Hello everyone, welcome to today's Senzime's fourth quarter presentation. My name is Emily, and I'll be your operator for today's call. After the presentation, you will have the opportunity to ask any questions, either by pressing star followed by one on your telephone keypad, or you can type your questions into the Questions tab above the slides on today's webcast. I will now turn the call over to our host, Pia Renaudin, CEO of Senzime. Please go ahead.
Thank you. Good afternoon, and welcome everyone to the first webcast ever for Senzime in conjunction with the quarterly report. Our intention is to continue to do this webcast in conjunction with the... I think they have some problems with the, with the sound. Welcome, and I'm really happy to be here and have the first webcast ever for Senzime at the quarterly report. We have the intention to continue to do the quarterly report every time we publish our quarterly report. Disclaimer. We published our Q4 report this morning, and I will start to give you some highlights. Our net sales for Q4 was SEK 4.6 million, 2% growth. If you look at the underlying growth, it was 59%, driven by the disposable which grew with 111%.
More importantly, I think at the phase we are right now is to look at the customer sales. The U.S. in market sale in Q4 actually grew with 298%, almost 300%. This is the real customer sale. We had operating costs at approximately SEK 40 million. There are about SEK 8 million here as a one-off, we believe that the beginning of the year will have a run- rate of or burn- rate of SEK 10 million per month, it will go down. Gross margin amounted to 65%. It was an increase with 20 percentage points, this was driven by the product and country mix. As you might have heard, we have published and announced rights issues to SEK 400 million.
Our mid and long-term financial outlook is unchanged. We've had a very exciting 2022, a lot of important milestones. First of all, we acquired RMI, and with the acquisition of RMI, we both expanded our product portfolio and the addressable market. We have also seen major hospital wins in the U.S. for TetraGraph. We have expanded our product portfolio to a pediatric sensor. The pediatric sensor was submitted and approved by the FDA in only four months, which is a very short time. The approval came in Q3, and we have already had a couple of big wins of university hospitals for the pediatric sensors. One that was announced this morning, and this, we are very happy to see this.
We signed probably the most important agreement ever in Senzime's history with the big patient monitor company, Masimo, this year. This connectivity agreement is in two parts. One, which is a connectivity where we actually can connect the patient data journals to our TetraGraph. The second one is a licensing agreement where we actually develop a Masimo TetraGraph Smart Cable, which can actually be used in all Masimo's root systems and make it easier for hospitals and healthcare providers to actually use TetraGraph when they have this system. The work is going according to plan, and the plan is to have the product ready by the end of this year and approved for launch at the beginning of next year.
Very exciting was also the new guidelines, both in Europe and in the U.S. I would like to highlight that actually the U.S. has never had clinical guidelines before, and they're actually recommending TetraGraph system, our type of technology. This is, this was very great news. We have now a critically mass on installed base, specifically our in our key markets, and this is now driving the acceleration of the sensor usage. You can see an overall strong, sales development, but even more importantly is of course the acceleration of the sales, sensors. Here I would also like to reiterate the fact that actually the in-market sales specifically in the U.S. actually grew with 300%.
This ramp up and the interest and the building of the pipeline is just continuing and we can see that since the guidelines was published end of last year, there is now an increasing demand for evaluation and interest from the customers. I would now like to talk a little bit about our product. Since the acquisition of RMI and the product ExSpiron, we have now expanded both our product portfolio and the addressable market. We can now cover almost the whole patient journey in the hospital. The Masimo product that they are developing will be more on the surgical part and the synergetical stage that they are doing is with both the products is in the postoperative unit.
For our legacy product, TetraGraph is really addressing a great unmet medical need. There are about 160 million surgeries taking place since some markets every year. In these cases, the patients are being put to sleep. In more than 50% of all these cases, the patients is also being given a neuromuscular paralyzing drug. When you get these drugs, you cannot breathe on your own and you will be intubated with a breathing tube. These paralyzing muscle drugs, if they are still left in the body when you are waking up the patients, they can lead to a lot of complications like re-intubation.
You can have pulmonary complications, or you can even have a critical respiratory event, which can actually be life-threatening. The doctors, they are very much aware about this, and they also know what they need to do to avoid the complication. They need to make sure that they extubate the patients when the patient has recovered more than 90% of the muscle function. What is being used today is often older technique and not so precise, and that's why TetraGraph is now the new gold standard in neuromuscular monitoring because it's a product that is built on more than 10 years of research and development. It's a unique product and also based on electromyography.
This technique and this product makes the TetraGraph really easy to use and very exact and precise in deciding and showing when the patient is at the right level to be woken up. More activities that happened during this year to actually support the rollout of TetraGraph is of course our new pediatric sensor development and approval and our first wins in university hospitals shows the importance of this more fragile patient group. We can also see that the publication of the new guidelines, they do create a willingness to, at the hospital level, create new protocols, which is actually forcing the usage at a certain hospital chain, and we have seen that started. In the Nordics, we have a new distributor at TIMIK. We are very happy with this distributor.
They are in specialty care. We are now present in university hospitals in all the Nordic countries. In Europe, we also are, we are a part of a lot of big tenders ongoing. The interest is just continuing to raise. We see the pipeline growing even in Europe. I mentioned before the agreement with Masimo. This partnership is seen as very important from our side. We believe that this partnership will help us in the midterm to really continue to accelerate sales of the TetraGraph system and of course of the TetraGraph sensors. The first part will be ready very soon, which is a connectivity to the patient journal.
Of course, the most important thing is this smart cable that we are developing, from our side. Senzime is the partner who's going to sell it, but we have a commercial agreement where we will share, this and work together to sort of make sure that this product is being marketed and sold. We have a mock-up already, and the product will be ready by the end of this year and ready for launch early next year. ExSpiron is the product that we acquired through RMI. ExSpiron is a very unique product. It's the only available product on the market, which is a non-invasive minute ventilator. Respiratory failure is one of the second leading causes of avoidable safety issue in the U.S., and 350,000 deaths every year is due to respiratory complications.
The respiratory failures can often be caused by the pain medication or the morphine that's being used in the hospitals. Of course, this medication and the need for monitoring goes through the whole hospital journey. ExSpiron has been shown to show inadequate breathing pattern more than one hour earlier than pulse oximetry. One hour and a few minutes can be the difference between life and death. It's really important. There's also another type of monitor in this segment, which is called capnography. Capnography is something where you actually have a mask on your face, and that's very, very difficult to tolerate for the patient, and there's also a lot of false alarms. There is a big need for something new and better in this segment.
We have now fully integrated ExSpiron into the commercial organization. Last week, I was in the U.S. for the national sales meeting, it's very clear that there is a lot of synergetic Benefits here. I mean, it could be a door opener for either of the other product, and a lot of hospital really wants both products. I'm really confident that over time, it will not only add to the growth, but it will also help accelerate accelerating the growth. In conclusion and an outlook. What we are doing here at Senzime is really driving a new technology, a true technology shift, in a market where there is high medical need.
We will continue our rollout in the U.S. and Europe, where we right now can see that we have an incredibly great momentum. The pipeline are building, the guidelines are with us, we have also signed this very important agreement with Masimo will help us midterm to really accelerate. We estimate our net sales to reach SEK 275 million-SEK 325 million by 2025 and a long-term EBITDA to exceed 40%. We will take a market share of at least 10% in those segments where we are addressing or where we are actually present. With that, I'm happy to take questions.
Thank you. If you would like to ask a question today, please do so now, either by pressing star followed by the number one on your telephone keypad, or alternatively, if you have joined today's call via the webcast, please type your questions into the Questions tab above today's slides. Our first question today comes from the conference lines. It comes from the line of Klas Palin from Erik Penser Bank. Please go ahead.
Thank you so much. Hi there. I have a couple of questions, if I may. My first would be about you mentioned that you're participating in several larger tenders. Is it possible to give us some further details about this and, particularly, would the tenders, were they triggered by the new guidance or have they been ongoing for a while? I understand that they all were not initiated at the same time. If you can give some sort of indication at least, it would be great. You could start with this one.
Okay. They are, I would say, mainly in Spain and France. The work has started before the European guidelines, but the guidelines, the new guidelines are of course not hurting and also in the U.K. For Spain and France, I'm talking about the tenders in the biggest cities there.
Okay, great. Great. Congratulations, by the way, for your latest pediatric order. I wonder, is there a difference between when you talk to children's hospitals compared to the more regular ones, or is it easier to get an understanding of the need for TetraGraph and TetraSens products?
It's a very good question, and it's maybe a little bit early to say, but given that we had the approval of the TetraSens Pediatric as late as August last year, it has been very quick to win these really big university hospitals. Either it's the fact that we are sort of out of the pandemic, but I do believe that there is nothing really that you can use for pediatric, and it is a fragile group where really, I don't think money is ever really a question. There is a group of patients that you wouldn't really hesitate, I would say.
Okay, perfect. My last question would be about the sales in the rest of the world. It was down quite a lot in Q4 and for the full year, if you have any c omments about this.
It's still fluctuating, of course, over quarter-over-quarter. That was also the reason why I showed the, for instance, in-market sales in the U.S. where we know exactly the numbers. Because in the end of 2021, we had two big stocking orders, and from those orders have actually sold to customers in 2022. Of course, that's not seen in the numbers. I think for me, it's really important to see that we had in the quarter in the U.S. where we know the exact numbers, almos t a 300% growth, which is very encouraging.
Okay.
We will talk about it.
Thank you.
Thank you.
Those are all the questions we have on the phone lines today. We'll go to the webcast questions. The next question comes from the webcast a nd asks, fantastic with the in-market sales of close to 30% growth in the U.S., can we expect these levels going forward?
Good question. We have a fantastic momentum right now. We have a lot of, the pipeline is building. We have a lot of events, and we have a lot of, sort of ongoing, finalization of deals. I look at very promising at it.
The next question from the webcast says, congratulations to the order you announced this morning. Do you see children's hospitals as an important entry to general hospitals?
Maybe a little bit like t he question I got before. Yes. We have seen in a couple of these big hospitals that they will actually start with the children's side, and then they're immediately starting to look at the adult side. Yes, I think so. Absolutely.
The next question asks, are you the only player with a sensor with a pediatric approval?
actually, there are other smaller sensors out there. We are the only one with a pediatric approval. Yes, that's correct.
The next question says, congratulations to a solid fourth quarter report. Looks like you have nice market momentum in 2023. Do you think that all hospitals in the U.S. will implement protocols this year?
Again, we have a great momentum, a lot of interest from hospitals. The protocolization, we see quite a few hospitals are interesting in implementing them, and we are also helping them to sort of speak to other hospitals that have done the same. Not all of them will implement them. No. I don't think so.
Before we take our next question, as a reminder, if you would like to ask a question today, please either press star followed by one on your telephone keypad, or type your questions into the Questions tab above the slides. Next question asks, regarding your sales of sensors, how much is relating to RMI in Q4?
sorry, can you repeat the question, please?
Sorry. Regarding your sales of sensors, how much is relating to RMI in Q4?
Okay. Some. A smaller part is related to RMI.
We currently have no further questions. As a final reminder, if you would like to ask a question today, please press star followed by one, or type your questions into the Questions tab above the slides. We'll just take a brief pause to allow any further questions to come in. With that, we have no further questions. Pia, I will hand back to you for any concluding remarks.
Well, just like to thank you for joining, and yes. Thank you.
Thank you, everyone, for joining us today. This conclu des our call. You may now disconnect your lines.