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Turning to the United States, year over year growth in the quarter was 16%. General surgery growth again accounted for the largest increase year over year, accompanied by expected moderation of growth in U.S. urology and gynecology. Underlying this performance, we saw continued strength in bariatrics and cholecystectomy with modest tempering of growth rate in hernia and colon resection.

Given the different types of procedures being performed by general surgeons, we see additional demands on system access and accounts as well as increased demands on our representatives time to support different procedure types. We believe system placement strength in the US is driven in part by the desire of general surgeons for increased access. We have efforts ongoing to manage these issues. Calvin will take you through global procedure dynamics in more detail later in the call.

With regard to our installed base, placement of new systems in the quarter was strong with growth in total placements rising 24% from Q2 of 2018. Net of trade-ins and retirements, our da Vinci installed base again grew 13% over Q2 2018 to approximately 5,270. The mix of system placements this quarter moved toward our flagship Xi System, where both sales of X systems and trade-ins remained healthy. The proportion of the systems placed under operating leases was 32% this quarter, compared with 33% last quarter. We do not anticipate this quarter-over-quarter variance is indicative of a larger trend in leasing.

With regard to capital average sales price, the mix of systems and geographies last quarter resulted in a lower ASP when compared to historical trends. The second quarter saw a reversal of mixed dynamics, with more fully featured system sales and a greater proportion of system placements in direct markets, resulting in an ASP that is higher than recent quarterly averages. As we said last quarter, this variance in ASP quarter-to-quarter is the result of system and regional mix, not a fundamental change in our philosophy.

Turning to expenses, we continue to invest as we launch new platforms, strengthen our computational capabilities and execute projects that support future scale and provide leverage opportunities as we grow. Our spending met our expectations, falling within the range of projections we shared with you last quarter and supported by solid procedure growth and capital placements.

Financial highlights of our second quarter results are as follows: Procedures grew approximately 17% over the second quarter of last year. We placed 273 da Vinci surgical systems, up from 220 in the second quarter of 2018. Our installed base again grew at 13% from a year ago. Revenue for the quarter was approximately $1.1 billion, up 21%. Pro forma gross profit margin was 71.3%, compared to 71.1% in the second quarter last year. Instrument and accessory revenue increased to $579 million, up 22%. Total recurring revenue in the quarter was $780 million, growing 21% over Q2 of 2018 and representing 71% of total revenue. We generated a pro forma operating profit of $455 million in the quarter, up 17% from the second quarter of last year and pro forma net income was $388 million, up 18%.

As you know, we measure our efforts by their ability to positively impact the quadruple aim, better outcomes, better patient experience, better care team experience and lower total cost to treat per patient episode. We believe intelligent surgery takes the integration of three elements: first, a deep understanding of human interactions that inform holistic system design; second, the development of high-quality smart and cloud connected robotic imaging and instrument systems; and lastly, informatics and AI to deliver relevant validated insights.

For our customer surgery has been digitized for the past 20 years. While we've made significant progress over our history, we believe continuous improvement is required, and we have deployed our investments toward these aims. We design instruments and accessories to enable repeatable high quality surgeries that are efficient and cost effective relating to total cost to treat. Taking one example of our advanced instrument platforms, our second generation SureForm staplers are now in the market at both 60 millimeter and 45 millimeter instrument lengths and represent product families.

Our 60 millimeter stapler has four staple lengths available and is sold in the US, Europe, Korea, Australia and now Japan. A 45 millimeter SureForm stapler has five different staple life cartridges, as well as a straight tip and curved tip instrument and is available in initial launch in the United States and our direct EU markets. Measured through Q2, surgeons have fired Intuitive staplers clinically over a million times cumulatively since our stapling launch.

Turning to systems, we are in our first phase launch of da Vinci SP. We installed 13 systems in Q2 to bring our clinical install base of SP to 34. Our teams have done a nice job resolving the manufacturing variances that slowed our installs in Q1. The highest per system utilization of SP is occurring in Korea, where regulatory clearances support the access to a large range of clinical applications. The Korean experience with SP is encouraging with regard to the broad possibilities for our platform. In Korea procedures in urology, gynecology, general surgery and head and neck surgery are being performed.

In the United States we have two cleared indications for SP, urologic and transoral surgery. As you know, we're pursuing additional clinical indications for SP and have engaged regulatory agencies regarding their requirements. These requirements are in discussion, which implies projected timelines for additional indications are not yet available. Our pipeline of interested SP customers is healthy and a combination of additional indications for SP and our readiness for deployment at larger scale pace the speed of our SP commercial expansion.

In flexible diagnostics, our Ion platform is focused on the need for accurate, timely biopsies to support definitive early diagnosis of suspicious lung cancers -- lesions for lung cancer. Ion received FDA clearance in the first quarter. With 510(k) clearance we have initiated our next phase focused on critical use, customer feedback, and production optimization. First cases on the cleared system were performed at the end of Q1 and we plan a measured rollout this year.

Placements to date or at hospital sites collecting data, so far three have been initiated and over 50 procedures have been performed so far. We're pleased with early clinical results and look forward to our customers continued progress. We expect commercial placements to commence in the next few months, along with the initiation of additional clinical collection sites. We do not anticipate material revenue from Ion in 2019.

Turning to imaging and analytics, this week we announced the acquisition of the 3D robotic endoscope business from our longtime supplier Scholly Fiberoptic. The transaction is subject to closing conditions and thereafter we look forward to welcoming their employees to the Intuitive team. Leading visualization has been a core pillar of our offerings and we believe it is essential to the future of intelligence surgery. This acquisition strengthens our design and supply chain capabilities and increases our manufacturing capacity for imaging products. For the balance of year our focus remains in completing the tasks we set for ourselves. First, supporting adoption of da Vinci and general surgery and in key procedures in global markets. Second, launching our SP and Ion platforms. Third, driving intelligence surgery innovation. And finally, supporting additional clinical and economic validation in our focus procedures in countries.

Before I turn the call over to Marshall, I'd like to take a moment to acknowledge our Chief Operating Officer, Mr. Sal Brogna, who announced his intention to step back from day-to-day operations after 20 years in Intuitive. Sal has made enormous contributions to building our product line, our capabilities and in the past few years our leadership team. I extend my personal thanks and that of the Company for his efforts over these past two decades. We anticipate working with Sal post transition on projects of mutual interest.

I'll now turn the call over to Marshall, who will review financial highlights.

Marshall L. Mohr -- Executive Vice President and Chief Financial Officer

Good afternoon. I'll describe the highlights of our performance on a non-GAAP or pro forma basis. I will also summarize our GAAP performance later in my prepared remarks. A reconciliation between our pro forma and GAAP results is posted on our website.

Key business metrics for the second quarter were as follows. Second quarter 2019 procedures increased to approximately 17% compared with the second quarter of 2018 and increased approximately 7% compared with last quarter. Procedure growth continues to be driven by general surgery in the US, and urology worldwide. Calvin will review details of procedure growth later in this call.

Second quarter system placements of 273 systems increased 24% compared with 220 systems last year and increased 16% compared with 235 systems last quarter. We expanded our installed base of da Vinci systems by 17% to approximately 5,270 systems. This growth is consistent with last quarter and slightly higher than the 12.5% increase last year. Utilization of clinical systems in the field, measured by procedures per system grew approximately 3.5%, which is slightly lower than last quarter growth of approximately 4% and below the 5% growth last year.

Our revenue overview is as follows. Second quarter 2019 revenue was $1.1 billion, an increase of 21% compared with $909 million for the second quarter of 2018 and an increase of 13% compared with $974 million last quarter. Instrument and accessory revenue of $579 million increased 22%, compared with last year, which is higher than procedure growth primarily reflecting customer buying patterns and increased usage of our advanced instruments. Instrument and accessory revenue realized per procedure was approximately $1,920, an increase of 4% compared with the second quarter of 2018 and a decrease of 2% compared with last quarter.

Systems revenues for the second quarter of 2019 was $344 million, an increase of 24% compared with the second quarter of 2018 and an increase of 39% compared with last quarter. Systems revenue in the quarter reflected higher system placements, higher ASPs and higher lease related revenue. We completed 88 operating lease transactions, representing 32% of total placements, compared with 44% or 20% of total placements in the second quarter of 2018 and 78% or 33% of total placements last quarter. As of June 30th, we have 486 operating leases outstanding and realized approximately $25 million of revenue related to these arrangements in the quarter, compared with $12 million last year and $20 million last quarter.

Operating leases create a future source of recurring revenue and reduce the volatility of system revenue. While the increased number of operating systems placed in the quarter dampened short-term revenue growth for the quarter in which they are placed. Operating leases include usage-based financing that we provide to certain experienced hospitals. We believe that our lease financing alternatives align with customer objectives and have enabled faster market adoption. Related to systems purchased over the lease period, we earn a small premium reflecting the time, value and money, and in the case of usage-based arrangements, the risk that those systems may not achieve anticipated usage levels.

The proportion of these types of arrangements could increase long-term and will vary quarter-to-quarter. We recognized $27 million of lease buyout revenue in the quarter, compared with $12 million last quarter and $13 million last year. These buyout revenue has varied significantly from quarter-to-quarter and will likely to do so.

We do not expect the second quarter of buyout -- level of buyout revenue to repeat. 38% of the current quarter system placements involve trade-ins, reflecting customer desire to access or standardize on fourth generation technology. This is an increase in the proportion of trade-ins compared to 34% in the second quarter of 2018 and 36% last quarter. 74% of the systems placed in the quarter were da Vinci Xi and 20% percent were da Vinci X system, compared with 67% da Vinci Xis and 25% of da Vinci X as last quarter. 13% of the systems placed, where SP systems. Our roll-out of the SP surgical systems is measured putting systems in the hands of experienced da Vinci users while we optimize training pathways in our supply chain.

Globally, our average selling price, which excludes the impact of operating leases and leased buyouts was approximately $1.54 million compared with $1.42 million last year and $1.31 million last quarter. Our mix of systems in customers in the second quarter of 2019 was very favorable relative to prior period. We had a high mix of Xis versus X and Si systems. We also had a low mix of distributor versus direct sales. In the second quarter of 2019, we also had fewer multi system arrangements where we provided volume discounts. The mix of systems, customers and size of arrangements will vary over time. We expect system ASPs to be in the range of the midpoint in the first two quarters.

Outside of the U.S., results were as follows. OUS procedures grew approximately 20% compared with the second quarter of 2018 and increased 4% compared with last quarter. Second quarter revenue outside of the U.S. of $314 million increased 19% compared with the second quarter of 2018 and increased to 11% compared with last quarter. The increase compared with the prior year reflects increased instruments and accessory revenue of $34 million or 29% growth. The increase in instrument accessory revenue was primarily driven by procedure growth in customer buying patterns.

Outside of the US we placed 80 systems in the second quarter compared with 82 in the second quarter of 2018 and 81 systems last quarter. Current quarter system placements included 30 into Europe, 24 into Japan and eight into China. 61% of the systems placed in the quarter were da Vinci Xi and 33% were da Vinci X systems, compared with 38% Da Vinci Xi and 44% da Vinci Xs last quarter. 12 of the system placements were operating leases compared with six last year and 11 last quarter. Placements outside of the US will continue to vary as some of the OUS markets are in the early stages of adoption. Some markets are highly seasonal reflecting budget cycles or vacation pattern and sales into some markets are constrained by government limitations.

Moving on to gross margin and operating expenses. Pro forma gross margin for the second quarter of 2019 was 71.3% compared with 71.1% for the second quarter of 2018 and 71.2% last quarter. The increase compared with the second quarter of 2018 and last quarter, primarily reflects higher system ASPs. Future margins will fluctuate based on the mix of our newer products, the mix of systems and instrument and accessory revenue, system ASPs and our ability to further reduce product costs and improve manufacturing efficiency.

Pro forma operating expenses increased 27% compared with the second quarter of 2018 and decreased 1% compared with last quarter. Spending is consistent with our plan and includes an order of magnitude of increase, costs associated with the expansion of our OUS markets, spending on our informatics capabilities and investment in our infrastructure in order to scale the business.

Our pro forma tax rate for the second quarter was 20%, and within our expectations of 19% to 20%. Our tax rates will fluctuate with changes in the mix of US and OUS income, changes in taxation made by local authorities and with the impact of one-time items. Our 2020 tax rate will increase with the return of the medical device tax. Our second quarter 2019 pro forma net income was $388 million or $3.25 per share compared with $327 million or $2.76 per share for the second quarter of 2018 and $312 million or $2.61 per share for the last quarter.

I will now summarize our GAAP results. GAAP net income was $318 million or $2.67 per share for the second quarter of 2019 compared with GAAP net income of $255 million or $2.15 per share for the second quarter 2018 and GAAP net income of $307 million or $2.56 per share for last quarter. The adjustments between pro forma and GAAP net income are outlined and quantified on our website and include excess tax benefits associated with employee stock awards, employee equity and IP charges, amortization of intangibles and acquisition related items in legal settlements.

We ended the quarter with cash and investments of $5.1 billion, approximately the same as March 31, 2019. Cash generated from operations was offset by stock repurchases and investments in working capital and infrastructure during the quarter. We repurchased approximately 400,000 shares for $200 million, on an average purchase price of $477 per share.

In the quarter we grew inventory by $45 million to $513 million, representing approximately 140 days of inventory. We continue to build inventory to address the growth in the business as well as mitigate risks of disruption that could arise from trade, supply or other matters. With the growth in the business and our focus on efficiency and scale, we expect our capital expenditures will increase to over $250 million in 2019.

And with that, I'd like to turn it over to Calvin who'll go over procedure performance and our outlook for 2019.

Calvin Darling -- Senior Director of Finance and Investor Relations

Thank you, Marshall. Our overall second quarter procedure growth was 17% compared to 18% during the second quarter of 2018 and last quarter. Our Q2 procedure growth was driven by 16% growth in US procedures and 20% growth in OUS markets. In the US Q2 procedure results were generally consistent with recent trends. Q2 growth was again driven by growth in US general surgery, thoracic and benign gynecology procedures.

Q2 2019 US procedure growth was 16% compared to 17% last year and last quarter, reflecting anticipated slight moderation in mature urology and gynecology procedures and general surgery growth rates. In US general surgery, second quarter hernia repair and colorectal procedure growth remain solid, although it's slightly lower growth rates than last quarter and last year. Other general surgery procedures such as cholecystectomy, bariatric and liver and pancreatic cases made increasing contributions to growth in Q2 with higher growth rates than last quarter.

As anticipated US procedure growth in mature urology and gynecology procedure categories moderated in Q2 compared to last year. US gynecology growth and urology growth were in the mid single digits. DVP growth specifically was in the low single digit range in close alignment with the underlying incident rate for prostate cancer.

As a mature procedure category, we believe that our US prostatectomy volumes have been tracking to the broader prostate surgery market. In other US procedures, adoption of lobectomies and other thoracic procedures was again solid during the second quarter. Second quarter OUS procedure volume grew approximately 20% compared with 22% for the second quarter of 2018 and 21% last quarter. Second quarter 2019 OUS procedure growth was driven by continued growth in dVP procedures and earlier stage growth in kidney cancer procedures, general surgery and gynecology.

Q2 OUS procedure growth based modest working day headwinds due to the timing of the Easter holiday, mostly affecting Europe and other national holidays, particularly in Japan. Japan procedure growth remains strong, but moderated somewhat in Q2, reflecting lower growth rates in mature urology procedures as we reach higher levels of market penetration. The impact of holidays and the anniversary of the new procedure reimbursements.

In China after several quarters of decline in procedure growth, procedure growth accelerated slightly in Q2, driven by procedures performed on new systems installed under the latest system quota. In Europe, procedure growth was driven by strong results in Germany and France. Overall, European procedure growth was largely consistent with prior periods with variation by country.

Now, turning to the clinical side of our business. Each quarter on these calls, we highlight certainly recent published studies of note. However, to gain a more complete understanding of the body of evidence, we encourage all stakeholders to thoroughly review the extensive detail of scientific studies that have been published over the years. We are pleased to see the evidence landscape regarding our recently cleared Ion endoluminal system started to grow. A manuscript describing the first [Indecipherable] experienced led by Dr. David Fielding from the Royal Brisbane and Women's Hospital in Brisbane, Australia has recently been accepted for publication in the peer reviewed medical journal Respiration.

Previously presented at the annual CHEST conference in 2017, this study was designed to evaluate the safety and feasibility of the Ion ndoluminal platform and included 29 consecutive subjects with follow up data through six months. Although each nodule was located in the peripheral part of the lung and the mean nodule size was approximately 15 millimeters, approximately 97% of the nodules were reached with the tissue sample suitable for assessment obtained.

Importantly, across the entire study population, no instances of pneumothorax, bleeding or device related adverse events were reported, suggesting a good safety profile. We believe that further scientific study and clinical evidence will be essential to build the market for Ion. Soon after receiving FDA clearance for Ion in the US, we initiated a postmarked clinical study called PRECISE [Phonetic], intending to enroll 360 subjects across six key centers in the United States. Full details regarding the construct of the PRECISE study are available on the web at clinicaltrials.gov.

In May of this year, a large scale real world comparative study using the National Cancer Database was published in the journal Colorectal Disease. The analysis led by Dr. Ravi Kiran from NewYork-Presbyterian/Columbia University Medical Center, compared the results of over 41,000 patients from between 2010 and 2015 by surgical approach.

The National Cancer Database captures data from over 1,500 cancer accredited facilities and represents approximately 70% of newly diagnosed cancer cases. The population for the study consisted of approximately 15% robotic assisted, 33% laparoscopic and 52% open procedures. In propensity score matched analysis with over 4,000 subjects in each cohort comparing the robotic LAR approach to the laparoscopic approach. The robotic LAR was associated with shorter length of stay, 6.3 days versus 6.8 days, and lower risk of conversion to open, 7.5% versus 14.95%.

With multivariate analysis showing laparoscopic LAR patients being 2.2 times more likely to be converted to open. Compared to open LAR, the robotic assisted approach had shorter length of stay, 6.3 days versus 7.8 days. A higher rate of negative margins, 97.01% versus 95.96% and higher nodal yield, [Indecipherable]. The authors concluded and I quote, "For patients with rectal cancer, robotic LAR shows recovery benefits over both open and laparoscopic LAR with reduced conversion to open compared with laparoscopic LAR and less prolonged length of stay compared with laparoscopic LAR and open LAR." Robotic LAR, is associated with short term ecological outcomes comparable to open LAR supporting it's use in minimally invasive surgery for rectal cancer.

I will now turn to our financial outlook for 2019. Starting with procedures. Last quarter, we forecast 2019 procedure growth of 15% to 17%. We are now refining our forecast to the upper half of this range and expect full year 2019 procedure growth of 16% to 17%.

Turning to gross profit, on our last call, we forecast our 2019 full year pro forma gross profit margin to be within 70% and 71% of net revenue. We now expect to come in at the higher end of that range. Our actual gross profit margin will vary quarter-to-quarter depending largely on product, regional and trade-in mix and the impact of new product introductions.

Turning to operating expenses, we continue to expect to grow pro forma 2019 operating expenses between 24% and 28% above 2018 levels. We continue to expect our non-cash stock compensation expense to range between $320 million and $340 million in 2019. We expect other income, which is comprised mostly of interest income to total between $130 million and $135 million in 2019, up from $120 million to $130 million forecast on our last call. With regard to income tax, we continue to estimate our 2019 pro forma income tax rate to be between 19% and 20% of pre-tax income.

That concludes our prepared comments. We will now open the call to your questions.

Questions and Answers:

Operator

[Operator Instructions] And our first question comes from line of Bob Hopkins with Bank of America. Please go ahead.

Robert Hopkins -- Bank of America-Merrill Lynch -- Analyst

Well, great and good afternoon.

Calvin Darling -- Senior Director of Finance and Investor Relations

Hey, Bob.

Robert Hopkins -- Bank of America-Merrill Lynch -- Analyst

So first question I want to about US procedure growth. If I ask the overall Q2 US growth on the procedure side accelerated a little bit when you take into consideration the year ago comp, but you called out some slight moderation in hernia and colorectal. So I was just wondering if you could just talk about that a little bit? Was that -- was the growth you experienced in hernia and colorectal this quarter different than you expected and how do you manage through this issue of kind of managing access? Thank you.

Gary S. Guthart -- President and Chief Executive Officer

Yeah. This is Gary. We saw a tad of moderation. I think demand remains strong and what we're really seeing is what we indicated to you. We have two things going on. One is, there are a lot of different procedure types and now in busy centers, competition for system access. We can, of course solve that with additional systems placed as well as work with folks on efficiency of abuse. And we're doing both. And you, you've heard that from us over the last several quarters.

The next one is, our commercial teams have been growing in the United States to support the growth of the Company. And it takes some time to have teams come up to full productivity and we are -- the percentage of new folks and new territories has been ticking up the last couple of quarters. And it's -- the new ratio is among the highest we've had in the last few years. Employee retention has been great. It's really around, increased need to get increased case coverage. And so, there it's supporting our new folks in the field with tools and and some of it is just time on task.

Calvin Darling -- Senior Director of Finance and Investor Relations

Yeah, Bob, you know, from just a pure mathematical standpoint, you know, we track adoption curves pretty regularly around here. And it's a mathematical reality that really all points along the curve, the rate of growth actually declines. So, our results here in Q2 is aligned with what we would have expected. And clearly there's a lot of substantial remaining opportunity in both hernia and colorectal procedures. And our checks with surgeons generally indicate healthy demand.

Robert Hopkins -- Bank of America-Merrill Lynch -- Analyst

That's great. Thank you for the color. And then just one on the systems side, because revenue growth from system sales this quarter was much higher than the first quarter due to mix as you called out. But the placement numbers and the placement growth in both quarters suggest very strong underlying demand for your systems in both quarters. I was just wonder if you could talk a little bit about the differences you saw from Q1 to Q2 in that mix dynamic? And you know what that suggests about the outlook for the rest of the year on systems side? Thank you.

Marshall L. Mohr -- Executive Vice President and Chief Financial Officer

Yeah, we're, This is Marshall. We have seen, as you suggested, reasonable strength in terms of system placements. I don't think there's anything really different quarter-to-quarter other than the mix. In other words, the buying behaviors of the customers haven't changed. We're seeing a nice cycle in trade outs and -- but we did see, again, more excise this quarter and there's volatility or variability between quarter-to-quarter as it relates to particularly our distribution channel. And so we saw fewer distributor sales this quarter and more direct sales and our direct sales are at a higher price than what we saw with our distributors since they incurred the selling costs associated with those systems. So that's really -- that's the color that we would provide on systems revenue.

Robert Hopkins -- Bank of America-Merrill Lynch -- Analyst

Great, thank you.

Gary S. Guthart -- President and Chief Executive Officer

Marshall, is it fair to look at it and say, you know, if you view the first half as a whole rather than in different quarters, you get a better picture?

Marshall L. Mohr -- Executive Vice President and Chief Financial Officer

That's true, Gary. You should -- when you look at ASPs, you should think about the combination of the two, because $1.31 million was a low point and $1.54 million is a high point.

Operator

Next question comes from the line of Tycho Peterson with J.P. Morgan. Please go ahead.

Tycho Peterson -- JP Morgan Chase & Co -- Analyst

Okay, thanks. Maybe I'll just follow up on that last question. Well, why should ASPs take a little bit of a step back? You did use Xi's [Phonetic] more thoughtfully featured system sales, obviously your procedure mix is expanding. Why logically should be ASP step down a little bit going forward?

Gary S. Guthart -- President and Chief Executive Officer

You should expect that the -- again distributor sales tend to be variable quarter-to-quarter. So, I think you should blend the first quarter and the second quarter when you're looking at what level of the distributor sales you should expect. And then I think same thing with the mix of Xi and X, just depending on the geography, X is targeting geographies where reimbursements are pressured. And so this quarter, just based on mix, we wound up selling fewer Xs and that should even out as well.

Tycho Peterson -- JP Morgan Chase & Co -- Analyst

And we've had, you know, a couple of quarters now of operating leases in kind of the low 30s, it was 29% at the end of last year. Is this kind of the new norm in your view or how should we think about operating leases in terms of mix going forward?

Gary S. Guthart -- President and Chief Executive Officer

I don't think about it as a norm. I think that, there's going to be variability quarter-to-quarter. And yeah, Q2 was slightly lower, if not close to being same as Q1. But I think over time we will accommodate customers and we think that on the other hand, leases are positive for the Company and as I said in my prepared remarks, it increases the recurring revenue. It eliminates volatility. It also enables a upgrade cycle when and if new systems come out. So we think it's a positive. And so we'll supply those to customers if they ask for them. I would guess that over time, we're predicting over time that there's the possibility that the percentage actually will increase.

Tycho Peterson -- JP Morgan Chase & Co -- Analyst

And then on IRIS, I know it's early days. I didn't really hear you bring it up in the comments, but can you just talk a little bit about interest levels for kidney and liver and how we should think about the extended use of that going forward?

Gary S. Guthart -- President and Chief Executive Officer

I think the interest from the four leading surgeons is very high. I think in general people looking out and saying additional access to data, IRIS, just a reminder for everybody is the integration of preoperative imaging, 3D imaging into a case in real time. We're not in the clinic yet, we do have our 510(K) clearance, we're working through agreements with customers. We don't expect revenue this year. I think directionally there's quite a lot of support. I think part of what we want to develop in the market as we go forward or use cases and really getting the value statement for them in terms of what it drives either accuracy or efficiency or both. Early response is great. But, you know, these things take a little time to develop and to develop the evidence base that goes behind it.

Tycho Peterson -- JP Morgan Chase & Co -- Analyst

Okay, thank you.

Operator

Next question comes from line of David Lewis with Morgan Stanley. Please go ahead.

David Lewis -- Morgan Stanley -- Analyst

Good afternoon. A couple questions here. I'll start with Gary. Gary, last year your procedures began to inflect momentum perspective and they still remain pretty strong. As you think about the next inflection for procedure growth, I mean, do you think it's more likely that it comes from new systems? Obviously, SP Ion creating this access, you've already talked about on this call or access in new geographies, Japan and China. I noticed you already mentioned that comment that just a few systems in Japan, sorry in China, was able to drive some demand, across those three buckets, Gary, systems, access, geographies, what is the most likely driver of the next wave of procedure inflection?

Gary S. Guthart -- President and Chief Executive Officer

I think in the near term access in core markets is going to be important, and, it's -- what's been nice here in the last few years is the procedure base has been building so healthy double digit growth rates in procedures in absolute growth numbers are starting to become substantial and making sure that those surgeons who want access to the system have it. It has been important. It's been one of the drivers for our increased flexibility and agility and capital acquisition models.

As you look at SP and Ion, both of those are interesting platforms that I think over time will expand the total available market for robotic systems in diagnostics and in single port or single access surgery. They take some time to develop and the speed with which they develop is, as I said in the script, paced by additional indications and manufacturing scale.

Longer term, I think those things are exciting, but it'll take some time to go through. Geography, we've seen real successes, but they take time. Japan has been a great success, they're doing a really nice job, but is really heavy lifting to do all the things required to build market access from factoring networks to training centers to clinical evidence base to support additional adoption. So I think those things are important. We have invested in them and we will continue to do so. So in short answer, maybe not a perfect modeling answer, but I'll leave that to you.

David Lewis -- Morgan Stanley -- Analyst

Okay. And then it just a follow up Gary. Just trying to get a sense of thinking about SP roll out and the Ion roll out. Your Ion commentary was fairly consistent with the first quarter. If I think about the first four quarters of SP obviously exiting out at the manufacturing issues last quarter, do you see Ion rolling out system placement perspective in a similar fashion to SP? Is there a reason why it would be faster in the first first four quarters of commercialization or slower? Thanks so much.

Gary S. Guthart -- President and Chief Executive Officer

Yeah, I'd anticipate measured in this first four quarters of launches as we optimize our systems on our side and also gathering our data. After that, we'll see, I don't think I predicted one way or another for you. The indications in Ion, we feel pretty good about to get started. I think the size of that market is real and so we'll see a year from now, I think is to how fast we want to move. On SP, it has, I think, great long term potential, it requires additional clearances in the US anyway to keep moving and so we'll do that in sequence.

Operator

Next, we go to a line of Amit Hazan with Citigroup. Please go ahead.

Amit Hazan -- Citigroup, Inc. -- Analyst

Thanks. Hey, good afternoon guys. Let me start with one in the quarter and just follow to that. So on the quarter the INA versus procedures, the INA with 0.2%, procedures up 17%. That's the widest gap I can recall in a little while. You touched on it a bit, but maybe just a little bit more color, did that we knew advance instrument is driving something that's sustainable or are there one-time things in there that we should consider?

Gary S. Guthart -- President and Chief Executive Officer

Yeah, I think in general we have seen increasing of revenue -- instrument and accessory revenue per procedure. Obviously, there's variability by quarter based mostly on the timing of customer orders. But in general, you know, we've been gradually increasing and the biggest aspect of that has been increasing usage of the advanced instruments from Vessel Sealing, the Vessel Sealer Extend. We launched recently now to stapling as well ini the 60 millimeter stapler we launched last year and more more fully available this year in the U.S. So I think that's been the biggest factor, that's probably been more than offsetting almost everything else, whether it's more procedures general surgery, hernia repair and others that maybe, lower tool usage. So I think that's the biggest factor there.

Amit Hazan -- Citigroup, Inc. -- Analyst

Okay, just a slightly longer term question on flexible endoscopy with surgical instruments. One of your bigger future robotic competitors has been -- talking about this publicly now for the first time in just the past month or so. Can you talk to how much of a priority this is for intuitive? What you can tell us about the opportunity from a robotic perspective?

Gary S. Guthart -- President and Chief Executive Officer

Sure. In general, as we've described before, we like to think in platforms, and what I mean by that is, if we can build some core technologies from advanced imaging to great precision to great software, then we can mix and match those core capabilities to pursue different endpoints clinically. And so, you look at SP, SP is exceptionally powerful system that brings together four instruments through a single access point. You look at Ion and Ion has exquisite sensing and a flexible endoscopy or a flexible diagnostic platform.

Over time, I think those two different sets of ingredients give us a lot of opportunity and optionality. And so, I think those things are interesting and they could be open for us additional clinical markets over the long term. That said, product design is subtle and architectural choices are really, really important. Doing it right, I'm getting a great clinical outcome comes down to some millimeter precision and microseconds findings of these electronics.

And as a result, we want to make sure that we really deliver on the things we put in the market from SP to Ion. So, we're not sprinting to go as broad as possible. We really want to make sure we deliver against the commitments we make and for the customers who purchase our products. There is a fair amount of history out there of companies that have failed to attend to the details and start strong and peter out. And so, we're very careful and thoughtful about it.

Amit Hazan -- Citigroup, Inc. -- Analyst

Thank you.

Operator

Next question comes from the line of Larry Biegelsen with Wells Fargo. Please go ahead.

Larry Biegelsen -- Wells Fargo Securities, LLC -- Analyst

Thanks, guys. Thanks for taking the questions. First, could you talk about the strategic and financial implications of the fiber optics acquisition? And I had one follow up.

Gary S. Guthart -- President and Chief Executive Officer

Sure, I'll speak to why we did it. This is surely is a strong team and supply chain partner that has been important for us over many years. Clearly great imaging, manufacturing capability, design capability and the processing is core part of the surgery in the future and interventions of the future. As we've grown, we've wanted to make sure that we can continue to invest in that space, both on the design side and on manufacturing and production capability side. It's been a great partnership with that team. We respect them and and have been very productive with them. And so that gives us additional optionality and agility going forward in a core part of our business. On more of a deal specifics and logistics I'll turn it over to Marshall.

Marshall L. Mohr -- Executive Vice President and Chief Financial Officer

So we entered into an agreement to acquire certain assets and operations from Scholly for cash consideration of approximately $100 million. The exact amount of consideration and timing of the closing is subject to certain closing conditions and so that will occur over the next future periods and employees will transfer after each of the closing events occurs.

Larry Biegelsen -- Wells Fargo Securities, LLC -- Analyst

Thanks, Marshall. And then on Ion, we haven't heard you talked about the opportunity or timing outside the US. What's the status, particularly in China and rest of the world? Thanks for taking the questions, guys.

Gary S. Guthart -- President and Chief Executive Officer

Yeah. On the specifics on China, we're in discussions with the Chinese regulatory agencies about how best to bring it to market and timing there. I don't have a definitive answer for you yet, but it's an active discussion. Clearly, we believe there are end user opportunities and value -- healthcare value to bring in China and in Europe and in other markets and we'll take it in sequence. We think this is a powerful set of technologies and a powerful platform. We are still in the early days.

Our greatest organizational focus right now is on really understanding the technology and the use of it carefully. The early clinical results are great and they are differentiated relative to other products in the market so far in these early days. That's really important to us. We will focus there and as we build strength and experience and scale, then it gives us a lot of opportunities to engage the rest of the world.

Operator

Next, we go to line of Lawrence Keusch with Raymond James. Please go ahead.

John Schuon -- Raymond James & Associates, Inc. -- Analyst

Great, thanks. This is John Schuon on for Larry. Maybe if we could start without providing guidance for 2020, can you give us some high level guideposts for how we should generally think about investment spend next year going into 2019? You obviously have a lot of products on your plate this year, but just any high level color would be greatly appreciated?

Marshall L. Mohr -- Executive Vice President and Chief Financial Officer

Well, we'll give you a better color when it comes to January about what's going to happen next year. But the things that we're investing in are not short term investment. They take -- they occur over a long period and so you should expect that spending will continue to -- continue on those and on other other matters going forward. And as we grow the Company, of course, there's an increased amount of support if necessary to grow the Company, particularly on the sales side in terms of personnel and commissions. And so, I think spending will increase. I won't give you anything more specific than that until we get later in the year.

Gary S. Guthart -- President and Chief Executive Officer

Maybe, I'll just speak for philosophy a little bit. We think the opportunity for improved performance and therefore opportunities for the business are substantial. And what paces us is how we decide, how much we'll invest and when is that, which we think we can do with excellence. Generally speaking, we see more opportunity than we think we can pursue. We wind up saying no to some things that are probably good ideas, but we don't know that we can perform them well. And so that's what balances our investment portfolio. And we'll continue to use that philosophy as we plan out 2020 and going forward.

John Schuon -- Raymond James & Associates, Inc. -- Analyst

Great. And then just on the balance sheet, you obviously have $5 billion plus in cash. You bought back stock in the quarter. You also did a tuck-in acquisition for imaging capabilities. Can you just remind us how you think about your capital deployment priorities at this point?

Gary S. Guthart -- President and Chief Executive Officer

Yeah, the philosophy and approach to capital deployment hasn't really changed. But to remind you, we think about that, cash, obviously, to operate the Company, we're making investments in our future. We want cash. The market is volatile in terms of -- the environment is volatile in terms of tariffs and other things going on. We want to make sure we've got proper investments to be able to deal with those and ultimately, we look for opportunities to buy back stock and returns cash to shareholders.

John Schuon -- Raymond James & Associates, Inc. -- Analyst

Okay, great. And then just, I could seek one last one on the tax rate. I think you mentioned the medical device tax coming back in 2020. By my estimate, I think we're coming up with an impact of roughly $30 million. Is that a decent ballpark for how you're thinking about the impact of product gross margin in 2020?

Gary S. Guthart -- President and Chief Executive Officer

Yeah. When we're talking about medical device tax, we were recognizing in the past, we charged that expense item to cost of sales. So, it impacts our gross margin there. You know, we saw an impact around 70 basis points to 100 basis points then, and it's probably a similar kind of impact, should that be reenacted.

John Schuon -- Raymond James & Associates, Inc. -- Analyst

Okay, great. Thank you.

Operator

Next, we go to the line of JP McKim with Piper Jaffray. Please go ahead.

JP McKim -- Piper Jaffray -- Analyst

Hi, good afternoon. Thanks for taking my question. I wanted to ask one on just, this push to on trade-ins and upgrading installed base to generation 4, I think after last quarter I think half the installed base was still older generation. So can you give us an update on where that is today? And then just how -- strategically how important is that to you to get everyone to Gen 4 ahead of competition that should come sometime next year or after that?

Marshall L. Mohr -- Executive Vice President and Chief Financial Officer

Yeah, I'll give you the numbers and let Gary talk to the strategy. You heard on this call was another 38% of our system sales involve trade-ins this quarter. It's likely to continue to be a significant part of our capital sales and future periods. At this point in time, it is about 45% of our installed base of [Indecipherable] systems that are Gen 3 in prior mostly Si's.

Gary S. Guthart -- President and Chief Executive Officer

We think it helps. I mean, after the strategy, we think our customers appreciate it. Many customers now are multi-system owners or across their integrated delivery network. They have systems at different hospitals where surgeons visit. So having consistency helps them. Gen 4 products have greater access to advanced instruments and other technologies and are well appreciated. So in that sense, we think we can lean in and help those organizations go do it. There is a different set of regulatory clearances in different countries around the world. There are different trade-in economics in each country. So as you think about the analysis, you think a little bit about which region and which country you can move most quickly and we work through that as well.

JP McKim -- Piper Jaffray -- Analyst

Okay, then, if I could ask one on just -- the comments you made on the general surgery dynamics [Indecipherable] something else is temporary based on lot of large numbers, but the shift to bariatrics, some more on chole, I mean, the shift in trend on general surgery, what does it do for your intermittent ASPs? Are there more advanced instruments as you shift to different procedures in general surgery?

Gary S. Guthart -- President and Chief Executive Officer

Highly variable, you look at chole's, those are lower revenue per procedure cases. You look at bariatric at the other side where a lot of staple fires are used. So it's highly variable landscape.

Marshall L. Mohr -- Executive Vice President and Chief Financial Officer

Bariatrics is in early innings, and as we start to optimize the instrument kit, there in we're seeing really pull from the market there. We haven't changed our priorities in the US sales force with regard to general surgery. We continue to believe there is opportunity in value and of course, hernia and colorectal procedures. The bariatric side are really customers coming to us and and starting to move that along.

JP McKim -- Piper Jaffray -- Analyst

Thank you.

Operator

Next, we go to line of Richard Newitter with SVB Leerink, please go ahead.

Richard Newitter -- SVB Leerink -- Analyst

Hi, thanks. I have two in housekeeping. With the housekeeping, can you just quantify what the selling date headwind was, what your procedure growth would have been, excluding the, not for selling give us some of the headwinds that you described related to the holiday timing and whatnot? And then, Gary, I was wondering if -- with respect to the the capacity issues, just getting robot [Phonetic] time. Are there certain types of procedure mix cases or certain types of institutions where you can proactively get in front of those capacity issues to get there before they occur? And is there any kind of characteristic of the institutions procedure mix that specifically is leading to the capacity constraints?

Gary S. Guthart -- President and Chief Executive Officer

Yeah. First on the working days, it's really minor in the quarter, not a big thing. We mentioned in the commentary. Overall, you know, maybe a 30-ish basis point impact on procedure volume with a much larger portion attributable outside of the US due to the timing of Easter. On the capacity side, as we've said in the past, our customer base doesn't -- one size does not fit at all. Each institution runs with different operating cadences within their organization. So, in some places we see extremely efficient capital utilization. Really appropriate activity approach, where they have very high predictability and get a lot of procedures out of the system. We're delighted to support that and we help to benchmark that and teach others as they need it.

We see other institutions that for various reasons are operating at lower capital capacity for some reasons that are quite good. Some may be teaching institutions, some be institutions that take on the most complex, comorbid patient sets where predictability of procedure duration is difficult. So you can imagine if you're sharing a system between a thoracic surgeon who's performing lung cancer procedures and a general surgeon who's doing hernia repairs, the cadences, rhythms and scheduling are quite different and you're going to get less optimal scheduling. To the extent that we can have those conversations up front and help them optimize, we do. That's something we've been strengthening over time. So I think we can do better than we do today.

Richard Newitter -- SVB Leerink -- Analyst

Great. Thanks. If I get one more. The China utilization pick up on just eight systems placed under the quota. Did that surprise you that it was able to translate into a pickup in volumes so quickly? I always also impression that you did it, there was gonna be a lag time to train institutions, if you could comment there? Thanks.

Gary S. Guthart -- President and Chief Executive Officer

I don't know if you're surprised. I'd say we were pleased. That tells you the level of commitment and motivation of those customers to make their investment productive.

Richard S. Newitter -- SVB Leerink LLC -- Analyst

Thank you.

Gary S. Guthart -- President and Chief Executive Officer

Last questionnaire please?

Operator

The last question comes from the line of Imron Zafar with Deutsche Bank. Please go ahead.

Imron Zafar -- Deutsche Bank AG -- Analyst

Hi. Good afternoon. Thanks for taking my question. First question is on Japan. I believe you noted some moderation in procedure growth there, but at the same time, we're still seeing some very strong capital equipment placement numbers this quarter. Can you just give us some color on what's driving these placements? Is it more sort of greenfield robotics programs that are looking to get into presumably urology or is it the established customers wanting to get more into general surgery? In light of sort of the less financial incentive that they have, I'm just wondering if there's any -- if the growth should continue to slow going forward in general surgery?

Gary S. Guthart -- President and Chief Executive Officer

Yeah, It's a combination of greenfields where you have hospitals that are positioning themselves to do the newer procedures that were approved for reimbursement last year, and they're still a trading cycle going on in Japan. Our distributor had sold a size on leases and as those leases are coming up -- or coming due, then we see customers wanting to upgrade to the newer technology.

Imron Zafar -- Deutsche Bank AG -- Analyst

Okay. Thank you. And then we've heard some mention from some surgeons on some third parties that hospitals can ship instruments to their -- that are approaching the end of their useful life. And that this limited useful life can be extended presumably via some sort of a software intervention or something. Is there something that you're seeing any impact from or is there any regulatory preclusion that would limit the ability for companies to do this kind of stuff?

Gary S. Guthart -- President and Chief Executive Officer

On the how good an idea is it? The people who reprocess like that are bound by the same regulatory framework that we are in terms of assuring the quality of that product and making sure it's not sold as an adulterated product and they have to take on that burden and it is a sophisticated one. Calvin, I'll let you response.

Calvin Darling -- Senior Director of Finance and Investor Relations

No. Yeah, I think that's that's essentially is.

Gary S. Guthart -- President and Chief Executive Officer

On terms of materiality...

Calvin Darling -- Senior Director of Finance and Investor Relations

Yeah. And you look at our revenue per procedure, I mean, it's -- we're talking about that a little bit and I don't think we've seen any impact on that.

Imron Zafar -- Deutsche Bank AG -- Analyst

Great. Thanks for taking my question.

Calvin Darling -- Senior Director of Finance and Investor Relations

Thank you. That was our last question. In closing, we believe there is a substantial and durable opportunity to fundamentally improve surgery and acute intervention. Our teams continue to work closely with hospital, physicians and care teams in pursuit of what our customers have termed the quadruple aim. Better and more predictable patient outcomes, better experiences for patients that are experiences for the care teams and ultimately a lower total cost to treat.

We believe that accomplishing the same takes the integration of three elements. First, a deep understanding of the human interactions across the continuum of care. Second, smart and connected systems, imaging and instruments that augment care teams. And third, the ability to measure impact through analytic insights and translation of these insights into action driving positive change. Thank you for support on this extraordinary journey. We look forward to talking with you again in three months.

Operator

Ladies and gentlemen, that does conclude your conference for today. Thank you for your participation and for using AT&T Executive Teleconference Service. You may now disconnect.

Duration: 62 minutes

Call participants:

Calvin Darling -- Senior Director of Finance and Investor Relations

Gary S. Guthart -- President and Chief Executive Officer

Marshall L. Mohr -- Executive Vice President and Chief Financial Officer

Robert Hopkins -- Bank of America-Merrill Lynch -- Analyst

Tycho Peterson -- JP Morgan Chase & Co -- Analyst

David Lewis -- Morgan Stanley -- Analyst

Amit Hazan -- Citigroup, Inc. -- Analyst

Larry Biegelsen -- Wells Fargo Securities, LLC -- Analyst

John Schuon -- Raymond James & Associates, Inc. -- Analyst

JP McKim -- Piper Jaffray -- Analyst

Richard Newitter -- SVB Leerink -- Analyst

Richard S. Newitter -- SVB Leerink LLC -- Analyst

Imron Zafar -- Deutsche Bank AG -- Analyst

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