A systematic review and meta-analysis comparing surgically-related complications between robotic-assisted thyroidectomy and conventional open thyroidectomy

An institutional experience of intraoperative neurophysiological monitoring application in robotic thyroidectomy: a retrospective case-control study

Purpose

Intraoperative neurophysiological monitoring (IONM) has been introduced in thyroid surgery to prevent injury of the recurrent laryngeal nerve (RLN). However, its effectiveness remains controversial in robotic thyroidectomy (RT). This study aimed to compare the surgical outcome of RT in patients with and without the application of IONM.

Methods

This retrospective case-control study included 100 patients who underwent total thyroidectomy via robotic bilateral axillo-breast approach in a tertiary center. A study group of 50 patients who had IONM during RT was compared to a control group of 50 patients who underwent RT with nerve visualization alone.

Results

The sex ratio (4:45 vs. 7:43, P = 0.538), mean age (39.3 ± 7.1 years vs. 37.5 ± 10.4 years, P = 0.304), and body mass index (23.1 ± 2.6 kg/m2 vs. 22.2 ± 3.9 kg/m2, P = 0.215) were comparable between the IONM and control groups. Pathologic features including tumor size (0.8 cm vs. 0.9 cm, P = 0.283), extrathyroidal extension (58.0% vs. 24.0%, P = 0.316), lymph node metastasis (30% vs. 34%, P = 0.668), and number of lymph nodes (5.3 vs. 5.3, P = 0.668) showed no differences. There was no permanent RLN palsy, postoperative bleeding, and wound complications. Transient hypoparathyroidism was observed in 12 (24.0%) and 14 (28.0%), permanent hypoparathyroidism in 0 (0%) and 1 (2.0%), and transient RLN palsy was observed in 3 (6.0%) and 3 (6.0%), respectively.

Conclusion

We did not demonstrate a clear advantage of IONM in RT. Controversies regarding the effectiveness of IONM is not closed.

Comparison of surgical outcomes of transoral robotic and endoscopic thyroidectomy: A systematic review and network meta-analysis

This study aimed to compare surgical outcomes of transoral robotic thyroidectomy (TORT) and transoral endoscopic thyroidectomy vestibular approach (TOETVA), concurrently compared with conventional transcervical thyroidectomy (CTT). A network meta-analysis, comprising 23 studies, was performed in this study. The operative time of the CTT group was significantly shorter than that of the TOETVA and TORT groups. The hospital stay of the TOETVA group was significantly longer than that of the CTT group. Rates of transient recurrent laryngeal nerve palsy and total complications were higher in association with TOETVA than with TORT. No significant differences were found between the three groups in intraoperative blood loss, retrieved lymph nodes, postoperative pain, and other complications. Cosmetic satisfaction was significantly superior with TORT and TOETVA than with CTT. Compared with CTT, TOETVA and TORT showed superior cosmesis but no significant difference in surgical outcomes except for operative time and hospital stay.

Efficacy and safety of thermal ablation modalities for the treatment of papillary thyroid microcarcinoma: Systematic Review and network meta-analysis

Background

Thermal ablation (TA) modalities such as radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) have been widely used in the treatment of papillary thyroid microcarcinoma (PTMC) patients. Based on previous small-sample meta-analyses, this network meta was designed to further compare the efficacy and safety of these thermal ablation methods in PTMC patients.

Methods

China National Knowledge Infrastructure (CNKI), Wanfang, PubMed, Embase, and the Cochrane Library databases were searched to retrieve relevant studies published before May 2022. The efficacy outcomes was recurrence and lymph node metastasis (LNM), the safety outcome included operation time, intra-operative blood loss, hospital stays and complications. The Newcastle-Ottawa Scale (NOS) was selected for the risk of bias assessment. Stata 14.0 was used for statistical analysis.

Results

Twenty-nine articles were included. Based on as least 6 months follow up, our analysis discovered no significant statistical differences in all efficacy and safety outcomes between MWA, RFA, and LA groups. Moreover, three TA treatments all produced significant least operation time, hospital stays, and complications than surgery group. Additionally, our study found that RFA showed relatively less complications, LNM, operation time and intra-operative blood loss, compared with other TA treatments. MWA indicated the lowest probability of recurrence, LA showed the longest hospital stays.

Conclusions

MWA, RFA, and LA are all effective treatment strategies for patients with PTMC, but could not completely replace conventional surgical treatment.

Future Directions in the Treatment of Thyroid and Parathyroid Disease

The surgical management of thyroid and parathyroid disease has evolved considerably since the era of Theodor Kocher. We review the current trends in thyroid and parathyroid surgery concerning robotic surgery for remote access, the use of parathyroid autofluorescence detection technology to aid in the prevention of hypocalcemia as well as the use of thermal ablation to target thyroid nodules in a minimally invasive way. We also discuss how artificial intelligence is being used to improve the workflow and diagnostics preoperatively as well as for intraoperative decision-making. We also discuss potential areas where future research may enhance outcomes.

Surgical outcomes of endoscopic thyroidectomy approaches for thyroid cancer: a systematic review and network meta-analysis

Objectives

This network meta-analysis assesses the outcomes of seven endoscopic approaches, offering valuable insights for researchers and practitioners in choosing the best method for thyroid cancer patients.

Methods

A systematic literature search was conducted in the PubMed, Embase and Web of Science databases up to March 2023. The analysis included seven endoscopic approaches, with a focus on their respective outcomes through network meta-analysis.

Results

This meta-analysis included 44 studies involving 8,672 patients. The axillo-bilateral breast approach (ABBA) and unilateral axillo-breast approach (UABA) showed advantages in terms of reduced operative time compared to other approaches (MD = 19.66 minutes, 95% CI = -31.66 to 70.98; MD = 30.32 minutes, 95% CI = -1.45 to 62.09, respectively). The UABA and anterior chest approach (ACA) exhibited superiority in controlling intraoperative bleeding (MD = -3.37 mL, 95% CI = -22.58 to 15.85; MD = -13.77 mL, 95% CI = -28.85 1.31, respectively). UABA and ACA also showed advantages in reducing hospital stays (MD = -0.39 days, 95% CI = -1.48 to 0.71; MD = -0.26 days, 95% CI = -1.33 to 0.81, respectively). The transoral approach (OA) yielded results comparable to those of conventional open thyroidectomy (COT) and outperformed other endoscopic surgeries with regards to lymph node retrieval and metastatic lymph node assessment. For the stimulated serum thyroglobulin (TG) levels, no significant difference was observed between bilateral axillo-breast approach (BABA) and OA compared to COT. However, chest-breast approach (CBA) showed significantly lower levels than COT (MD=-0.40 ng/ml, 95% CI =-0.72 to -0.09). Patients in the gasless unilateral transaxillary approach (GUA) group experienced a significant improvement in cosmetic satisfaction (MD=-2.08, 95% CI =-3.35 to -0.82). Importantly, no significant difference was observed in the incidence of surgical complications between endoscopic thyroidectomy and COT.

Conclusion

Endoscopic thyroid surgery is a safe and effective choice for thyroid cancer patients. Different approaches have their advantages, allowing personalized selection based on the patient's needs. ABBA and UABA have shorter operative times, while UABA and ACA excel at controlling bleeding and shortening hospital stays. OA shows promise for lymph node assessment. These findings contribute to the growing evidence supporting endoscopic methods, expanding treatment options for thyroid cancer patients.

Advancing Preoperative Strategies for Thyroidectomy in Graves' Disease: A Narrative Review

Graves' disease is an autoimmune disorder characterized by thyroid-stimulating antibodies that can potentially lead to thyrotoxicosis, goiter, skin disease, and eye disease. Available treatment options for Graves' disease include management with antithyroid drugs (ATDs), thyroid ablation with radioactive iodine (RAI), and surgical thyroid gland removal. For individuals unable to reach a normal thyroid hormone level, promptly considering a thyroidectomy is essential. Preoperative strategies to achieve a euthyroid state prevent thyroid storms and minimize postoperative complications and are therefore crucial. While variations in professional guidance exist, this review focuses on standard medical interventions as well as compares respective guidelines set forth by the American Thyroid Association, the European Thyroid Association, the American Association of Clinical Endocrinology, and the American Association of Endocrine Surgeons. There is consensus among these organizations underscoring the importance of rendering patients euthyroid prior to surgery and the use of ATDs. Most guidelines recommend screening for vitamin D deficiency as well as endorse thyroidectomy as the preferred treatment option for hyperthyroidism with skilled surgeons. Nevertheless, discrepancies do become apparent in aspects such as potassium iodide (SSKI) course duration and preoperative dexamethasone administration. By understanding these differing approaches, healthcare professionals can more effectively manage Graves' disease prior to surgery, resulting in improved patient outcomes and enhanced surgical success.

Clinico-pathological initial outcome of a newly adopted novel surgical technique for nodal metastatic thyroid cancer at a large-volume centre in a high-income developing country

Introduction

Thyroid cancer is the most common tumour in the endocrine system. In the past decade, the incidence of lymph node metastasis has increased, and so has the patient demand for a smaller scar. This research reports the surgical and patho-oncological short-term outcomes of a novel, minimally invasive neck dissection approach for thyroid carcinoma with lymph node metastases at the UAE's leading endocrine surgery centre.

Methods

This study employed a prospectively maintained surgical database to retrospectively analyse relevant parameters such as surgical complications, including bleeding, hypocalcaemia nerve injury and lymphatic fistula, as well as oncological metrics such as the type of tumour and the ratio of lymph node metastasis to the number of harvested lymph nodes in 100 patients that underwent open minimally invasive selective neck dissection.

Results

The study comprised 50 patients with thyroidectomy, with bilateral central compartment neck dissection (BCCND; 50%); 34 with thyroidectomy, BCCND and selective bilateral lateral compartment neck dissection (BLCND; 34%); and 16 patients with selective unilateral central and lateral compartment neck dissection by recurrent nodal disease (ULCND; 16%). The female-to-male gender ratio was 78:22, with median ages of 36 and 42 years, respectively. Histopathology findings revealed that 92% of patients had papillary thyroid cancer (PTC) and 8% had medullary thyroid cancer. The mean total number of lymph nodes removed was 22 in the BLCND group, 17 in the ULCND group and 8 in the BCCND group (p = 0.001). Furthermore, the average lymph node metastasis was significantly higher in the BLCND group (p = 0.002). The percentage of temporary hypoparathyroidism was 29.8% and it persisted for 1.3%. The lateral compartment dissection morbidity was as follows: Four male patients with tall cell infiltrative PTC presented with pre-existing vocal cord paresis, necessitating nerve resection and anastomosis, and two more developed it after surgery (1.1% of the nerve at risk). Lymphatic fistulas occurred in four patients (4%) who were treated conservatively. Two patients were readmitted due to symptomatic neck collection. Horner syndrome was discovered in just one female patient. Male gender, aggressive histology and lateral compartment dissection independently increased surgical morbidity. In a high-volume endocrine centre, the adoption of minimally invasive selective neck dissections to treat nodal metastatic thyroid cancer did not increase specific cervical surgery complications.

Recent Advances in the Surgical Management of Thyroid Cancer

A growing incidence of differentiated thyroid cancer (DTC) has been reported in most developed countries, corresponding mainly to incidentally discovered small papillary thyroid carcinomas. Given the excellent prognosis of most patients with DTC, optimal therapeutic management, minimizing complications, and preserving patient quality of life are essential. Thyroid surgery has a central role in both the diagnosis, staging, and treatment of patients with DTC. Thyroid surgery should be integrated into the global and multidisciplinary management of patients with DTC. However, the optimal surgical management of DTC patients is still controversial. In this review article, we discuss the recent advances and current debates in DTC surgery, including preoperative molecular testing, risk stratification, the extent of thyroid surgery, innovative surgical tools, and new surgical approaches.

Management of the brachial plexus in head and neck cancer

PURPOSE OF REVIEW

The brachial plexus is an important anatomical structure that is regularly encountered by head and neck surgeons and radiation oncologists. Surgical or radiation-induced brachial plexus injury have great impact on arm function and quality of life. Anatomical variations and management of the brachial plexus in head and neck cancer treatment are discussed.

RECENT FINDINGS

The brachial plexus consists of spinal roots from C5-C8 and T1. The most prevalent anatomical variations in brachial plexus anatomy include the prefixed brachial plexus (additional contribution from C4) in 11%, the roots of C5 and C6 piercing the belly of the anterior scalene muscle in 6.8%, and presence of the scalenus minimus muscle in 4.1-46%. Due to its location, the brachial plexus is at risk of inadvertent division or neuropraxia during surgical procedures such as neck dissection or robot-assisted transaxillary thyroid surgery (RATS). In case of inadvertent division, nerve reconstruction surgery is warranted and may lead to improved function. The risk of radiation-induced brachial plexus injury is dose-dependent and occurs in approximately 12-22%. Currently, no successful treatment options exist for radiation-induced injury.

SUMMARY

Knowledge of anatomical variations is important for head and neck surgeons to minimize the risk of brachial plexus injury. Limiting radiation therapy dose to the brachial plexus is desirable to decrease the risk of brachial plexus injury.

Surgical completeness and safety of minimally invasive thyroidectomy in patients with thyroid cancer: A network meta-analysis

BACKGROUND

To assess the surgical outcomes of various minimally invasive and remote-access surgical approaches for thyroid cancer patients.

METHODS

We collected studies from January 2020 to July 2022 in 6 databases. Pairwise and network meta-analyses were performed for outcomes and complications of 9 minimally invasive interventions (minimally invasive video-assisted, endoscopic or robotic bilateral axillo-breast approach, endoscopic or robotic postauricular, endoscopic or robot transaxillary approach, transoral endoscopic thyroidectomy vestibular approach or robotic thyroidectomy) and conventional thyroidectomy (control).

RESULTS

Multiplicity and bilaterality of cancer, lymph node metastasis, and coincidence of thyroiditis showed no significant difference between minimally invasive interventions and control. However, larger tumor size (robotic bilateral axillo-breast approach standardized mean difference -1.3989, 95% confidence interval [-2.1717 to -0.6262]), higher body mass index (robot transaxillary approach standardized mean difference -0.5350, 95% confidence interval [-0.9557 to -0.1144], robotic bilateral axillo-breast approach standardized mean difference -0.2301, 95% confidence interval [-0.4389 to -0.0214]), and frequent extrathyroidal extension (robotic bilateral axillo-breast approach standardized mean difference 0.7435, 95% confidence interval [0.5602-0.9869]) were observed in control. In surgical outcomes and adverse effects, there was no significant difference in hospitalization or retrieved lymph node number between minimally invasive interventions and control. However, longer operative time was observed in the robotic bilateral axillo-breast approach(standardized mean difference 6.5393, 95% confidence interval [5.0476-8.0309]) and transoral robotic thyroidectomy (standardized mean difference 5.4946, 95% confidence interval [2.9984-7.9907]) groups than in control. In surgical completion, the rate of low postoperative serum thyroglobulin, postoperative thyroglobulin level, and postoperative radioactive iodine ablation dose showed no significant difference between minimally invasive interventions and control.

CONCLUSION

Minimally invasive thyroidectomy did not show inferior results compared to conventional thyroidectomy despite the longer operative time. Surgeons need to prudently consider all aspects of patients to determine the proper surgical approach for thyroid cancer.

Quality of Life Following Robotic Transaxillary Versus Conventional Hemithyroidectomy: A Comparative Analysis

Background: Robotic technology has proven safe and effective for thyroidectomy procedures. Few studies have addressed the quality-of-life outcomes of robotic thyroidectomy compared with conventional thyroidectomy. Materials and Methods: The database of a tertiary medical center was retrospectively reviewed for all patients with thyroid disease who had undergone robotic hemithyroidectomy in 2012-2020. All patients treated by transaxillary robotic surgery and a similar number of randomly selected patients treated by conventional cervical surgery completed a standardized self-administered thyroid disease-specific quality-of-life (QOL) questionnaire (ThyPRO). Clinical data were derived from the medical files. The results were compared using mean comparison tests and multivariate logistic regression models. Results: The cohort consisted of 131 patients: 63 after robotic thyroidectomy and 68 after conventional thyroidectomy. The mean age was 38.87 ± 14.11 and 58.85 ± 14.1 years, respectively (P < .0001). The robotic hemithyroidectomy group reported better QOL outcomes in physical and mental health parameters, including decreased anxiety, depression, lower sex life impairment, and cognitive impairment scores (P < .0001). Furthermore, after adjusting for age, gender, malignancy status, and surgical approach, we found that patients undergoing robotic hemithyroidectomy had a lower probability of experiencing depressive symptoms than the conventional hemithyroidectomy group (odds ratio = 0.31; 95% confidence interval, 0.11-0.88). Of interest, no significant difference in cosmetic outcomes was found. Conclusions: Patients who underwent robotic thyroidectomy report better postoperative QOL after surgery than patients operated by the conventional approach in terms of anxiety, depression, cognitive and sex-life scores.

Remote Access Thyroid Surgery: A Review of Literature

Since the first description of endoscopic thyroid lobectomy in 1997, a variety of techniques have been developed to avoid the visible cervical scar conventionally been associated with thyroidectomy. These "remote access" approaches, which typically use either endoscopic or robotic instrumentation, have successfully avoided the anterior neck scar, which has a measurable impact on the patient's quality of life (Graves and Suh Surgery 168(5):845-850, 2020; Sakorafas World J Surg 34(8):1793-1804, 2010). The main advantage of these techniques is better cosmesis compared to conventional transcervical approaches (Graves and Suh Surgery 168(5):845-850, 2020) However, these techniques have failed to gain widespread acceptance in the surgical community because of the technical challenges, scepticism about oncological safety and cost factors. This review presents an overview of the various methods of remote access thyroid surgery (RATS) and also evaluates the selection criteria, oncological efficacy, training requirements and key advantages of this technique.

Safety and efficacy of ultrasound-guided thermal ablation in treating T1aN0M0 and T1bN0M0 papillary thyroid carcinoma: A meta-analysis

BACKGROUND

Papillary thyroid cancer (PTC) is the most common thyroid tumor, and early diagnosis and treatment can effectively improve prognosis. Many controversies surround the treatment method of T1N0M0 PTC. Recently, thermal ablation (TA) has shown some benefits in the treatment of PTC patients, but the safety and efficacy of its treatment remain controversial. This article performs a meta-analysis of TA in patients with T1aN0M0 and T1bN0M0 PTC.

METHODS

The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched for retrospective or prospective studies of TA for treating patients with T1N0M0 PTC from the database establishment to May 1, 2022. Data on volume reduction rate (VRR), disease progress, and complication rate were collected. In addition, a meta-analysis was performed using the Stata 12.0 and Review Manager 5.3.

RESULTS

A total of 9 eligible studies were included. Our study demonstrated the effectiveness of VRR and disease progress. The VRR was reduced after 3 months (-75.90%; 95% CI [-118.46-33.34%]), 6 months (34.33%; 95% CI [15.01-53.65%]), 12 months (78.69%; 95% CI [71.69-85.68%]), and 24 months (89.97%; 95% CI [84.00-95.94%]). The disease progress was 1.9% (95% CI [1.1-3.0]). Safety is justified by the complication rate, which was 6.5% (95% CI [3.5-10.2]). Pain and hoarseness were the most common complications, and no life-threatening complications were reported. Egger's test demonstrated that publication bias was acceptable.

CONCLUSIONS

TA is an effective and safe method for managing T1aN0M0 and T1bN0M0 papillary thyroid nodules.

Robot-Assisted Thyroidectomy Versus Open Thyroidectomy in the Treatment of Well Differentiated Thyroid Carcinoma

BACKGROUND

The incidence of thyroid cancer has increased worldwide during the last decade, becoming the most common endocrine malignancy and accounting for 3.8% of new cancer diagnosis. Surgical resection, namely conventional thyroidectomy, remains at the frontline of therapy, as surgical outcomes are undoubtedly successful. Minimally invasive techniques gained popularity through the years, in terms of feasibility, safety, and cosmesis. However, endoscopic approach could be characterized by some limitations concerning thyroid surgery. Robotic technology with its unique features was introduced to overcome these limitations. Since then, robotic thyroidectomy has been used for both benign and malignant thyroid disease.

DATABASE

This study presents the use of robot-assisted transaxillary thyroidectomy in well-differentiated thyroid carcinoma through an extensive review of the literature in the PubMed database, including previous meta-analyses and case series.

CONCLUSION

In terms of oncological efficacy, morbidity, and quality of life, outcomes seem comparable in thyroid cancer patients undergoing either open or robotic thyroidectomy. Surgical completeness also appears similar. Moreover, the rates of locoregional recurrence and survival outcome at 5 years are similar between the former and the latter, thus confirming the oncological value of robotic thyroidectomy for differentiated thyroid cancer. In order for more surgeons to adopt robotic approaches several issues need to be resolved, namely: expansion of robotic thyroidectomy in treating larger well-differentiated carcinomas and neck dissection, equipment costs, and prolonged operation times.

Comparison of thermal ablation and routine surgery for the treatment of papillary thyroid microcarcinoma: a systematic review and Meta-analysis

BACKGROUND

Thermal ablation (TA), as an alternative to surgery, has shown some benefits in the treatment of papillary thyroid microcarcinoma (PTMC) patients, especially for those who are at high risk for surgery or refuse surgery. We performed a systematic review and meta-analysis to evaluate the efficiency, safety, and economy of TA, compared with those of routine surgery (RS), for the treatment of PTMC.

METHODS

PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, and VIP databases were retrieved from inception to 10 January 2020 to identify relevant original studies on comparison of TA and RS for treatment of PTMC. The recurrence rate, recurrence-free survival (RFS), complication rate, operation time, postoperative length of stay, and cost during the perioperative period were extracted as main indices. The pooled standardized mean difference (SMD) or odds ratio (OR) with 95% confidence intervals (CI) were calculated and analyzed. Chi-square test and I ² statistic were applied to determine the heterogeneity among studies. The sensitivity analysis was applied to explore the origin of heterogeneity, and the publication bias was evaluated by Egger's test.

RESULTS

Seven retrospective studies with a total of 867 patients met the eligibility criteria and were included in the final meta-analysis. Our study demonstrated that TA showed significant reduction in complication with a pooled OR 0.24 (95% CI 0.13 to 0.43), postoperative length of stay with a pooled SMD -3.14 (95% CI -4.77 to -1.51) and cost during the perioperative period with a pooled SMD of -1.69 (95% CI -3.18 to -0.20). It also demonstrated that both TA and RS had similar pooled proportion of recurrence of OR 0.93 (95% CI 0.38 to 2.30) and recurrence-free survive (RFS). The sensitivity analysis showed that each included study had no significant effect on the results and the results were stable and reliable. The Egger's test demonstrated publication bias was acceptable.

CONCLUSIONS

TA may not be oncologically inferior to RS, and it is a relatively safe and economical alternative for the treatment of PTMC.

Surgical outcomes of different approaches in robotic assisted thyroidectomy for thyroid cancer: A systematic review and Bayesian network meta-analysis

BACKGROUND

The aim of the study was to assess the feasibility, safety, and potential benefits of four approaches of robotic assisted thyroidectomy (RT). The approaches mentioned above are also compared with traditional open thyroidectomy (OPEN).

MATERIALS AND METHODS

Medline, Embase, Cochrane library (CENTRAL) and Web of Science databases were searched up to 13th Dec 2019. Data of surgical outcomes and complications were extracted to conduct the statistical analyses.

RESULTS

A total of 30 studies with 6622 patients were included. Ten were prospective study and 1 declared prospective randomized comparative study. The number of retrieved lymph nodes (LNs) in central compartment were similar between gasless transaxillary approach (GAA), bilateral axillo-breast approach (BABA) and transoral approach (OA). OPEN retrieved more LNs than BABA and OA. More metastatic LNs were seen in GAA and BABA than OA, as was for OPEN. The operation time was significantly shorter in GAA and gasless unilateral transaxillary approach (GUAA) than BABA and OA, while shortest for OPEN. Lower incidence of transient hypoparathyroidism was found in BABA than OPEN. No significant difference was observed in other indexes.

CONCLUSIONS

BABA, GAA, GUAA and OA in RT appear to be feasible and safe for patients with thyroid cancer with unique benefits. Surgical outcomes of different approaches were not identical for operation time, cosmetic effects, central neck dissection. Surgeons would consider more about patients' will.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): Surgical Outcomes and Learning Curve

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has excellent cosmetic effects and its popularity is increasing worldwide. We present our experience with TOETVA and its short-term outcomes. This study included 110 consecutive patients who underwent TOETVA at a single institution between July 2016 and June 2020. We analyzed clinicopathologic data, short-term postoperative outcomes, and learning curve using cumulative summation (CUSUM) analysis. Of the 110 patients who underwent TOETVA, 101 had malignant disease and 100 (90.9%) underwent lobectomy. The mean age was 39.7 ± 9.7 years, and the mean tumor size was 1.0 ± 0.7 cm (range, 0.3–3.6 cm). Operation time was 168.0 ± 63.4 min for total thyroidectomy, 111.0 ± 27.7 min for lobectomy, and 73.7 ± 18.1 min for isthmusectomy. Five patients (4.5%) experienced transient vocal cord palsy (VCP) and one (0.9%) had permanent VCP. The swallowing impairment index-6 score was 2.18 ± 3.21 at postoperative three months, and 0.97 ± 1.72 at postoperative six months. The learning curve for lobectomy was 58 cases in CUSUM analysis. TOETVA is a safe and feasible approach with an acceptable operation time and a low complication rate. This approach is a surgical option for patients who desire excellent cosmesis.

Evaluation of YouTube videos as a patient education source for novel surgical techniques in thyroid surgery

Background

Patients and physicians are increasingly utilizing online video sharing sites such as YouTube for obtaining and disseminating health-related information in multimedia format; however, due to its free, open-access platform, YouTube videos fall short in providing validated, up-to-date medical information, and may even convey unintended messages to patients who are seeking additional information on surgeries. We evaluated the relevance, reliability, and quality of YouTube videos on novel surgical techniques in thyroid surgery.

Methods

The top 50 indexed YouTube videos for the queries, "robotic thyroid surgery" and "transoral thyroid surgery", were assessed by two independent reviewers for video quality and reliability for patient understanding. Videos were scored using Global Quality Score (GQS), a scale for video quality, and DISCERN Scoring, a questionnaire for reliability and quality measures of information presented.

Results

The mean ± standard deviation (SD) duration of the videos (n=50) was 8.1±3.7 minutes. Total views were 261,440 and the mean ± SD time since upload was 3.6±2.6 years. The median and interquartile range of video power index (VPI) was 1.9 (0.5-3.7), GQS was 3.0 (2.0-4.0), and DISCERN score was 2.8 (2.3-3.2). Most videos were uploaded by physicians (75.8%) and the highest number of videos (63.6%) uploaded were from the United States (US). Videos with higher quality and reliability scores were uploaded by academic professionals, and included videos of physicians who described procedural information, perioperative instructions, and possible postoperative complications (P<0.05). Adequate medical information on the procedure and discussion of complications in YouTube videos were independent predictors of advanced educational quality and reliability.

Conclusions

Clinical information on new surgical techniques such as transoral and robotic thyroid surgeries in YouTube videos scored low on quality and reliability as a source of patient education. Physicians should provide supplemental educational material online and offline to aid patient understanding of novel procedures.

Personalized treatment for differentiated thyroid cancer: current data and new perspectives

More conservative and personalized treatment options have been developed in recent years to face the rising diagnosis of low-risk differentiated thyroid carcinoma (DTC). The present review describes the change towards a more risk-adapted management either in the treatment or in the follow-up of DTC. Particular attention is given to the innovations introduced by the latest guidelines for low-risk tumors, starting from the most appropriate extension of surgery up to the postoperative management. The emerging role of active surveillance for low-risk microcarcinoma is discussed, as well as the development of percutaneous strategies in the setting of malignant thyroid disease. The recent use of approved new systemic target therapies for advanced radioiodine refractory thyroid cancer is reported, together with the description of new compounds in trial. Finally, we provide some considerations to improve the risk evaluation in a presurgical setting, especially related to the rising role of genetics, to enable better risk-based cancer management and personalized treatment choices.

Robotic surgery versus open surgery for thyroid neoplasms: a systematic review and meta-analysis

PURPOSE

Robotic surgical system has been gradually applied in thyroid neoplasms as a novel treatment for years, with presenting some superiorities as well as limitations. To compare the effectiveness and safety of robotic surgery with open surgery for the patients with thyroid neoplasms, this review was conducted METHODS: We performed electronic search in CENTRAL, MEDLINE, EMBASE, CNKI, CBM, Opengray, and Sciencepaper Online databases and manual search in specific online databases and according to the reference list of relevant papers to get all the studies that compared the effectiveness and safety of robotic surgery with that of open surgery for patients with thyroid neoplasms. Last update was conducted in March 2020. Randomized-controlled trials, case-control studies, cohort studies, and cross-sectional surveys were all included.

RESULTS

In this review, 59 studies were included: two RCTs, 15 NRSs, 40 cohort studies, and two cross-sectional studies. Robotic surgery was found to be associated with longer operative duration, less retrieved lymph nodes, higher postoperative thyroglobulin before radioactive iodine ablation, similar complication incidence but less blood loss, better functional recovery, and higher cosmetic satisfaction compared to open surgery.

CONCLUSIONS

Robotic surgery is a safe and feasible approach with remarkable superiority in reducing intraoperative damage and improving patients' quality of life compared to open surgery for thyroid neoplasms. Meanwhile, this procedure is also associated with long operative duration, insufficient removal of neck lymph nodes, which need to be given careful consideration.

Surgical approaches to thyroid

Thyroidectomy is the most frequent procedure in endocrine surgery. The conventional approach through a collar incision, as described by Kocher in XIX^th century, has become the "gold standard". It is continuously evolving in spite of, many years ago, it showed to be safe and efficient with quality standards difficult to beat. Endoscopic and robotic surgery have developed "new approaches" to thyroid in order to improve the cosmetic results, looking even for invisible scars. We have done a thoughtful review of most of them trying to understand their benefits and drawbacks. Currently none of these "new approaches" have been shown to be better than conventional open thyroidectomy beyond offering a better cosmetic result. Besides, only a small percentage of patients can benefit of them. However, most of these approaches will remain if they treat the diseased thyroid and also improve the quality of life of our patients.

Preoperative scar perception study comparing 'scarless' in the neck endoscopic thyroidectomy with open thyroidectomy: a cross-sectional study

INTRODUCTION

Open thyroidectomy is the most common approach to thyroid surgery. However, 'scarless' (in the neck) endoscopic thyroidectomy, consisting of endoscopic and robotic surgery, is progressively being adopted for its perceived cosmetic benefits. This study aims to determine the patient's preferred surgical approach and to identify the factors that influence their decision.

MATERIALS AND METHODS

A pilot study consisting of 100 patients with a surgical thyroid disorder were prospectively recruited from a single tertiary centre. An interviewer-administered survey was conducted. Demographic, socioeconomic status, scar perception and an adapted body image scale were evaluated to identify factors that shaped the patient's perception of the surgical approach.

RESULTS

The mean age of participants was 54.5 ± 13.0 years; 72% were women and 87% Chinese. Of the 100 patients, 75 patients considered scarless endoscopic thyroidectomy as their preferred surgical approach while 25 patients opted for open thyroid surgery. Improvement in scar perception score between scarless endoscopic thyroidectomy and open thyroid surgery is associated with an increased willingness to choose scarless endoscopic thyroidectomy. The mean body image scale score was 6.9 ± 2.8, indicating no statistical difference between the surgical approaches. On multivariate analysis, improvement in scar perception score (odds ratio 3.38, 95% confidence interval 1.11-10.29) and having surgeon recommendation (odds ratio 6.38, 95% confidence interval 1.80-22.63) were independently associated with interest in scarless endoscopic thyroidectomy.

CONCLUSION

Patients interest in undergoing scarless endoscopic thyroidectomy is driven by improved scar perception and surgeon's recommendation compared with open thyroid surgery.

Robotic thyroid surgery

Various remote access robotic thyroidectomy techniques have been developed using the da Vinci® surgical system (Intuitive Surgical Inc., Sunnyvale, CA) to hide or avoid neck scarring and overcome the limitations of endoscopic thyroidectomy. Among those used today are the gasless transaxillary approach, the bilateral axillo-breast approach (BABA), the gasless postauricular facelift approach, and the transoral approach. Especially, the recently introduced transoral approach (including robotic and endoscopic procedures) is prominent and now popular worldwide. The most significant advantages of remote access robotic thyroidectomy are excellent postoperative cosmesis and voice outcomes. The important limitations to the adoption of robotic thyroidectomy are the difficult technique, high complication rate during the learning curve, and high cost. In addition, cultural differences, longer operative times, and medicolegal issues are a barrier to the diffusion of robotic thyroidectomy. However, remote access robotic thyroidectomy is feasible, and the outcomes are comparable to those of conventional transcervical thyroidectomy if performed by experienced surgeons in highly selected patients. This article reviews the evolution and recent advances in robotic thyroid surgery.

Assessing National Utilization Trends and Outcomes of Robotic and Endoscopic Thyroidectomy in the United States

OBJECTIVE

We aimed to evaluate trends and outcomes of surgical approaches to thyroid surgery. We hypothesized that there have been changes over time in the utilization of approaches to thyroidectomy, including endoscopic, robotic, and open approaches, and that patient outcomes may differ between open surgery and endoscopic or robotic approaches.

STUDY DESIGN

Retrospective analysis.

SETTING

The National Cancer Database (NCDB) was queried between 2010 and 2016.

SUBJECTS AND METHODS

National cohort of patients. Descriptive statistics were performed using χ² test, Mann-Whitney U test, t test and analysis of variance. To investigate complication rates, patient matching was performed with subsequent analysis using simple and multivariable logistic regressions.

RESULTS

We identified 217,938 patients within the NCDB. While endoscopic thyroid surgery increased, relatively, in use over time (0.93% to 2.34% of cases in 2010 and 2016, respectively), robotic thyroid surgery started to decline relatively to other approaches from 2013 to 2016 (0.39% to 0.25% of cases, respectively). The endoscopic approach was performed more commonly than the robotic approach within individual facilities that have reported both procedures (P = .025). Robotic thyroid surgery was associated with increased risk of positive margins (P = .046), while endoscopic thyroid surgery was associated with a higher rate of unplanned hospital readmission (OR, 1.55; 95% CI, 1.09-2.22), longer inpatient stays (OR, 1.55; 95% CI, 1.19-2.02), and higher 90-day postoperative mortality (OR, 4.45; 95% CI, 1.58-12.6).

CONCLUSION

Endoscopic thyroid surgery has increased in utilization since 2004 but may have worse morbidity and mortality outcomes compared to open surgery.

The effect of robot-assisted transaxillary thyroidectomy (RATT) on body image is better than the conventional approach with cervicotomy: a preliminary report

BACKGROUND

Cosmetic satisfaction is not only based on the patient's perception of the scar itself but is also related to body image self-evaluation. Cosmetic superiority of Robot-assisted transaxillary thyroidectomy (RATT) over conventional thyroidectomy (CT) has not yet been clearly demonstrated. Aim of our study was to compare body image in patients undergoing CT versus RATT.

METHODS

The study included 160 (80 CT and 80 RATT) patients undergoing thyroidectomy between August 2014 and March 2018 at the Endocrine Surgery Department. The inclusion criteria were age 18 to < 60 years, female sex, thyroid volume < 30 mL, and nodule diameter < 5 cm. Scar length, operative time, and complications were analyzed. The body image questionnaire (BIQ) was used 3 months postoperatively. The Student t test was used for statistical analysis.

RESULTS

Age was lower in RATT group (38.2 vs 41.4 years) (P < 0.0001). The nodule diameter was larger in RATT group (27.1 vs 23.1 mm) (P = 0.028). Operative time was longer in RATT group (93.7 vs 47.6 min) (P < 0.0001). The scar was longer in RATT group (59.9 vs 37.7 mm) (P < 0.0001). The groups had similar complication rates. BIQ showed that RATT patients answered more favorably to question 2, "Do you feel the operation has damaged your body?" (P = 0.042) and to question 3, "Do you feel less attractive as a result of your treatment?" (P = 0.024). Also self-global satisfaction was better in RATT group (P = 0.019).

CONCLUSIONS

In our experience, RATT has a significantly better impact on body image than the conventional approach.

Robotic thyroidectomy via bilateral axillo-breast approach: Experience and learning curve through initial 220 cases

OBJECTIVE

This study is aim to summarize the experience of robotic thyroidectomy via bilateral axillo-breast approach of our center and also to find out the learning curve of this technique.

METHODS

In total 220 initial patients who have undergone robotic thyroidectomy via bilateral axillo-breast approach from May 2015 to September 2017 were involved in this study. The data of operation time, clinical characteristics, surgical outcomes and oncological outcomes were collected. The moving average method is use to explore the learning curve.

RESULTS

All patients had undergone robotic thyroidectomy successfully without conversion to other surgical approaches. The mean age of the enrolled subjects was 34.4 ± 7.8 years old, while the sex ratio (male/female) was 38/182. There were 50 benign tumor cases and 170 malignant tumor cases. The mean total operation time was 105.3 ± 37.6 min. Lymph node metastasis was observed in 61 (35.9%) patients. The mean retrieved lymph node count was 5.1 ± 3.8 while the mean metastatic lymph node count was 0.7 ± 1.5. The operation time decreased significantly after about 30-35 cases and formed the plateau. After 80 cases, the operation time significantly decreased again.

CONCLUSION

For skilled endocrine surgeons, robotic thyroidectomy has proved to be safe and feasible, which could be applied extensively in patients strictly selected in high-volume centers, with a relatively short learning curve of about 30-35 cases. While the surgeons getting more experienced, this technique would be more efficient.

A Propensity Score-matched Comparison Study of Surgical Outcomes in Patients with Differentiated Thyroid Cancer After Robotic Versus Open Total Thyroidectomy

INTRODUCTION

The aim of this study, from a surgical, oncological, and functional perspective, was to identify whether bilateral axillo-breast approach robotic total thyroidectomy (RTT) for differentiated thyroid cancer (DTC) has different surgical outcomes compared to open total thyroidectomy (OTT).

METHODS

Initially, 796 patients who underwent total thyroidectomy were primarily reviewed and 178 who were ineligible for analysis were excluded. Propensity score matching analysis adjusted for clinicopathological characteristics (sex, age, body mass index, extent of central node dissection, tumor size, extrathyroidal extension, and thyroiditis) was conducted, with 246 patients in the OTT group matched with 123 patients in the RTT group.

RESULTS

There were no significant differences in surgical outcomes in terms of surgical safety and oncological safety between the OTT and RTT groups, except in mean operation times (123.51 ± 32.63 vs. 198.39 ± 37.93 min, respectively; P < 0.001). However, the median parathyroid and laryngeal function recovery times were shorter in the RTT group than in the OTT group [88 ± 33.09 (95% CI: 23.148-152.852) vs. 100 ± 16.20 (95% CI: 68.242-131.768) days; P = 0.044 and 87 ± 32.40 (95% CI: 23.489-150.511) vs. 118 ± 49.50 (95% CI: 20.985-215.015) days; P = 0.002].

CONCLUSIONS

The recovery times of laryngeal and parathyroid function were significantly shorter in RTT patients than in OTT patients for DTC. To verify a definitive conclusion about the superiority of robotic total thyroidectomy in terms of parathyroid and laryngeal function recovery, further studies may be necessary.

Evolution Strategies in Transaxillary Robotic Thyroidectomy: Considerations on the First 449 Cases Performed

Background: In the past 20 years, the fast spread of new surgical technologies has reached an important peak with the advent of the robotic surgery. Many studies have been run about a cosmetic desire to avoid neck scars after thyroid surgery and this has led to the development of remote access robotic thyroidectomy (RT). Among the various RT approaches, unilateral transaxillary access is one of the most widely used, reporting excellent results in terms of feasibility and patient's compliance. The mini-invasive technique demonstrated many potential shortcoming overcomes with the robotic approach. At our institution a team of 3 skilled endocrine surgeons with experience in laparoscopic and robotic procedures performed RT. Our aim is to report our 8-year single-centre robot-assisted thyroidectomy experience, by applying a gasless unilateral transaxillary approach with the so-called hybrid technique, and to demonstrate its safety and feasibility.

Methods: In the period between September 2010 and June 2018 at our institution, a total of 472 patients underwent thyroid and parathyroid transaxillary surgery. The hybrid technique was applied for all the robotic procedures. A total of 412 procedures were performed with the use of external “Modena Retractor” (CEATEC^® Medizintechnik) and with 3 surgeons. According to international guidelines, our indications for robotic surgery were benign lesions with a diameter <5 cm, Graves' disease, well-differentiated thyroid cancers, and parathyroid adenomas.

Results: In this series, a total of 449 cases were registered. General data of patients were analyzed: gender, age, body mass index, tumor size, preoperative fine-needle aspiration examination, definitive histological examination, operative time, and postoperative complications.

Conclusions: This study confirms the application of robotic approach in thyroid surgery as a feasible technique in terms of safety and complications risk. The hybrid technique, together with a dedicated surgical team, can lead to obtaining the same outcomes of traditional anterior cervicotomic surgery, adding a scarless thyroidectomy.

Total endoscopic thyroidectomy versus conventional open thyroidectomy in thyroid cancer: a systematic review and meta-analysis

Background

Despite the considerable experience gained thus far using endoscopic technologies, the role of total endoscopic thyroidectomy (ET) for papillary thyroid cancer (PTC) remains controversial. We conducted a systematic review and meta-analysis to investigate the safety and effectiveness of total ET compared with conventional open thyroidectomy (OT) in PTC.

Methods

A systematic search was conducted using the PubMed, Embase and Cochrane Library electronic databases up to March 2018. The quality of included studies was evaluated using the Newcastle–Ottawa Scale. Review Manager software version 5.3 was used for the meta-analysis.

Results

Twelve studies including 2,672 patients were ultimately included in the systematic review and meta-analysis. ET was associated with longer operative time (P<0.00001), drainage time (P<0.00001) and hospital stay (P=0.03), higher transient recurrent laryngeal nerve (RLN) palsy rate (P=0.004) and a greater amount of drainage fluid (P<0.0001) compared with OT. Furthermore, no significant differences were detected between ET and OT in terms of retrieved lymph nodes (P=0.17), blood loss (P=0.22), transient hypocalcemia (P=0.84), permanent hypocalcemia (P=0.58), permanent RLN palsy (P=0.14), hematoma or bleeding (P=0.15) and seroma (P=0.54). In addition, the rates of tumor recurrence were comparable (P=0.18), whereas the proportions of stimulated thyroglobulin levels <1 ng/mL measured after completion of thyroidectomy and radioactive iodine therapy were less (P=0.02) in the ET than in the OT group.

Conclusion

ET is not superior to OT in terms of operation and drainage time, amount of drainage fluid, hospital stay or transient RLN palsy, but is comparable to OT in terms of retrieved lymph nodes and permanent complications. Despite the similar tumor recurrence rates between the two approaches, the level of surgical completeness in ET may not be as good as that for OT.

Meta-analysis Comparison of Bilateral Axillo-Breast Approach Robotic Thyroidectomy and Conventional Thyroidectomy

Objective. Despite gaining popularity, bilateral axillo-breast approach robotic thyroidectomy (BABA RT) remains controversial. We performed a meta-analysis to evaluate the safety and effectiveness of BABA RT compared with open thyroidectomy (OT) in thyroid disease. Methods. A literature search was conducted using various databases, including PubMed, Web of Science, and Cochrane Library, up to February 2018. Outcomes of interest included patient characteristics, surgical outcomes, adverse events, complications, and surgical completeness. Results. A total of 11 publications including 2733 patients (1070 in the BABA RT and 1663 in the open group) were finally selected for the meta-analysis. BABA RT was associated with an equivalent complication rate, including transient and permanent hypocalcemia, transient and permanent recurrent laryngeal nerve palsy, bleeding, chyle leakage, and seroma, as well as surgical outcomes including tumor size, length of hospital stay, total drain amount, and pain score. BABA RT was also associated with an equivalent surgical completeness, including total dose of radioactive iodine, proportion of stimulated thyroglobulin (sTg) <1.0 ng/mL, and level of sTg. Moreover, BABA RT involved longer operative times (weighted mean difference [WMD] = 110.13; P < .00001), smaller number of retrieved lymph nodes(WMD = −1.26, P = .003), and more cost (WMD = 5811.18; P < .00001) compared with OT. Conclusions. BABA RT is safe and feasible and provides similar perioperative outcomes and complications when compared with OT. However, BABA RT was associated with longer operating time, fewer retrieved lymph nodes, and more cost. Randomized clinical trials with large samples and longer follow-up data are needed to more rigorously examine this effect.

Thyroid surgery for differentiated thyroid cancer - recent advances and future directions

Population-based studies have demonstrated that an increasing number of incidental thyroid nodules are being identified. The corresponding increase in thyroid-based diagnostic procedures, such as fine-needle aspiration biopsy, has in part led to an increase in the diagnoses of thyroid cancers and to more thyroid surgeries being performed. Small papillary thyroid cancers account for most of this increase in diagnoses. These cancers are considered to be low risk because of the excellent patient outcomes, with a 5-year disease-specific survival of >98%. As a result, controversy remains regarding the optimal management of newly diagnosed differentiated thyroid cancer, as the complications related to thyroidectomy (primarily recurrent laryngeal nerve injury and hypoparathyroidism) have considerable effects on patient quality of life. This Review highlights current debates, including undertaking active surveillance versus thyroid surgery for papillary thyroid microcarcinoma, the extent of thyroid surgery and lymphadenectomy for low-risk differentiated thyroid cancer, and the use of molecular testing to guide decision-making about whether surgery is required and the extent of the initial operation. This Review includes a discussion of current consensus guideline recommendations regarding these topics in patients with differentiated thyroid cancer. Additionally, innovative thyroidectomy techniques (including robotic and transoral approaches) are discussed, with an emphasis on patient preferences around decision-making and outcomes following thyroidectomy.

Fluorescence imaging-guided robotic thyroidectomy and central lymph node dissection

BACKGROUND

The purpose of this study was to evaluate the feasibility of complete central compartment node dissection (CCND) using fluorescence imaging (FI) during robotic thyroidectomy.

METHODS

A total of 110 patients underwent robotic thyroidectomy and CCND from August 2015 to June 2016; 55 patients underwent robotic surgery using FI (FI group) and the other 55 patients without it (control group). The FI group was injected with indocyanine green into the thyroid to enhance the identification of lymph nodes (LNs).

RESULTS

Indocyanine green-stained LNs were easily detected using FI. The number of harvested LNs was 7.0 in the FI group and 4.8 in the control group (P = 0.004). There was lower rate of transient hypocalcemia in the FI group (18.5%) than control group (26.7%), but there was no significant difference (P = 0.417). There were no other significant differences between the two groups.

CONCLUSIONS

The use of FI during robotic thyroidectomy facilitated the identification of LNs and guided complete CCND.

Comparison of short-term oncologic outcome of robotic thyroid surgery using dynamic risk stratification: A propensity score-matched comparison study

BACKGROUND

The long-term oncologic outcome of robotic surgery for thyroid cancer is not well established. The aim of this study was to predict the long-term oncologic outcome of robotic surgery by using dynamic risk stratification in classic papillary thyroid carcinoma.

METHODS

A total of 444 propensity score-matched pairs of patients with papillary thyroid carcinoma treated with robotic surgery and conventional open surgery were classified into 4 response-to-therapy categories. The results were compared between the robotic surgery and open surgery groups.

RESULTS

The median follow-up duration was 60 months. After propensity score matching, the robotic surgery group showed less extensive thyroid surgery and lymph node dissection and a higher proportion of patients who underwent radioactive iodine remnant ablation than the open surgery group; however, the dynamic risk stratification did not differ between the 2 groups (P = .086).

CONCLUSION

The long-term oncologic outcome of robotic surgery is expected to be comparable with that of open surgery based on the dynamic risk stratification.

Robotic and Endoscopic Thyroid Surgery: Evolution and Advances

To minimize surgical morbidity and neck scarring, minimally invasive thyroidectomy and robotic/endoscopic thyroidectomy via cervical, axillary, anterior chest, breast, postauricular or transoral approaches have been developed over the past 20 years. In this article, we review the evolution of robotic and endoscopic thyroid surgery and recent advances. Among remote access approaches, the gasless transaxillary approach, bilateral axillo-breast approach, postauricular facelift approach, and transoral vestibular approach are in common use today. Each procedure has its own advantages and disadvantages. Therefore, we need to understand these advantages and limitations, and to select the appropriate method for each patient. The most significant advantage of remote access thyroidectomy is its excellent cosmesis. The complication rate is similar in patients undergoing a remote access approach and those undergoing conventional surgery if the former is performed by experienced surgeons. Operative time is significantly longer in remote access thyroidectomy. In conclusion, remote access thyroidectomy is feasible and its outcomes are comparable to those of conventional transcervical thyroidectomy in highly selected patients.

Variations and results of retroauricular robotic thyroid surgery associated or not with neck dissection

Background

Technological advances in the last decades allowed significant evolution in head and neck surgery toward less invasive procedures, with better esthetic and functional outcomes, without compromising oncologic soundness. Although robotic thyroid surgery has been performed for some years now and several published series reported its safety and feasibility, it remains the center of significant controversy. This study shows the results of a case series of robotic thyroid surgery, combined or not with robotic neck dissection.

Methods

A retrospective cohort including 48 cases of robotic thyroid surgery with or without neck dissection, using retroauricular or combined approaches, performed in a tertiary cancer center, comprised the study.

Results

Between 2015 and 2017, we performed 2,769 thyroid surgical procedures, of which 48 (1.7%) were robot-assisted, in 46 patients [26 hemithyroidectomies, 7 total thyroidectomies, and 12 total thyroidectomies (or totalization) with selective neck dissection (SND) II-VI; and 3 neck dissections for thyroid carcinoma]. There were 43 (89.6%) women, and the median age was 35 years. The mean hospital stay was 1.9 days. In 3 (6.2%) cases, drains were not placed (hemithyroidectomies), whereas the other 45 (93.8%) cases had a mean drain stay of 4.4 days (range, 1-9 days). The console time (robotic thyroid resection and neck dissection) ranged from 11 to 200 min (mean 66.1 min; median 40 min), and the total operating room time ranged from 80 to 440 min (mean 227.9 min; median 170 min). Three (6.2%) patients had transient vocal cord paresis. Transient hypocalcemia was reported in three cases (6.2%). There were 30 carcinomas (62.5%), and the mean number of retrieved lymph nodes (LNs) (considering only cases that included robotic neck dissection) was 27.2 (range, 17-40). The mean follow-up time was 17.4 months (range, 1.4-31.9 months), and no recurrence was diagnosed.

Conclusions

The quality outcomes and complication rates are comparable to the conventional approaches. Therefore, robotic thyroidectomy can be an option for selected patients that are motivated to avoid a visible neck scar, treated in high-volume centers. For the patients who require lateral neck dissection, the retroauricular robotic approach could be even more attractive, especially for young patients.

Robotic-assisted modified radical neck dissection using a bilateral axillo-breast approach (robotic BABA MRND) for papillary thyroid carcinoma with lateral lymph node metastasis

BACKGROUND

Although safe in patients with papillary thyroid carcinoma (PTC), robotic thyroidectomy using a bilateral axillo-breast approach (BABA) has not been frequently performed in patients with advanced PTC. This study describes surgical outcomes in patients with PTC and lymph node metastasis (LNM) in lateral neck compartment who underwent robotic-assisted modified radical neck dissection with BABA (robotic BABA MRND).

METHODS

The medical records of patients with PTC and lateral LNM who underwent robotic BABA MRND from March 2010 to July 2016 were retrospectively reviewed.

RESULTS

Fifteen patients, 14 women and 1 man, of mean age 37.1 ± 9.3 years, were enrolled. Mean operation time was 272.7 ± 33.8 min. A mean 20.7 ± 7.2 lymph nodes were retrieved from the lateral neck compartment, with a mean 5.3 ± 4.4 lymph nodes being metastatic. The rates of transient and permanent hypocalcemia were 46.7 and 0%, respectively, and the rates of transient and permanent vocal cord palsy were 6.7 and 0%, respectively. Fourteen patients (93.3%) had stimulated thyroglobulin concentrations below 2 ng/mL after the first treatment with radioactive iodine.

CONCLUSIONS

Robotic BABA MRND could be safely performed and may be a good surgical option in selected patients with PTC and lateral LNM.

Postsurgical Outcomes and Surgical Completeness of Robotic Thyroid Surgery: A Single Surgeon's Experience on 700 Cases

BACKGROUND

Advanced technology and understanding of robotic surgical system have rendered robotic thyroid surgery more expanding. The aim of this study was to identify the periodic changes in postsurgical outcomes of robotic thyroid surgery performed by a single surgeon.

METHODS

We conducted a retrospective review of 700 robotic thyroid surgery cases using gasless trans-axillary approach.

RESULTS

All patients underwent successful operations without conversion to open surgery, and were mostly younger than 45 years, female, less-extended thyroid surgery and lymph node dissection, and thyroid cancer. The median follow-up period was 67 months (12-99 months). Regarding technical outcomes, the operation time declined steeply after 100 consecutive cases, and reached 120.0-132.7 minutes for thyroid lobectomy and 162.9-174.1 minutes for total thyroidectomy (TT). The most common complication was transient hypoparathyroidism (43.7%), whose incidence decreased steeply to a range of 9.1% to 25.0% after 300 consecutive cases. Regarding surgical completeness for thyroid cancer, an average of seven lymph nodes was retrieved through central compartment node dissection without fluctuation over time. The proportion of the patients with serum stimulated thyroglobulin levels <10 ng/mL at the time of radioactive iodine remnant ablation after TT and <1 ng/mL 6-12 months after the first remnant ablation ranged between 86.4%-100% and 66.7%-100%, respectively, without significant fluctuation.

CONCLUSION

For properly selected patients, robotic thyroid surgery is useful surgical option with reliable technical outcome and surgical completeness and cosmetic benefit.

Factors affecting operative time in robotic thyroidectomy

BACKGROUND

The purpose of this study was to evaluate factors related to operative time in robotic thyroidectomy.

METHODS

We retrospectively analyzed 240 patients who underwent robotic thyroidectomy. The total thyroidectomy cases and lobectomy cases were both categorized into those with long operative times (LOTs; upper 25% of cases) and those with short operative times (SOTs; lower 25%).

RESULTS

Among the total thyroidectomy cases, body mass index (BMI) ≥23 kg/m² (hazard ratio [HR] 5.34; P = .008) and bilateral central neck dissection (CND; HR 14.92; P = .028) were more frequent in the LOT group in multivariate analysis. Among the lobectomy cases, BMI ≥23 kg/m² (HR 12.92; P = .003) and unilateral CND (HR 21.38; P = .017) were the only independent risk factors for prolonged operative time.

CONCLUSION

Body habitus and clinical nodal status in the central compartment should be considered in deciding the indications for robotic thyroidectomy.

Risk factors of central lymph node metastasis of papillary thyroid carcinoma: A single-center retrospective analysis of 3273 cases

Due to the lack of an accurate preoperative diagnostic method of central lymph node metastasis (CLNM) of papillary thyroid cancer (PTC), the prophylaxis of central lymph node dissection remains controversial. The present study investigated the clinicopathological features of PTC patients and the risk factors of CLNM. The clinicopathological features of PTC patients with respect to sex, age, initial symptoms, observation, tumor diameter, multifocality, extrathyroidal invasion, and pathological data combined with other thyroid diseases, were analyzed retrospectively. The risk factors of CLNM were analyzed by Chi-squared test and multivariate logistic regression model. The CLNM rate of PTC was 40.6% (1331/3273). On average, 7.0 (4.0, 12.0) central lymph nodes were dissected, and 3.70 (±3.8) lymph nodes were proved to be metastatic. Univariate analysis showed that sex (P < .001), age (P < .001), tumor diameter (P < .001), extrathyroid invasion (P < .001), multifocality (P = .001), concurrent nodular goiter (P < .001), initial symptoms (P < .001), and observation or not (P < .001) were related to CLNM. The observation time was neither related to CLNM (P = .469) nor extrathyroidal invasion (P = .137). Tumors localized in the lower part of the thyroid were the risk factors for CLNM (P < .001) while multifocality was unrelated (P = .68). The metastasis rate of bilateral multiple regions > unilateral multiple regions > single region (P = .003). Multivariate logistic regression analysis showed that sex, age, tumor diameter, extrathyroidal invasion, and observation were independent risk factors of CLNM. Male, younger age, large tumor size, and extrathyroidal invasion were independent risk factors for CLNM. CLNM was related to multiple regions occupied by tumors in the thyroid but unrelated to multifocality. The tumor occupying a single region and localized in the lower part of thyroid could be used as a predictive factor for CLNM. For tumors that could not be diagnosed as benign or malignant, observation may be an option, since no evidence of disease progression was presented during observation.

Bilateral axillo-breast approach robotic thyroidectomy: review of evidences

The bilateral axillo-breast approach (BABA) is one of the most popular contemporary remote-access thyroidectomy techniques. While the initial experiences with BABA endoscopic thyroidectomy (ET) were associated with some technical challenges and safety concerns, many limitations of the technique could now be substantially overcome by BABA robotic thyroidectomy (RT). In this review, the current literature evidences of BABA RT were analyzed. Data regarding the patient selection, the learning curve, and the comparison with open thyroidectomy (OT) and BABA ET were examined. Careful case selection for BABA RT should be undertaken according to factors related to the patient and the thyroid pathology. The learning curve of BABA RT was about 40 cases. Comparing to OT, BABA RT was comparable to OT for the complication profiles and most perioperative outcomes. But it was associated with longer operative time, higher cost and possibly inferior oncological control with lower number of central lymph node (LN) retrieved. When compared to BABA ET, BABA RT was comparable for most perioperative outcomes except longer operative time and higher cost. Yet, BABA RT was superior to BABA ET for better oncological control. BABA RT is a safe and effective procedure for most benign thyroid conditions and low-risk differentiated thyroid cancers (DTC).

Overview of robotic thyroidectomy

With the advancement and adaptation of technology, there has been a tremendous evolution in the surgical approaches for thyroidectomy. Robotic thyroidectomy has become increasingly popular worldwide attracting both surgeons and patients searching for new and innovative techniques for thyroidectomy with a superior cosmetic result when compared to the conventional open procedures. In this review, we describe the following surgical approaches for robotic thyroidectomy: transaxillary, retroauricular (facelift) and transoral. The advantages and disadvantages as well as limitations of each approach are examined, and future directions of robotic thyroidectomy are discussed.

[Alternative approaches in thyroid surgery]

In thyroid surgery multiple different cervical minimally invasive (partly endoscopically assisted) and extracervical endoscopic (partly robot-assisted) approaches have been developed in the last 20 years. The aim of all these alternative approaches to the thyroid gland is optimization of the cosmetic result. The indications for the use of alternative and conventional approaches are principally the same. Important requirements for the use of alternative methods are nevertheless a broad experience in conventional thyroid operations of the thyroid and adequate patient selection under consideration of the size of the thyroid and the underlying pathology. Contraindications for the use of alternative approaches are a large size of the thyroid gland including local symptoms, advanced carcinomas, reoperations and previous radiations of the anterior neck. The current article gives an overview of the clinically implemented alternative approaches for thyroid surgery. Of those the majority must still be considered as experimental. The alternative approaches to the thyroid gland can be divided in cervical minimally invasive, extracervical endosopic (robot-assisted) and transoral operations (natural orifice transluminal endoscopic surgery, NOTES). Since conventional thyroid operations are standardized procedures with low complication rates, alternative approaches to the thyroid gland are considered critically in Germany. The request for a perfect cosmetic result should not overweigh patients' safety. Only a few alternative approaches (e. g. MIVAT, RAT) can yet be considered as a safe addition in experienced hands in highly selected patients.