PROCEPT BioRobotics Corporation (PRCT) Earnings Call Transcript & Summary

Hello. Good afternoon, everybody. My name is Brandon Vasquez. I'm a research analyst at William Blair, covering medical devices and some animal health names. I am required to inform you that for a complete list of disclosures and potential conflicts of interest, you can go to williamblair.com for more information. Excited to have with us here PROCEPT BioRobotics and we have the CEO of PROCEPT, Larry Wood, who is going to give us a corporate presentation. And then after that, we are going to JennyA for our breakout session after this. So with that, I'll turn it over to Larry.

Thank you. Well, thank you. Thank you guys for spending your lunch with us. This is our safe harbor statement, and I want to say I've seen a lot of these, and I think this is the best-in-class safe harbor statement that exists in our industry. So I know you'll all have a chance to read that. And non-GAAP financial information. I know you'll read through that diligently. So I'll talk a little bit about the opportunity and just kind of give an overview of our company and what we're excited about and how we see the opportunity playing out. Right now, there's about 400,000 people men a year who undergo procedures for BPH. And we're only about 10% penetrated into that space last year. It's a very undertreated disease. You have about 8 million men above the 400,000 who are on drug therapy for BPH symptoms and some of them on dual drug therapy. But there's about 1.1 million men a year that actually stopped their drug therapy because they're either unhappy with the side effects or they're unhappy with the results of their therapy. And if you go beyond that, there's about 40 million men that are sitting there with the disease. So we think this not only is there a near-term opportunity in terms of the men that are having alternative procedures, but we think there's a rich opportunity beyond that. And delay getting therapy because in many cases, the cure feels worse than the disease. And what people don't talk about is the delay in seeking therapy actually has long-term repercussions. It has long-term repercussions for bladder health. It has long-term repercussions for potential for incontinence and other sort of complications. So our technology, we believe, is an absolute game changer as it relates to this space. And when we think about what we've been doing, we've been building a deep clinical base. And this is an area that I think in the urology space that we need to up our game as it relates to the quality and the significance of the data that we have. And I'll talk about that a little bit more in a bit as we move to speaking about prostate cancer. But really, our pathway right now and kind of what our goals for our company is from a financial side is, one, the #1 thing on our play right now is we want to advance and accelerate procedure growth. We're underpenetrated in this space, and this is a huge area of focus for us. Next is we want to drive to a path to profitability. We've signaled that in Q4 of this year, we'll be EBITDA profitable. And so that's another important part of our corporate journey. And then we want to continue to add to our evidence base and look at some of the adjacencies and be the leading therapy in this space. So we have been growing procedures, and we've been growing our installed base. So we've now treated over 125,000 patients worldwide. Our global base is approaching 1,000 systems. And in the beginning of this year, we got Category 1 reimbursement. So this is no longer like a new-to-the-game procedure. We've established reimbursement. We've established a procedure, and we think it's time for us to really advance the therapy now and really truly become the standard of care. When we look at the procedures and we look at the competitive space and for the modern BPH procedures, you can see that most of these procedures have been sort of flat or have been declining. And you can see we've seen tremendous growth in Aquablation over the same period of time. And by the end of this year, we expect to be the leading modern surgical BPH treatment. If you look at adding TURP to this, TURP remains a procedure that has remained very resilient for several different reasons. But this is the next opportunity for us to really convert patients. Patients that are having TURPs today, we believe our procedure offers significant clinical quality of life advantages over TURP, and this is where we believe the big conversion opportunity is for us on a go-forward basis. But we expect this year to be second only to TURP in the surgical treatment of BPH. So why is this -- and this is really the journey that exists for men. When you have men, and this is true of all prostate sizes, they sort of have 2 options. One is having a resective procedure. And the problem with a resective procedure is they tend to be very durable and they tend to be long-lasting and they can tend to be a one-and-done procedure. But they have significant complications as it relates to quality of life as it relates to sexual function as it relates to urinary function. So the other alternative is they can have alternative nonresective procedures and that will preserve their sexual function and will preserve their urinary function. The problem with that is the symptom relief is much, much less, and they typically are going to need a repeat procedure because these procedures don't offer a lot of durability. Aquablation actually sits in this perfect space where we can offer the advantages of a resective procedure in terms of symptom relief, but we can offer the quality of life advantages of a nonresective procedure. And that makes us unique in this space, and this is really what gives us the opportunity to be the procedure of choice because of our best-in-class outcomes. One of the things that we don't talk about enough is what matters most to patients. And when we do the patient-centric research and we say, what are the things that impact patients the most, here's the things that they continually say. Risk of bladder control issues after surgery. That is the #1 thing. People don't want to wear depends. They don't want to wear those things, and that's the #1 thing. The second thing on their list is minimizing the need for a second procedure. Third is magnitude of symptom relief, which makes sense, then we worry about their recovery time. They worry about the risk of erectile dysfunction. So it's this urinary function, it's sexual function and it's not needing another procedure or the things that are really huge to them. But when we talk to clinicians, that's not always how clinicians see the world. Clinicians will often say, well, we'll start with drugs, which probably makes sense. But from drugs, maybe we'll move to a nonresective procedure. And if that doesn't work, maybe will you do another nonresective procedure. And if that doesn't work, maybe we'll try something else. And only then will we proceed to a resective procedure. And in their mind, they're saying we're going to do something less invasive, nonresective as we move to something more invasive with resective. Here's the problem with that. All of these procedures require a 24 French device to go through your urethra. Once a 24 French device goes through your urethra, tell me how one procedure feels less invasive than another. I think the number of times that a man should have a 24-French device to the urethra is between 0 and 1. Show of hands for any of the men in the room would disagree with me. And so if that's the case, patients deserve to have a procedure that prioritize what matters most to them, which is having a procedure that gives them the highest likelihood of maximum symptom relief, preserving their urinary and sexual function and not needing a secondary procedure. And so this is a case that we need to take to clinicians, and it's a case we need to make to patients. And I know people will talk a lot about the profitability of this procedure versus the profitability of that procedure. And I will tell you, for those of you who followed Edwards Life Sciences in my career there, I heard the same sorts of things when people were talking about heart valves because I had the most expensive heart valve on the market. And I will say this, in my 40 years at Edwards Life Sciences and working in the heart valve space, I never met a single patient that said, you're not going to believe the margin my hospital got on my heart valve. It is not what matters to patients. What patients want is the best solution for them. And what we need to make sure is that we're leading with our data, we're leading with the science, but we're also holding the physicians accountable for doing what is best for their patients in terms of what matters to the patient most. And part of this is we need to take our case to the patients themselves so that they're aware of the latest data and they're aware of the latest evidence, so they know what to go ask their physician and they know what to go request in terms of the procedure they want. But we also have to hold that lens up to the physicians themselves and remind them of their obligation that they have to their patient, which is not maximizing the margin for their hospital or even their margin for themselves. It's maximizing the benefits of the procedure that their patient is going to get and the things that matter to them most. When we talk about the durability of the procedure, you can see where Aquablation lands. And TURP is pretty much the reference standard, and you can see in terms of people only wanting to have one procedure done, you can see we perform very, very well. And again, you can have a simple prostatectomy, but you're going to have quality of life penalties that you simply don't have with aquablation. There's a lot of discussion that happens with PAE, and you can see the durability of PAE right here. And PAE doesn't work, and it doesn't work very well and it doesn't work very quickly. So that may be a procedure that's very lucrative for the clinicians, but it's certainly not a procedure that's very lucrative for a patient. And again, this is where we need to hold the medical community accountable and focus on the things that matter most to patients. So we need to unlock the growth. We have this amazing technology. We now have over 125,000 patients treated. Frankly, we should be the standard of care, and we're not. And so one of the things that are going to take for us to be able to drive this. And some of this was just our own ability to execute at a high level. And one of the things that we did when we came in was when I came in and I looked at the organization, we had people that were very specialized. So we had a clinical support group that kind of reported up to our clinical function. We had sales support, and we had a capital team. And all of these people were kind of working for their own goals and their own objectives, all reporting up to different leaders. And what that just meant is, organizationally, we weren't always aligned. You'd have a capital team and their job was to make sure they sold the capital. But once they sold the capital, then all of a sudden, it was almost a grenade over a wall to the utilization team and they'd have to pick it up and figure out how to drive it. And that didn't happen in all cases. Sometimes it was integrated, but it was more by happenstance rather than by design. And even having the clinical specialists who covered cases and the sales reps, because they didn't report it for the same leaders, sometimes they might show up at the same case to do the same effort and energy, which dilutes our resources. So what we've done is we've realigned. So for the utilization team, -- we now have the procedure team. And whether you're in sales support or clinical procedure support, everybody reports up to a common region director. That means the region director is like a mini GM for that area of the country, and they have all the resources available to them to where they can direct them. But we eliminate all of the overlap, we eliminate any of the inconsistencies. And now everybody has a shared goal, which is making sure that we are driving procedure growth, but we're also delivering that with clinical excellence. Now we report up through the same management structure. We've massively simplified the compensation plan. Everybody runs under the same compensation plan, and it is all based on procedure growth now rather than some of the other things that I will say were in the comp plan that were sort of behavioral. I think when you ask people to do a lot of different things and they're pulling a lot of different directions, they forget what matters most. And so we try to simplify this plan and make it much more consistent. The other thing though that we did was we actually created a launch team concept. And what we did is we took some of our most experienced people, some of our most experienced utilization people, and we said we want to create a launch team, and they're integrated with the capital team now. And the reason for that is the capital team knows when we're most likely to close the PO for a new system placement. So what happens is when they know they're getting within about a month of that process, we turn the launch team loose. We say, who's going to be the physician champion at this site? Are they lining up patients? Are they going to be ready to be trained? Are they going to be ready to go and show up? Where is the robot going to go? Do they have the power requirements? Do they have all the things they need to be able to integrate this? Where are they going to store it? All of those things all get done so that when we actually close on that PO, we actually can get that robot installed and we can make it productive very, very quickly. It wasn't uncommon in our old world. Sometimes a robot would get sold and it would get placed immediately. But sometimes we'd sell the robot, and it would sit for a quarter or sometimes 2 quarters waiting for the facility to get upgraded or figuring out who the physician champion was going to be and all of that work. Now all of it is happening under a parallel process under the launch team. What we saw when we ran a pilot on this late last year was we saw a 50% reduction from the time of the PO until the time of what we consider to be appropriate utilization. And we think that, that just adds a big benefit. The other thing that I think makes this so important is when you start a program well and it does well from the beginning, those programs tend to stay healthy. One of the things that happens is if you launch a robot and then people just paid $500,000 for it, they're going to have their shoulder behind it. They're going to get lab time, they're going to get technician resources. They're going to get all the things they need. And they start doing 5 cases a week and doing that, and that just becomes routine. 3 months later, -- that's just they've carved out their boundaries, they've carved out their space, they've carved out their time and their resources. If they start and they do one case every 2 weeks, and that goes on for 3 months. Now 3 months later, well, that's the time allowed that they have, and that's the resources that have been allocated to them. My experience is, and this is true whether I was in structural heart, and I think it's going to be true here as well, is if somebody starts slowly, now you need to go compete for those resources, it's much harder than starting somebody correctly. So having the launch teams, I don't want to have to go back and rehabilitate centers. I want to have all these centers launch with excellence. We're building that process up this year. We're scaling it. We launched about 20% of our systems under the launch team model in Q1. I think that will probably be closer to 40% in Q2. And by the end of the year, we'll be capable of launching all of our systems under a launch team model. So going into 2027, that will just be the way that every new system launches. So greenfield placements remain the overwhelming part of our strategy, and so that's what we're driving to. If you look at what happened in Q1, in Q1, we sold more systems than I think what consensus anticipated, but we also did at our highest ASP, indicating a continued strong demand for capital. I think in Q4, our system ASP was around $425,000. In Q1, I think it was about $485,000. So we saw a significant step-up in the pricing of capital while we still saw strong demand for capital. Now we didn't have any IDNs in Q1, and so that can obviously impact our pricing. So we don't anybody modeling 45,000. I think we told people to model like 450 to 460. That's not because we'll be less disciplined. It's just going to be because the customer mix can change. But I think we're going to be much more disciplined about how we do this on a go forward. We also introduced a replacement strategy. I think historically, we thought that people would just be inclined to upgrade from a legacy AquaBeam system to a newer hydro system because it's such a better system and it's so feature-rich. I think the struggle with that is for a hospital that has a working robot for them to upgrade to a new robot, especially if that one wasn't completely depreciated off the books, it just didn't really work for them. The other thing is it probably doesn't work very well for us. We need to sunset AquaBeam at some point and get everybody converted over to Hydros. So if somebody just buys another robot, I don't know that, that really helps me because the legacy system is still out there. What we really need people to do is to trade in their AquaBeam system and get a Hydros system so we can retire some of these legacy systems. So we did that. We offered trade-in value. And I think it completely changed the discussion around replacements, and it gave us an opportunity to talk to customers and really try to be a good partner. And so if the system -- the old system isn't completely depreciated off the books or there's some other challenge there, they get value for the replacement. We can take that AquaBeam back. We can use it for spare parts. We can do other things with it, but it's an opportunity for them to upgrade. It's also an opportunity for us to relaunch these systems. We see a higher utilization typically with Hydros versus AquaBeam. For every system that we upgrade, we want to make sure we have a launch team involved so that we can relaunch it and reestablish this as a therapy of choice. We are exploring some leasing alternatives. There's just some hospital systems that just simply historically are never going to pay for capital. We want to make sure some of these systems have access to this therapy for their patients. So we are exploring some of those models. I don't think that's going to be a big part of 2026, but we want to make sure we have a playbook about that. So if the capital markets ever did change or if we ran into more systems that simply aren't going to purchase capital, we want to make sure we have an alternative for them that we validated so that people can have access to our system. The next big frontier for us is prostate cancer. This is obviously a natural adjacency. And I will say it's rare that you can have an adjacency that creates as much leverage as this does. It's largely the same customer base. We can leverage our same exact system, and we can leverage our sales force. So there's a lot of leverage opportunity here. We think that this has the opportunity to be a great therapy because prostate cancer is not a focal disease. Most patients have cancer and it's in different places and not all of it is visible on MRI. So we think you need a whole gland treatment to be able to completely eradicate the prostate cancer, and that's what we can offer with Aquablation. So we designed the WATER IV trial. The WATER IV trial is probably one of the highest quality trials that's ever been done in the urology space. It's a 280-patient study. It is a randomized study, and it is comparing Aquablation versus the current standard of care, which is radical prostatectomy. This trial is fully enrolled. It enrolled faster than we anticipated it to, and I've always felt that clinical trial enrollment was a good marker for how much patient interest there is, but also how much physician interest there is. So we have a 6-month endpoint on this. We also have a 12-month secondary endpoint on this. But importantly, we also have 10-year follow-up on these patients. But I believe we have the opportunity here to remove the cancer from the patient, but at the same time, protect their urinary function and protect their sexual function. And if we can do that, we think this will be a really, really attractive therapy option for patients. Now that being said, the #1 treatment option that patients are choosing today for prostate cancer is actually active surveillance. It's watchful waiting. And I don't think that's because men want to live with cancer in their body and pray that they're a slow progressor. It's because when they look at the cure, the cure feels worse than the disease. And what I mean by that is when I was in the structural heart space, patients didn't want to have open heart surgery, but it was a bit irrational because patients actually do tend to recover pretty well from a sternotomy. But there's nothing irrational about a man not wanting a radical prostatectomy. There's a 25% to 33% incontinence rates after a radical prostectomy and the overwhelming majority of men have severe erectile dysfunction. When you're talking about men in their 50s and 60s and they're faced with having to wear depends or alternatively and having no sexual function anymore or severe debilitated sexual function, that's not an attractive option. So a lot of men will just choose to just wait and undergo active surveillance. And so this is an area that I think we need to continue to focus on. And one of the things that we just did was we added a new trial that is going to be about active surveillance. And what we're going to do in this active surveillance trial is we're going to compare patients to having an aquablation versus watchful waiting. Again, this is going to have a 10-year endpoint because we fundamentally don't believe waiting is benign. We believe damage is being done not just to bladder health, but we also believe some of these patients are not going to be slow progressors. And that's the problem with all of these diseases. You can sit here and say, for the majority of men, prostate cancer is a slow progression. The problem is nobody knows who's who. And for men that are fast progressors, there are real penalty risk of waiting. Now if the risk of treatment is, I'm going to lose all my sexual function and there's a third -- 1 in 3 chance I'm going to need to wear depends, then maybe I'm going to wait and see whether I'm going to be a slow progressor or not. But if we can show and we can prove that we can preserve your sexual function and we can produce your urinary function and we can remove the cancer for your body, I think that's going to be a very compelling case. The combination of these 2 data sets, I think, is going to be the definitive story around cancer. For men that are absolutely ready to undergo a therapy, and they're deciding between a radical prostateomy and Aquablation, we will have a data set that will tell them what the risks and benefits of both of those procedures are. For men who are saying, "I'm not ready to undergo a procedure yet, I don't think. I'm just going to watch for wait. We'll be able to tell them what watchful waiting looks like versus Aquablation. So these combined data sets, I think, is going to provide the definitive picture for us. And I think this is just an area again where we have to be better about informing the clinical community of what the current standards of care, what the options are for the patients and what the true quality of life and complication rates are for these procedures. So our financial outlook, we have a strong track record of revenue growth and expanding margins. We continue to grow our gross margins. In Q1, we were at 65%, which is what we've modeled for this year, and we continue to drive down our EBITDA loss. And by Q4 this year, we expect to be EBITDA positive. This is sort of our revenue profile. We expect to land in this range from the $390 million to $410 million for this year. And next year, we expect to -- in 2027, we expect to be about 25% to 30% growth and continue to grow our installed base. We have a lot of initiatives that we're really trying to drive hard to improve the quality of our business. I will say the actions that we've taken around pricing, the actions that we've taken around just bringing more discipline to the organization, more discipline around the spending, I think are some of the things that have absolutely derisked our path to clear profitability. And this is one of these things that when we cross that path to profitability, the line is never perfectly straight, perfectly linear, but I don't have any plan to just purpose around the profitability line. I think we need to cross that line and keep going and do it in a very definitive way. So we have the ability to achieve a 68% to 70% margin by 2027. And so I think that margin expansion is really important. As we move more to a disposable company from a capital company, we get better margins on that as we continue to grow, that will be big. We still believe that the capital market is going to be robust, and we're going to continue to sell capital similar to what we've been able to do. And we've had a good tariff mitigation strategy, and I think we've been working on those things. And so I feel really good about our long-term financial picture. And even beyond 2027, that's when I think things like cancer, assuming those trials are successful, those where those things can actually be real adjacencies and real continued growth drivers for us over the long term. So in 2027, we're expected to be $25 million to $30 million EBITDA positive. We expect to get a lot of leverage out of our sheet. We expect to see leverage for SG&A, but we also expect to see leverage out of R&D. And it's not because we're going to reduce R&D spending. I think if R&D spending can stay about the rate that it currently is, even if it grows a little bit, it's not going to grow anywhere near the rate of sales. And all of these things are going to generate leverage for us over time. So with that, that's pretty much our story. That's what we're doing. I'm very excited to be here after 40 years at Edwards Life Sciences. I probably thought I would -- in my career there, I don't think anybody had me labeled as the fight risk. But when I had the opportunity to be on the Board and I had the opportunity to see this technology and the potential of it to change men's lives in such a dramatic way, it just became something that I really want to be a part of. And so I'm excited every day to be here. I'm excited for what our future holds. So thank you very much.