Current Indications for Transoral Robotic Surgery in Oropharyngeal Cancer

Transoral robotic surgery with free flap reconstruction: Functional outcomes of 241 patients at a single institution

BACKGROUND

Transoral robotic surgery (TORS) for oropharyngeal malignancy optimizes oncologic outcomes while preserving functionality. This study identifies patterns of functional recovery after TORS with free flap reconstruction (FFR).

METHODS

Retrospective cohort study at a tertiary care center of patients with primary oropharyngeal tumors treated with TORS with FFR between 2010 and 2022. Patients were categorized into: adjuvant chemoradiation or radiation, or no adjuvant therapy (NAT). Functional outcomes were measured by functional oral intake scale (FOIS).

RESULTS

241 patients were included. FOIS declined at first postoperative appointment (median = 7.0 to 2.0, IQR = [7.0, 7.0], [2.0, 4.0]), and progressively improved to 6.0 (5.0, 6.0) after 1 year, with NAT having the highest FOIS (7.0, p < 0.05). Predictors of poor long-term FOIS included RT and hypoglossal nerve (CN XII) involvement (p < 0.05).

CONCLUSIONS

TORS with FFR leads to good long-term function with minimal intake restrictions. Radiation therapy and CN XII involvement increase risk of worse functional outcomes.

Transoral Robotic Surgery for Head and Neck Cancer: Advances and Residual Knowledge Gaps

Minimally invasive surgery is a growing field in surgical oncology. After acquiring its first Food and Drug Administration approval in 2009 for T1–T2 malignancies of the oral cavity, oropharynx, and larynx, transoral robotic surgery (TORS) has gained popularity thanks to its wristed instruments and magnified three-dimensional view, enhancing surgical comfort in remote-access areas. Its indications are expanding in the treatment of head and neck cancer, i.e., resection of tumors of the larynx, hypopharynx, or parapharyngeal space. However, this expansion must remain cautious and based on high-level evidence, in order to guarantee safety and oncological outcomes which are comparable to conventional approaches. This narrative review assesses the current role of TORS in head and neck cancer from an evidence-based perspective, and then identifies what knowledge gaps remain to be addressed.

Radiofrequency Coblation-Assisted Transoral Surgery for the Treatment of Oropharyngeal Squamous Cell Carcinoma: A Comparative Study with Open Surgery

Objective

Radiofrequency coblation (RFC) is a relatively new method that has opened up new perspectives in treating oropharyngeal squamous cell carcinoma (OPSCC). Our study was designed to explore the feasibility and effectiveness of RFC-assisted transoral surgery (RFC-TOS) for primary OPSCC.

Methods

Sixty-nine cases of OPSCC from February 2005 to November 2020 were retrospectively analyzed, including 31 in the RFC-TOS group and 38 in the open surgery group. No difference was observed in demographic and oncological characteristics.

Results

The significance between the RFC-TOS group and the open surgery group was proved in intraoperative bleeding volume (34.10 ± 10.10 ml vs. 193.68 ± 21.00 ml, P < 0.001), durations of surgery (79.58 ± 8.45 min vs. 217.87 ± 17.65 min, P < 0.001), time to resume oral feeding (1.64 ± 0.41 d vs. 11.58 ± 1.41 d, P < 0.001), duration of hospitalization (7.84 ± 0.66 d vs. 15.66 ± 1.62 d, P < 0.001), and the total costs (22846.22 ± 1821.55¥ vs. 41792.24 ± 4150.86¥, P < 0.001). The rates of 5-year overall survival (OS), 5-yeardisease-specific survival (DSS), and 5-year local control rate (LC) were 69.1%, 71.7%, and 75.7%, respectively, in the RFC-TOS group and 71.0%, 73.4%, and 73.7% in the open surgery group (P > 0.05).

Conclusions

RFC-TOS is a feasible alternative transoral approach for OPSCC. The reported perioperative and oncologic outcomes are satisfactory.

Close Margins After Transoral Robotic Surgery for Human Papillomavirus-Positive Oropharyngeal Carcinoma: A Review of the Literature and Practical Recommendations

The purpose of this article is to summarize the literature and practical recommendations from experienced centers for close margins after transoral robotic surgery for human papillomavirus-positive oropharyngeal carcinoma.

Transoral robotic surgery with neck dissection versus nonsurgical treatment in stage I and II human papillomavirus-negative oropharyngeal cancer

Background

Surgery + adjuvant therapy was shown to have improved overall survival (OS) versus nonsurgical treatment in T1‐T2N1‐N2b human papillomavirus (HPV)‐negative oropharyngeal cancer (OPC). Our objective was to compare OS in transoral robotic surgery (TORS) with neck dissection versus nonsurgical treatment for T1‐T2N0 HPV‐negative OPC.

Methods

Patients with T1‐T2N0 HPV‐negative OPC were identified in the National Cancer Database. OS was compared between groups: (1) TORS with neck dissection +/− adjuvant therapy, (2) primary radiotherapy (>60 Gy) +/− chemotherapy using Kaplan–Meier and multivariable Cox proportional hazards models.

Results

There were 665 (78.4%) patients treated nonsurgically and 183 (21.6%) patients in the TORS group. Adjusting for age, comorbidity score, facility type, tumor subsite, and tumor stage, primary nonsurgical treatment was associated with worse OS (hazard ratio: 1.90, 95% CI: 1.34–2.69).

Conclusion

For T1‐T2N0 HPV‐negative OPC, TORS with neck dissection may be associated with a survival benefit over nonsurgical treatment.

Transoral robotic cordectomy for glottic carcinoma: a rapid review

OBJECTIVE

The objective of this study was to investigate feasibility, surgical, oncological, and functional outcomes of transoral robotic cordectomy (TORS-Co) and whether TORS-Co reported comparable outcomes of transoral laser microsurgery (TLM).

METHODS

PubMed, Scopus, and Cochrane Library were searched by three laryngologists for studies investigating feasibility, surgical, oncological, and functional outcomes of patients benefiting from TORS-Co. The following outcomes were investigated according to the PRISMA statements: age; cT stage; types of cordectomy; surgical settings; complications; and functional and feasibility features.

RESULTS

Nine studies published between 2009 and 2021 met our inclusion criteria, accounting for 114 patients. There was no controlled study. TORS-Co was performed in cT1 or cT2 glottic cancer through types II, III, IV, V, or VI cordectomies. The exposure was inadequate in 4% of cases, leading to conversion in transoral laser cordectomy. Margins were positive in 4.5% and local recurrence occurred in 10.7% (N = 8/75). Tracheotomy and feeding tube requirement varied across studies, depending on the types of TORS-Co. The mean duration of robot installation/vocal cord exposure and operative times ranged from 20 to 42 min and 10 to 40 min, respectively. The mean duration of hospital stay ranged from 2 to 7 days. Complications included dyspnea, bleeding, granuloma, synechia, and tongue hematoma and dysesthesia.

CONCLUSION

The current robotic systems do not appear adequate for TORS-Co. TORS-Co was associated with higher rates of complications and tracheotomy than TLM.

National Analysis of Oropharyngeal Salivary Gland Malignancies Treated With Transoral Robotic Surgery

OBJECTIVES

(1) To compare perioperative outcomes and overall survival of patients with oropharyngeal salivary gland malignancies (OPSGMs) treated with transoral robotic surgery (TORS) versus other approaches. (2) To identify clinical factors associated with a robotic surgical approach.

STUDY DESIGN

Retrospective analysis of the National Cancer Database (NCDB).

SETTING

NCDB.

METHODS

Data obtained from the NCDB were analyzed between 2010 and 2017 for patients with T1-T4a OPSGMs without distant metastases treated surgically. Patients were stratified by surgical approach (TORS vs nonrobotic), and clinicopathologic factors were compared with the t test or chi-square test for continuous or categorical variables, respectively. Overall survival was analyzed by patient demographics and clinical factors according to Kaplan-Meier and Cox proportional hazards models. Factors associated with TORS were assessed with logistic regression.

RESULTS

A total of 785 patients were analyzed. A non-soft palate primary site (odds ratio, 12.9; 95% CI, 6.6-25.2) and treatment at an academic facility (odds ratio, 2.0; 95% CI, 1.2-3.5) were independently associated with TORS. There were no significant differences in the positive margin rate, 30-day mortality, or overall survival between the groups. The 30-day unplanned readmission rate was higher in patients treated with TORS versus nonrobotic resections (5.8% vs 1.7%, P = .0004). When stratified by tumor subsite, there was a significant decrease in hospital length of stay in patients with tongue base tumors undergoing TORS versus nonrobotic resections (P = .029).

CONCLUSION

This study suggests that TORS may be a viable treatment modality for appropriately selected patients with OPSGM.