. And so we just took a step. I think we also wanted to recondition our customers that these practices are behind us and that we're not going to be doing these things anymore. And so they can just order based on their procedural usage rather than ordering on other things. And none of the changes we made impact our future growth trajectory, and they don't impact our path to profitability. So I think they were just the right decisions for us to make. I understand the point that you're making, and sometimes it may look tempting to try to bleed this stuff over time. But then I think you just continue to confuse your customers with these incentive plans. And we just wanted to put that behind us and be done with it.
Suraj Kalia: Fair enough. And Larry, my second question, so you mentioned customer behavior a couple of times in your remarks, presumably that is referring to wanting end-of-quarter discounts and whatnot. So these customers have been -- their behavior has been primed by PROCEPT's sales practices, and it is over multiple years, right? Have you all done a sensitivity analysis based on your existing customer base where the switch that you all are turning on or off, it's going to now change the end customer behavior once again and almost instantaneously?
Larry Wood: Yes. Thanks. We've had multiple weeks of this where we've been dealing with it. Again, we did this in December of last year, we made these changes. So I think we've had a decent run now where we've been able to evaluate that. And we don't really see any impact or change there, and I don't expect that we will. I think the -- I see it in terms of customer conditioning, but we're a party to that as well. We were offering incentives. We were offering discounts. Customers were taking advantage of those. And it just wasn't a good healthy practice for us, I don't believe over the long haul. I think it's far more beneficial for us to see the impact on ASP, but also to have a stable, reliable ordering pattern and revenue stream. And so I think those are just the things that we needed to do, and that's the structural impact of this change, but I think it benefits us over the long term.
Operator: Our next question comes from the line of Michael Sarcone from Jefferies.
Michael Sarcone: I guess just first one for me. I know you're going to give more detail at the Investor Day tomorrow, but you carved out this team that's focused on the launch process. Can you maybe just help crystallize that, give us 1 or 2 examples of what you're attempting to change in the launch process now that will kind of position you for success?
Larry Wood: Sure. Well, here's what happened in the previous org structure was our team -- we just had sort of one field team that was focused on procedures. And then obviously, we had the capital team as well. In the old process, the capital team, they would sell the instrument. And then at some point, the procedure team gets notified of it. And in addition to supporting the installed base, they would have to figure out how to launch this new system, how to provide the support, what doctors want to be trained, how they wanted to be trained. So they were sort of pulled in multiple different directions. And when you think about it this way, you have a capital team that's trying to move capital. You have the procedure team, which is made up of salespeople and clinical people, that they reported up into different leaders and sort of had their own incentives and their own plans and their own objectives. And those weren't always aligned. And so by creating the launch team, it sits under our capital organization so that when the capital team is close to closing on an order, we're already lining up who are the clinicians that need to be trained, what that process is going to be. And then we took some of our most tenured people and put them on the team because we want to make sure for every new system that's placed that they get the best support, the best care so that they have a great launch. And the metric that we're tracking to is time for PO, the time that they complete like their first-line cases. It's not just getting one case under their belt. So we're really trying to drive that repeated excellence and predictability of launches and really running a very standardized playbook, which we didn't really have historically. You have different people doing it differently. And again, they were being pulled from trying to support existing accounts and also trying to launch systems. And in some cases, maybe you're having junior level people do some of these activities. Now we have our best people in place to do those things. The impact of that is we have to rebuild those positions on the procedure team and rebuild those relationships and do those things. But again, we think that's going to pay dividends for us. We ran a pilot in Q4 when we ran that pilot, we saw about a 50% reduction in time to first-line cases when we did under the launch team model, which I think is going to have a lot of impact for us on a go forward. And again, we'll talk more about this tomorrow and go into more detail on it. But these are the foundational pieces that I think we have to get in place. And our goal is by the end of the year that everybody is launching in a launch team model.
Michael Sarcone: Very helpful, Larry. And I guess the second one from me is I'll echo the sentiment from other folks here, 70% procedure growth is pretty impressive. I mean, can you give us any color on how that's split out between maybe older cohorts of existing customers versus newer cohorts?
Larry Wood: Yes. Thanks. Yes, while the growth number was pretty good, I will tell you, we have much more ambitious goals than that, and that's again why we made some of these changes because we want to drive and accelerate that. In terms of where the growth comes from, I will tell you, it's highly variable. And we'll provide a little bit more color on some of our insights tomorrow, but there's just not an easy one answer. It's not to say that every customer is a snowflake, but there's not as much commonality as maybe one would think. But we're going to talk about that tomorrow. And again, we're going to be really transparent tomorrow walking people through our strategy through the changes we've made, why we believe they're going to benefit us and what we're going to do differently on a go forward that hopefully will give people confidence in our strategy and our long-term out.
Operator: Our next question comes from the line of Mason Carrico from Stephens Inc.
Benjamin Mee: This is Ben on for Mason. Are you -- in light of some of the recent changes that you've discussed today, could you update us on maybe your IDNs level strategy? Are you planning to lean more heavily into these negotiations in 2026? And is there any opportunity for maybe some bulk system placements in the 2026 guide?
Larry Wood: I don't know that anything really changes year-over-year. We always are focused on -- we have a team that focuses really on IDNs. We have teams focusing on new greenfield placements. I don't know that anything really materially is going to change from last year to next year. But we're going to talk broadly about our capital strategy tomorrow and try to shed maybe a little bit more light on that, but I don't think there's any massive changes from last year to this year.
Benjamin Mee: Okay. Great. And then you previously noted that maybe Aquablation improved outcome story -- the Aquablation improved outcome story may not be as widely understood by patients today. Are there any patient activation initiatives you plan to launch in 2026 to maybe help drive this messaging?
Larry Wood: Well, if you're interested in that, then you're definitely going to want to tune in tomorrow. We have a very specific plan and strategy about making the clinical case both to patients and to clinicians about the value proposition of Aquablation. But one of the things that I may really want to stress is I think when some people hear patient activation, they think it's just about getting people off the sidelines. But there's about 400,000 people a year that get an invasive procedure for their BPH. And we're only about -- in 2025, about 10% penetrated into that group. So we have a lot of headroom just in taking share from the patients that are already being treated. You go beyond that, there's a whole other funnel of people who are on drugs and other things that we will shed light on tomorrow. But our near-term execution is all going to be focused on moving share. But I think certainly, the patient education and the physician education is going to be a key component of that. I think the other thing that people hear a lot of time is when they hear patient activation, they think Super Bowl commercials and millions of dollars of spend. And that's not anywhere in the ballpark that we're in. We're very focused on our path to profitability and the programs that we have are not going to be of that scale. And what's -- what's really good about this market for us is it's very easy for us to target and identify men with BPH. It's much simpler than, for example, in my old world where you're looking for the 5% of the people over the age of 80 that have valvular heart disease. We know exactly who these people are. So you don't have to cast as wide a net to be able to target the people with BPH. And so we can do much more targeted education programs that I think are going to be impactful.
Operator: Our next question comes from Stephanie Piazzola from Bank of America.
Stephanie Piazzola: I'm sure we'll get more detail tomorrow, but if there's anything you could share now on how to think about that step-up to 62,000 U.S. procedures in 2026 versus the Q4 run rate was a little under $50,000. And then also I just wanted to clarify on the ASP uplift that you expect this year. Is that just a result of the change in the customer ordering practices or something else, too?
Larry Wood: Yes. Thanks. I'll take your second question first. Yes, the ASP pickup is just by not offering incentives or discounts for end of the quarter purchases. And by eliminating that practice, we've already seen the impact on our ASP, and we expect that to continue. On the procedure walk, we are going to go into detail on that tomorrow, but it's going to be a combination. I think the biggest drivers of it, frankly, are going to be the new systems that we're adding, the benefits of the launch team, the growth that we're going to get from that. We don't have massive uptick in our installed base. There's obviously going to be some growth that comes there, but we know it's going to take a little bit of time for some of our programs to take hold. But we're going to go on a detailed walk tomorrow to walk through kind of the puts and takes on how we take our procedure total from what we had in 2025 to what we had in 2026.
Stephanie Piazzola: Got it. And then just on the sales force realignment and some of the potential disruption there, how do we think about where you are in that process and how much is left to go? And how do we think about the disruption turning to a benefit and when that happens?
Larry Wood: Yes. Thanks. All of the changes structurally in the organization have been made. So those are all made. Those are all in place. We rolled them out at our sales meeting in January. And so all of that work has been done. Everybody has their account targets, everybody has their quotas, everybody has their revised incentive plans. All of that work has been done. I think it's now just a matter of people maturing into these roles, learning their new accounts, building those relationships and doing the things they need to do. And just -- again, I don't want to overstate things. It's not like every single customer got a new rep. A lot of things did hold over from the old as we realigned territories. And we did pull some people out to the launch team, but it wasn't like 30% of our field force or anything. But all of these things have some impact. They do create some headwinds for us. And -- but I do believe as the organization matures, having a team of people, their only focus is improving utilization in our installed base, I think is going to pay dividends for us and ensuring that there's streamlined incentives between the commercial team, the sales team and the clinical team and having them report to a common leader in that region is going to drive a lot more focus. It's going to drive a lot more accountability and ultimately improve our execution and performance.
Operator: Our next question comes from the line of Danielle Antalffy from UBS.
Danielle Antalffy: I imagine we are going to get this more for this tomorrow. But Larry, I'm just curious, in the 6 months or so that you've been there, how much of a heavy lift do you think the market development component is here? I appreciate you've talked a lot about the sales force realignment and adjustments there. But just from a pure market education perspective, what's the plan? I mean, as much as you feel like saying on this call versus tomorrow? And how much of that is going to be part of this procedure volume bridge and the long-term plan?
Larry Wood: Yes. Thanks, Danielle. Here's what I will say. The company historically has really been focused on placing systems and then working through the people that acquired the symptoms to make sure that they knew how to do the procedure and they delivered good outcomes with the system. And I think the team did a great job on that. In terms of marketing programs and in terms of awareness and in terms of those things, the value proposition, I'm just real frank about it, none of that work was done. If you -- if I pretended to be a patient and I went out live and tried to find information on BPH therapy, I couldn't even find Aquablation on WebMD going through what I think a patient would normally do for search firms or any of those things. So there's just some very basic fundamental work that had never been done that had never really made our value proposition case to patients. But doing these things and getting out WebMD and getting in social media and doing the comparison how our procedure compares in terms of outcomes and durability and the things that matter most to patients, we have to do that work, but this is always a build. It's never a light switch. I mean you look at TAVR journey during my entire time at Edwards, and it's a continual build that you have to do. But there's just so much basic work that can be done quickly that I think is going to make a difference. And I think we're going to spend a fair amount of time on that tomorrow during the investor conference, and I hope you're there because I think when you see the work that we're doing, you see the value proposition we have, I think we're going to make a compelling case to clinicians and also to patients.
Danielle Antalffy: Okay. That's helpful. And again, I don't want to front-run tomorrow, but one thing we heard in our diligence and speaking to docs was some level of appetite to have the ability to do this in the ASC. I know you guys aren't ready for that yet. But just from a capacity perspective, is that something that could be part of the long-term plan? Anything you can say about that?
Larry Wood: Yes. Thanks, Danielle. Certainly, for the long-term plan, that's going to be something that's going to become part of our story as we go through time. So I think that, that's very fair. I don't think it's something that's so much of a near-term thing for us. The other thing, and I'll just address it and we're going to talk about it tomorrow is we have people saying, like, are you going to cover cases forever because that's been our model we've done historically. And we'll provide an update on that as well on how we think these things evolve over time, and that can improve our efficiency and again, improve our ability to execute.
Operator: Our next question comes from Mike Kratky from Leerink Partners.
Michael Kratky: I wanted to follow up on Chris' question again earlier. I mean, if handpieces sold have consistently been above procedure volumes every single quarter for the last 3 years outside of the fourth quarter, I mean, wouldn't your customers still have a pretty substantial buildup of handpieces that they have available, that they need to work through? When you talk about this 1:1 ratio, can you just help us understand why that is -- you have confidence that, that's going to be the case? And was there anything in the voluntary field action that might have impacted that?
Larry Wood: Yes. Well, I'll start with the second part. There was nothing in the field action that had any impact on this one way or the other, completely separate event that didn't have any impact. In terms of the handpieces, what I can tell you is customers still need to maintain inventory levels. Nobody is sitting there with one hand piece on the shelf. So they need to continue to carry inventory levels. It's just a matter of what inventory levels are they carrying. And I think what was happening with the incentive plans is people would stock way much -- way more inventory than they wanted and then they reverted down in the first couple of months of the quarter, and then they would repeat the process and reorder again and take advantage of these incentives. I think we eliminated that and now what we've seen is a settling into where accounts are just carrying the inventory levels that they feel are appropriate based on their usage and based on whatever their inventory policies are. We modeled next year at 1:1 and that's what has been actually happening as we look at the last several weeks since we made these policy changes or practice changes, I guess. And so that's what gives us confidence on a go forward. But the other thing is, again, we're going to install a couple of hundred systems next year, and they're all going to have to take stocking orders and they're all going to have to establish inventory levels as well, and we're still modeling it at a 1:1. So those are the things that give us confidence next year that 1:1 ratio is going to be in line.
Michael Kratky: Got it. And then maybe just the last one on my side, but can you provide any additional color on the cadence of OpEx and your sales force expansion or SG&A throughout the year?
Kevin Waters: Yes. On the cadence of OpEx, maybe I'll just point to what our EBITDA guidance implies. So we had said at both the low and the high end of guidance will be EBITDA positive in the fourth quarter. We're forecasting an EBITDA loss in Q1 of somewhere in the $20 million range, which would put OpEx somewhere between $85 million to $88 million in the first quarter and then build from there. And again, we're going to go through kind of that walk tomorrow as well.
Operator: Our last question comes from Nathan Treybeck from Wells Fargo.
Nathan Treybeck: So it sounds like handpiece sales have exceeded procedure volumes by wide margin for a long time. I guess, can you talk about what this implies for actual utilization levels at your accounts? And I guess, how would you put that into context the monthly utilization numbers that the company gave in the past for other BPH surgical procedures?
Larry Wood: Yes. Utilization is highly variable. And I think, again, what we're focused on is procedure growth. I probably can't go as deep on the history here. I don't know, Kevin, do you have anything you want to add?
Kevin Waters: I think if you look at it, it's been relatively consistent over the last 3 years. And just to maybe put a number that's been thrown around a few times to highlight, I think it is correct. If we're at a 1:1 ratio, you would see about 11,000 units out in the field. But remember, we're adding over 200 systems in 2026, which would put given current procedure trends, average customer inventory just a little over a month to 7 weeks, which we feel really comfortable with.
Nathan Treybeck: Okay. And so on your capital funnel, I think last time you mentioned there might have been more scrutiny of budgets. It sounds like you're expecting flattish system placements in '26. I guess talk about the level of price sensitivity you're seeing in the accounts that you're pursuing now and I guess, the willingness to place an Aquablation system with just a BPH indication.
Larry Wood: Yes. Well, we actually had a very strong capital quarter in Q4. We had 65 systems, which is an all-time high for us. And so I think that supports that we continue to see demand now, just the natural nature of capital, the fourth quarter tends to be our biggest quarter every year. And we are modeling about the same number of placements in 2026 is what we had in 2025, and we'll provide more detail on that. But we're actually modeling ASP to be flat or up in 2026 from where they were in 2025. And so we continue to see good demand for -- and we think the capital market, I don't want to say it's ever easy, but I don't think there's anything structurally that's changing from 2025 to 2026 that would impact our ability to execute our plan.
Operator: At this time, that does conclude the question-and-answer session. I would now like to turn it back to Matt Bacso, CEO, for closing remarks.
Matthew Bacso: Thanks, operator. I appreciate everyone's time today going through Q&A, listening to the Q4 call. I just want to remind everybody that we are hosting our Analyst Day tomorrow in New York at 8:00 a.m. Eastern, and please show up a little early. There will be breakfast provided, but we will start promptly at 8:00 a.m. Hope to see you there. Thank you.
Operator: Thank you for your participation in today's conference. This does conclude the program. You may now disconnect.