Current status and outlook of robotic surgery in the Nordic countries

Robotic-assisted surgery (RAS) has gradually evolved from experimental procedures in the late 1990s, to become standard minimally invasive surgery (MIS) in a variety of specialties. Wristed instruments, stability, and good vision seem to be ideal in confined spaces like the pelvis and thorax. Scandinavian Surgical Society covers Sweden, Denmark, Finland, Norway, and Iceland. There are currently 120 robotic systems in use in the region as of May 2023, spanning from one system in Iceland to 52 systems in Sweden, the country with most systems. Since the frontier days, the number of procedures is rapidly increasing in the Nordics (Fig. 1). Claims that RAS is posing increased costs on strained healthcare budgets have led to a discrepancy between surgeons’ enthusiasm and the Health Authorities skepticism. Conversely, RAS is perceived as more precise and with less risk by surgeons. But the literature on the short- and long-term outcomes including overall costs remains undecided. The aim of this letter is to urge Nordic robotic surgeons and Health Authorities to provide and facilitate new knowledge on all aspects of RAS, including hospital costs.

Fig. 1.

Trends in robotic procedures in the Nordic countries. Trends in robotic procedures per specialty in the Nordic countries from 2010 to 2022 are shown. Colored graphs representing each specialty: light green, Urology; purple, Gynecology; blue, General Surgery; red, Thoracic Surgery and light blue, TransOral Robotic Surgery (TORS).

In urology, RAS has become standard of care. Evidence on outcome varies in different studies, but at least RAS seems non-inferior to open or laparoscopic surgery if not superior in several aspects. In a randomized controlled trial (RCT) between open and robot-assisted radical cystectomy, blood loss was significantly less in the RAS group, ¹ and reduced long-term prostate cancer–specific mortality has been reported after robot-assisted laparoscopic prostatectomy compared to open prostatectomy. ² In colorectal surgery, a recent RCT comparing robotic versus laparoscopic resections for middle and low rectal cancers showed less trauma, better short-term oncological results, and faster recovery in the robotic group. ³ However, showing improved oncologic results in general compared to open or laparoscopic surgery is difficult as RAS is merely a tool to achieve good and accurate surgery and not a new procedure. Thus, oncologic non-inferiority might be the preference and other end points will judge the cost-benefit. In liver surgery, laparoscopic surgery has been proven beneficial, and RAS has been found to facilitate the shift to MIS in hepato-pancreato-biliary (HPB)-surgery showing improvements in selected outcomes. ⁴ In pancreatic surgery, no difference in major morbidity (defined as Clavien–Dindo grade IIIA and higher) was seen when comparing laparoscopic distal pancreatectomy to robotic distal pancreatectomy, but the RAS group had lower conversion rates, lower readmission rates, and higher rates of spleen preservation potentially reducing long-term post splenectomy sequela. ⁵ Hernias are responsible for patient morbidity and healthcare costs. Although it might be difficult to show better results compared to laparoscopic hernia surgery, recent evidence points to better outcomes in complex ventral hernia repair. ⁶ In breast surgery, patient reported outcome scores following mastectomies, showed better patient satisfaction after RAS compared to open mastectomy. ⁷ Interestingly, surgeons’ ergonomics seem to be improved by RAS reducing musculoskeletal disorders compared to laparoscopic surgery, ⁸ and emerging data on potential shorter learning curves compared to laparoscopic surgery facilitating training of new surgeons are also interesting when studying RAS.

RAS is still considered a new surgical method although two decades have passed since the introduction in the Nordics. Some studies have shown RAS to be peri- and post-operative superior to open and laparoscopic surgery although conflicting results exists. On 25 May 2023, the Scandinavian Surgical Society arranged the webinar: “Robotic surgery in the Nordics, all hype or the way forward,” with over 50 participants. From all the participating countries and specialities, it was apparent that RAS facilitated new possibilities in MIS and was not “just a hype.” RAS is well established in many centers and is perceived by the public as modern and avant-garde, questioning but not excluding the possibilities to conduct RCTs. Challenging the surgical communities to legitimize their enthusiasm, we call for studies to be done in all aspects of RAS. The Nordic robotic train has left the station, clearing the tracks for Nordic multi-center studies. All initiatives should be much encouraged.