Transoral Robotic Surgery Resection Research Articles

Oncological outcomes post transoral robotic surgery (TORS) for HPV-associated oropharyngeal squamous cell carcinoma, a single-centre retrospective Australian study

We present a cohort review of TORS resection for HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) and its associated oncological outcomes spanning a 10-year period. A retrospective case series review was performed of patients undergoing primary surgical treatment for HPV-associated OPSCC through the St. Vincent’s Head and Neck Cancer service from 2011 to 2022. The primary outcomes were to investigate complete resection of the primary tumour, rates of recurrence, and survival analysis. Secondary outcomes included complications, rates of adjuvant therapy, sites of recurrence and rates of percutaneous endoscopic gastrostomy (PEG). 184 patients underwent TORS-based therapy with neck dissection, and guideline-directed adjuvant therapy for HPV-associated OPSCC. Our median follow-up was 46 months. The positive margin rate on final histopathology analysis was 10.9%. Adjuvant therapy was indicated in 85 patients (46%). The local recurrence rate was 10.9% with the majority (80%) of patients recurring in the first 3 years since treatment. The disease-specific survival at 3 years was 98.6% and at 5 years was 94.4%. The 3-year and 5-year OS for the cohort was 96.7% and 92.5%, respectively. The presence of extranodal extension and positive margins were associated with increased risk of recurrence, whereas adjuvant therapy was found to be a protective factor for both overall recurrence and survival. Major complications occurred in 12 patients (6.5%), resulting in one death. This study has demonstrated that primary surgical therapy for HPV-associated OPSCC is a safe and effective treatment modality with low local recurrence and complication rates, and overall survival benefits.

Specimen-Based Resection Margins and Local Control during Transoral Robotic Surgery for Oropharyngeal HPV-Mediated Squamous Cell Carcinoma

Objectives: The aim of the study was to investigate the association of surgical margin conditions, including positive specimen margins revised to negative relative to local recurrence, disease-free survival, and overall survival (OS) within a cohort of HPV-mediated oropharyngeal squamous cell carcinoma (OPSCC) who underwent en bloc resection via transoral robotic surgery (TORS). Materials and Methods: Retrospective cohort of patients with untreated HPV-mediated OPSCC cT1 or T2 undergoing TORS resection between October 2014 and March 2020. The methodologic description of our interdisciplinary institutional approach, number of cut-through margins (CTMs) during intraoperative consultation, percentage of final positive margin cases, and disease-free survival and OS stratified by margin status and margin tumor-free distance is identified. Results: 135 patients with primary cT1/T2 HPV-mediated OPSCC met inclusion criteria. Twenty-eight of 135 (20.7%) specimens revealed CTM and were revised during the same operative setting. Three of 135 (2.2%) surgical cases had positive final margin status. Local control rate was 97%. On univariate analysis, margin distance did not impact OS. CTM and final positive margins had lower OS than initially negative margins (p = 0.044). Pathologic N-stage significantly impacted OS (p < 0.001). Conclusions: High local control rate and low final positive margin status confound the study of specimen margin-based techniques in HPV-mediated OPSCC resected en bloc with TORS. Pathologic N-stage may impact OS more than margin status. Larger numbers are needed to confirm differences.

A Phase II Study of Volume and Dose De-Intensification Following Transoral Robotic Surgery (TORS) and Neck Dissection for p16+ Oropharyngeal Squamous Cell Carcinoma

<h3>Purpose/Objective(s)</h3> Current efforts to de-intensify adjuvant therapy for patients with p16+ Oropharyngeal Squamous Cell Carcinoma (OPSCC) have focused on dose de-escalation (ECOG 3311) or volume reduction (AVOID trial). We conducted this prospective Phase II single institution study combining volume and dose de-intensification, in patients with pT0-T3 pN0-N2c p16+ OPSCC, with the goal of maintaining high rates of locoregional control (LRC) and reducing treatment-related toxicity. <h3>Materials/Methods</h3> Eligible patients had pT0-T3 N0-N2c p16+ OPSCC (per AJCC 7th Ed), s/p TORS and neck dissection, with < 5 positive lymph nodes, who met standard indications for adjuvant radiotherapy +/- chemotherapy. Adjuvant RT was delivered in 25 fractions over 5 weeks. The primary site was spared in patients with pT1-T2 tumors resected with negative margins and no LVI or PNI, as per the AVOID trial. If RT to the primary operative bed was indicated, patients received 50, 52.5, or 55 Gy for negative, close, or positive margins, respectively. The neck level(s) with confirmed pathologic disease received 50 Gy, and areas of minor or macroscopic ENE were boosted to 52.5 or 55 Gy, respectively. Other at-risk ipsilateral nodal regions received 45 Gy. The treated volume of the contralateral neck was reduced to mirror the pathologically involved nodal levels in the ipsilateral neck, and received 45 Gy. Concurrent chemotherapy was according to guidelines, but could be omitted in patients with ENE ≤ 1 mm. The trial was powered to demonstrate 2-year LRC rate > 90%. <h3>Results</h3> 118 patients were enrolled between October 2018 and July 2021. Patient characteristics are detailed in the Table. Median follow up is 23 months (range 6 - 40 months). One patient developed regional recurrence after developing distant metastases (DM). No other patients had locoregional failure (LRF), yielding an estimated 2-year LRC rate of 98.8% (95% CI, 92-99.8%). Eight patients (7%) developed DM, and one patient has died of metastatic disease. The TORS resection bed was spared in 55% of patients; due to proximity to level 2, the median dose to the operative bed in these cases was 32.5 Gy (range 16.5 – 46 Gy). Twenty patients had ENE > 1 mm (considered "high risk" per ECOG 3311) and none had LRF. At one-year post-RT, the median MDASI-HN "difficulty swallowing/chewing at its worst" score was 2 (IQR, 1-3), and "choking/coughing with swallowing at its worst" score was 1 (IQR, 0-3), on a scale from 0 (not present) to 10 (as bad as you can imagine). <h3>Conclusion</h3> The combination of adjuvant RT dose de-intensification over 5 weeks and volume reduction, with omission of the primary site in appropriate patients, and reducing the volume of the treated contralateral neck, appears safe. Additional follow up is warranted and ongoing.

The omission of intentional primary site radiation following transoral robotic surgery in 59 patients: No local-regional failures.

We assessed locoregional control with omission of intentional primary site radiation after transoral robotic surgery (TORS) and quantified nontargeted primary site dose. Following Institutional Review Board (IRB) approval, patients treated with primary TORS resection for squamous cell carcinomas of the oropharynx were reviewed. Patients with cT1-2 tumors, >2 mm margins, in whom the surgeon resected the primary without revising specimen-driven margins, qualified for omission of primary site radiation. From 2014 to 2019, 112 patients met criteria. Fifty-nine (52%) patients did not receive radiation targeting the primary site; of whom, 22 received no radiation. In this group, there were no local failures; mean age was 58 years and median follow-up was 25 months. Thirty-seven patients received adjuvant radiation targeting the neck, mean bystander dose to the primary site was 28.8Gy (range, 13.3-50.6Gy). In a 59 patient population, omission of radiation to the primary site after TORS resulted in no locoregional failures.

Tumor phantom for training and research in transoral surgery.

ObjectiveWith the paradigm shift towards minimally invasive surgical techniques such as transoral laser microsurgery and transoral robotic surgery for resection of head and neck malignancies, there is a need to enhance the surgical training of these techniques as well as provide a platform for testing new approaches and technologies. The steeper learning curve associated with minimally invasive surgical techniques may be mitigated with the use of tumor phantoms (TP) placed in cadaver models.MethodsAn injectable TP was developed using an agar‐gelatin base, unsalted chicken stock, deionized water, food coloring for visual mimicry, and iohexol for radiographic mimicry. Four percentage glutaraldehyde was used as a cross‐linking agent for solidification of the TP. The TP was then injected in various mucosal anatomic sites in four unfixed cadaver heads. Visual, radiographic, and tactile mimicry was assessed via endoscopy, CT scan, and tumor dissection and palpation, respectively.ResultsTumor phantom injection was successfully achieved in all four cadaver heads. Visually and tactilely, the TP demonstrated similar color change, induration, and firmness of a typical squamous cell carcinoma (SCCa). However, ulceration that is often seen with SCCa could not be replicated. CT mimicry was compared with nine patients with known SCCa. Tumor radiodensity in the nine patients was between 77 and 110 HU (mean 86.3 HU) whereas TP radiodensity was 59 and 127 HU (mean 93.7 HU), with no significant difference between groups (P = .21).ConclusionThis inexpensive, easy to apply, and unique tumor phantom could be used both to train transoral techniques and as a tool to further investigate new approaches and technologies for transoral surgery.Level of EvidenceNA.

Occupational exposure of oropharyngeal human papillomavirus amongst otolaryngologists.

Human papillomavirus (HPV) is a DNA virus that causes cancer in multiple sites. Although sexual activity is the primary means of oropharyngeal HPV acquisition, studies suggest HPV transmission through occupational exposure from medical instruments and surgical fumes. We assess if aerosolization of HPV16 DNA via electrocautery places otolaryngologists at risk for exposure. Animal and human laboratory model. Plasmid (pLXSN16E6E7) expressing HPV p16 E6/E7 genes was transformed into DH5α Escherichia coli cells using the heat shock method. Miniprep and maxiprep purification of transformed DNA with subsequent restriction enzyme double digestion confirmed presence of E6E7 fragment. We injected 2 μg plasmid DNA in 20 μL TE (Tris and ethylenediaminetetraacetic acid) buffer intradermally into freshly severed mouse tail then cauterized for 5 to 10 seconds. Generated fumes were collected through a suction tube fitted with Whatman filter paper. Filter paper was placed in 100 μL TE buffer. Additionally, six patients undergoing transoral robotic surgery for resection of oropharyngeal cancer were identified, three with p16-negative tumors and three with p16-positive tumors. Intraoperatively, Whatman filter paper was exposed to electrocautery fumes, then placed in 100 uL TE buffer. Additional samples were collected from the suction tubing and filter, the surgical mask of the surgeon at head of the bed, and the robot arm. Samples were analyzed via polymerase chain reaction with an assay sensitivity of 1.5 ng E6E7 DNA. None of the patient or mouse tail samples yielded detectable HPV16 DNA in the electrocautery fumes. We did not detect HPV16 DNA on the surgical masks, suction apparatus, or robot arm intraoperatively. There is likely minimal risk of occupational exposure to HPV16 via electrocautery fumes. NA Laryngoscope, 130:2366-2371, 2020.

Postoperative opioid-prescribing practices in otolaryngology: A multiphasic study.

In otolaryngology, postoperative pain management lacks evidence-based guidelines. We designed a prospective, multiphasic study aimed to develop evidence-based guidelines for postoperative pain management within our institution. In this first phase of our project, we investigated opioid prescription and consumption as well as pain trends for common otolaryngologic procedures. Patients (n = 161) who underwent procedures between July 2018 and February 2019 were surveyed on their postoperative opioid usage and pain from day of discharge to first clinic visit. Opioid prescriptions were converted to standardized units of morphine milligram equivalents (MME). The procedures selected for analysis were parathyroidectomy/thyroidectomy, parotidectomy, sialendoscopy, and transoral robotic surgery resection (TORS). In total, 19,748 MME were prescribed: 8,588 MME (43.5%) were used, leaving 11,159 MME (56.5%) unused. TORS average MME used: 221 ± 227; total MME unused: 38%. Sialendoscopy average MME used: 31 ± 46; total MME unused: 67%. Parathyroidectomy/thyroidectomy average MME used: 30 ± 37; total MME unused: 66%. Parotidectomy average MME used: 43 ± 53; total MME unused: 65%. Male gender, smoking (current and former), and psychiatric medication use were positive predictors of opioid consumption in postoperative patients (P < 0.001). At our institution, over 50% of prescribed postoperative opioids went unused. This was most pronounced for nonmucosal surgeries. Postoperative pain management should account for this to minimize unnecessary opioid prescriptions. Based on our findings and review of current literature, we are in the process of developing prescribing recommendations to be implemented within our institution. 2 Laryngoscope, 130:659-665, 2020.

Margin Status, Lymphovascular Invasion, and Number of Neck Levels Involved Predict Distant Failure in p16+ Oropharyngeal Squamous Cell Carcinoma (OPSCC) Following Transoral Robotic Surgery (TORS)

Current management paradigms in p16+ OPSCC are exploring de-intensification strategies due to the generally favorable prognosis of p16+ OPSCC and the high morbidity burden of traditional curative treatment. One of the main concerns with this approach is the heterogeneity within p16+ disease and recognition that there are subpopulations at significant risk of disease failure. Therefore, we sought to examine our own outcomes with p16+ OPSCC to identify pathologic factors associated with significant risk of distant metastasis following TORS. We evaluated 424 consecutive patients who underwent TORS resection for p16+ OPSCC between January 2008 to December 2016 at our institution. Overall survival (OS), locoregional relapse-free survival (LRFS), and distant metastasis-free survival (DMFS) were measured from the date of surgery and calculated using the Kaplan-Meier method. The log-rank test was used to compare survival between patient groups. Clinical and pathologic factors associated with DFMS were determined by Cox proportional hazards regression analysis. A two-sided P value of less than 0.05 was considered statistically significant. Median follow-up was 3.4 years (range 1 day – 7.1 years). Median pack-years was 2 years (range, 0 – 100 years). 120 patients (28.3%) received TORS resection alone, 304 patients (71.7%) received post-operative RT, and 143 patients (33.7%) received adjuvant chemoradiation. The majority of patients were Stage IVA (68.6%) and tonsillar cancers (55.0%). Median package time from the date of surgery to the completion of RT was 14.3 weeks. For the entire cohort, 3-year OS was 94.6% (95% CI 92.3% - 97.0%), LRF 89.3% (95% CI 86.1% - 92.5%), and DMFS 94.1% (95% CI 91.7% - 96.5%). On multivariate analysis, lymphovascular invasion (LVI) (HR 2.59, 95%CI 1.09 – 6.16, p = 0.031), margin status (HR 1.91, 95%CI 1.12 – 3.24, p = 0.017) and increased number of neck levels involved (HR 1.75, 95%CI 1.16 – 2.65, p = 0.008) were significantly associated with worse DMFS. Patients with and without LVI had a 3-year DFMS of 87.7% and 96.8% (p = 0.001), respectively. The 3-year DMFS for patients with negative, close, or positive margins was 95.4%, 92.7% and 78.7% (p < 0.001), respectively. Patients with zero, one, two, or three neck levels involved had a 3-year DFMS of 98.5%, 95.6%, 91.6%, and 80.6% (p < 0.001), respectively. This study examines pathologic factors associated with distant relapse in the largest series to date of patients undergoing TORS for p16+ OPSCC. Patients with positive margins, LVI and 3 or more positive neck levels have substantial rates of distant metastasis. These pathologic factors may identify a patient population who may benefit from intensified systemic therapy.

Robotic lateral oropharyngectomy following diagnostic tonsillectomy is oncologically safe in patients with high risk human papillomavirus related squamous cell cancer.

Diagnostic tonsillectomy is rarely an oncologic operation owing to close or positive margins. The standard of care is for further treatment to the primary site, typically with adjuvant radiotherapy. 14 patients with close or positive margins following a diagnostic tonsillectomy underwent transoral robotic surgery (TORS) and lateral oropharyngectomy; five patients with the longest follow-up had their excision specimens examined with a step serial sectioning technique (SSS). Conventional histopathological examination of the TORS resection specimens did not demonstrate residual carcinoma in 13 patients, confirmed by examination using SSS in 5 patients. There were no post-operative complications or long-term functional deficit. Seven patients received surgery alone with 100% overall and disease specific survival, respectively (median follow-up 27.5months; range 5.2-50.4). This prospective study suggests that TORS lateral oropharyngectomy alone is an oncologically safe treatment when close or positive margins are identified on diagnostic tonsillectomy in HPV-positive SCC.

Transoral robotic resection of benign tumors of the upper aerodigestive tract: Experience of the French group of GETTEC.

The purpose of this study was to assess the current use of transoral robotic surgery (TORS) in benign tumors of the upper aerodigestive tract through a case series and a literature review. This multicentric retrospective study was conducted in 6 French centers between November 2009 and July 2017. Twenty-one patients had a TORS resection of a tumor at varied locations with differing histopathologic characteristics. The mean postoperative hospital stay was 6.1 days. Eight patients had nasogastric tubes, which were removed after a mean of 5.6 days. Two patients had a prophylactic tracheostomy for an average of 5.5 days. A third tracheostomy was performed secondarily for postoperative bleeding. No recurrences were observed during the 2-year follow-up. This technique caused few complications and resulted in short hospitalization, with satisfactory functional and recurrence outcomes. However, the risk of bleeding and edema must be considered, and the need for a tracheostomy must be approached wisely.

Novel Approach Using Transoral Robotic Surgery for Resection of Cervical Spine Chordoma

Novel Approach Using Transoral Robotic Surgery for Resection of Cervical Spine Chordoma

Transoral Robotic Surgery for Parapharyngeal Space Tumors Reduces Risk of Postoperative First Bite Syndrome

Background: Transoral robotic surgery (TORS) has extended the applications of transoral surgery for a variety of conditions. Tumors of the parapharyngeal space (PPS) may be excised with a minimally invasive approach transorally and TORS provides many technical advantages. Our early experience with TORS parapharyngeal space resection suggests that one major advantage of TORS over open surgery for prestyloid tumors is the relatively infrequent occurrence of first bite syndrome (FBS). Objective: This study aims (1) to evaluate the prevalence of FBS in TORS PPS resection and (2) to compare the prevalence of FBS in our largest subset of patients (prestyloid parapharyngeal space pleomorphic adenoma) to a control group of patients who had open surgery with parapharyngeal pleomorphic adenoma (PA) resection. Methods: An IRB-approved retrospective review of parapharyngeal space resection was conducted. Patients who underwent TORS and those who underwent parapharyngeal space resection for PA were included. Results: A total of 43 patients underwent TORS resection. Only one patient experienced signs or symptoms of first bite syndrome. This patient had a schwannoma of the sympathetic chain. Overall, 26 patients had TORS resection of PPS minor salivary gland tumors, and 21 of these patients were for pleomorphic adenoma. None of these patients experienced FBS. Among a similar cohort who underwent open resection, 7 of 21 did experience symptoms of FBS. This difference is highly significant (p < 0.05). Conclusion: Although the study is not randomized, our series of prestyloid parapharyngeal space pleomorphic adenoma cases has accumulated to a significant cohort. The complete absence of FBS in our TORS group and the high prevalence of FBS for open resection of PPS pleomorphic adenoma in both the literature (range, 22–60%) and our control group (33%) strongly suggest that the transoral approach reduces the risk of FBS in this group. It also supports the theory of sympathetic denervation of the parotid gland, which appears less likely to occur from the transoral approach. Transoral robotic surgery for removal of parapharyngeal space tumors has numerous advantages and is considerably less invasive than open surgery. Our most frequent indication for TORS PPS resection is minor salivary gland pleomorphic adenoma. Absence of FBS appears to be one of the major benefits of TORS parapharyngeal space resection for this group or patients.

Controversies in Robotic Surgery

Program Description: Transoral robotic surgery (TORS) has become a popular approach for management of oropharyngeal carcinoma. The miniseminar will be organized as a tumor board panel staffed with a head and neck surgeon, radiation oncologist, medical oncologist, and pathologist. Two cases will be presented to highlight 3 controversial topics: (1) What are acceptable surgical margins and does human papillomavirus (HPV) status affect margin status? (2) Following TORS with negative margins, does the primary site require radiotherapy and does HPV status affect that decision? (3) How do “poor prognostic factors” affect decisions regarding adjuvant therapy, radiation dose, and treatment fields? Educational Objectives: (1) Differentiate the pathologic characters of HPV-positive and HPV-negative tumors and demonstrate how this finding affects treatment margins. (2) Explain the indication for treating the primary site after TORS resection. (3) Recognize impact of poor prognostic factors of adjuvant therapy decisions, including treatment dose.

How often parapharyngeal space is encountered in TORS oropharynx cancer resection.

Early stage oropharyngeal squamous cell carcinoma (OPSCC) may occasionally invade parapharyngeal space (PPS). Tumor invasion of PPS structures such as the carotid artery, internal jugular vein and cranial nerves IX-XII may add significant morbidity. We analyzed 73 patients who underwent transoral robotic surgery (TORS) for OPSCC between 2008 and 2012. Patients were selected based on preoperative evaluation including detailed physical and endoscopic examination, neck CT and/or PET-CT scan. T1, T2 and selected T3 cases were included in this study. None of the patients had obvious PPS extension on preoperative evaluation. All patients had OPSCC in palatine tonsil (60; 82.2 %) and base of tongue (13; 17.8 %). Twenty-seven patients had cT1 (37 %), 39 had cT2 (53.4 %), and 7 had cT3 (9.6 %) disease in clinical and radiologic evaluation. None of the oropharyngeal lesions had obvious radiologic PPS extension prior to operation. During TORS procedure, we encountered PPS in 18 (24.6 %) patients while resecting the deep margin. These parapharynx resections involved external carotid artery in 1, medial pterygoid muscle in 2, and parapharyngeal fat with or without styloid musculature in the remaining 15 patients. Except three cases, we were able to remove the lesions en bloc with negative surgical margins. TORS resection of oropharyngeal cancer extending to PPS appears to be a safe and feasible technique with minimal complications. Significant experience with TORS and further understanding of the endoscopic anatomy of PPS could obviate the morbidity associated with tumor resection in this dense neurovascular region.

Preoperative cephalometric analysis to predict transoral robotic surgery exposure.

Transoral robotic surgery (TORS) is being increasingly used in the treatment of head and neck cancer and we wanted to determine the feasibility of predicting TORS access using cephalometric measurements obtained from preoperative imaging. 20 cephalometric measurements were obtained from imaging on 31 TORS base of tongue (BOT) resections and compared to adequacy of exposure. Three measurements were found to be significantly different between the restricted and adequate exposure groups. Distances from posterior pharyngeal wall (PPW) to hyoid, PPW to soft palate and epiglottis to vertical laryngeal angle were all statistically different between the two groups. Receiver operating characteristic (ROC) analysis revealed strong correlation to exposure for all three measurements with cut offs ≤30 mm between the PPW and the hyoid, ≤8.1 mm PPW and soft palate and ≥130° between the epiglottis and vertical plain of the larynx all representing restricted exposure. Duration of surgery for the restricted group, 85 min, was significantly longer than the adequate exposure group, 51 min (p = 0.026). Preoperative measurements of radiographic images of the oropharyngeal working space can predict restricted exposure for TORS resection of the BOT. These measures may be used in conjunction with other subjective assessment parameters to predict which patients could benefit from a staging endoscopy to determine adequate TORS exposure.

Transoral robotic surgery of the parapharyngeal space: A case series and systematic review

The purpose of this study was to evaluate the current use of transoral robotic surgery (TORS) in the treatment of parapharyngeal space (PPS) neoplasms through a case series and systematic analysis. A case series review of 4 patients was combined with a PubMed, Web of Science, and Scopus search that identified 82 reports. Fifty-three articles remained after screening for duplicates, finally, 8 reports with adequate patient data were included. Statistical analyses and graphical representations were performed with Microsoft Excel (Redmond, WA) and GraphPad Prism software (La Jolla, CA). Forty-four patients had TORS resection of PPS neoplasms. Overall, mean length of stay was 3.0 days with mean time to oral diet of 1.0 day. There were no recurrences but there was a mean follow-up time of only 18.5 months. Twenty-nine of these neoplasms (65.9%) were pleomorphic adenomas of which 7 (24%) had unintended capsule violation or tumor fragmentation during surgery and 2 patients had pharyngeal dehiscence that was managed conservatively. There were no neurovascular complications. TORS is a viable approach to resection of neoplasms of the PPS with minimal surgical morbidity. However, further long-term evaluation, especially for pleomorphic adenomas, is needed to define patient selection and the role of TORS for PPS salivary gland neoplasms.

Mandibular osteotomy for expanded transoral robotic surgery: A novel technique

Transoral Robotic Surgery (TORS) has revolutionized the surgical treatment of malignant lesions of the oropharyngeal region. Recent studies have shown that this approach is a very safe procedure and can provide favorable clinical and functional outcomes with respect to traditional approaches. However, a small minority of patients who present with lesions amenable to TORS resection may not be candidates due to anatomical access issues. Anatomic features such as a retrognathic mandible, macroglossia, trismus, dentition, and small oral aperture limit the ability to perform TORS with current technology. We propose a modified TORS approach in which transoral mandibular osteotomies are performed that can greatly improve exposure to oropharyngeal subsites and expand access to the larynx in selected patients. Five experimental procedures were performed on five cadavers. Five cadavers were obtained for the investigation. Measurements including retractor opening, lateral cephalography, acoustic pharyngometry, and high-resolution photographs were taken prior to mandibular osteotomies and then repeated following the osteotomies. An increase in retractor opening, transoral exposure, and oral cavity was observed in all specimens. Mandibular osteotomies increase exposure to oral cavity and oropharyngeal lesions in the setting of TORS.

Late Consequential Surgical Bed Soft-tissue Necrosis in Advanced Oropharyngeal Squamous Cell Carcinomas (OP-SCC) Treated With Transoral Robotic Surgery (TORS) and Postoperative Radiation (PORT)

Select patients (pts) with OP-SCC are managed with initial TORS resection and PORT +/- chemotherapy as indicated. A subset of pts develop soft tissue necrosis (STN) in the surgical bed months after completion of PORT. We sought to identify the incidence of and risk factors for surgical bed STN.

Transoral robotic surgery total laryngectomy

has been reported with feasibility trials andpromising initial data. The combination of the two proce-dures, supraglottic and hypopharyngeal TORS resection,can be adapted to perform a TORS total laryngectomy(TORS-TL). In the past, TORS-TL has been met with skep-tical criticism as to its ultimate clinical benefit. Conversely,the authors suggest that the minimally invasive TORSapproach offers significant benefits toward improvingpatient recuperation and the avoidance of substantial post-operative morbidity. However, such benefits can only bedemonstrated following repeated clinical experience. It isthe purpose of this report to describe the surgical protocolutilized by the authors to encourage further application andstudy of this promising surgical advancement.

Selective neck dissection and deintensified postoperative radiation and chemotherapy for oropharyngeal cancer: A subset analysis of the university of pennsylvania transoral robotic surgery trial

The purpose of this study was to determine the regional recurrence rate of node-positive oropharyngeal squamous cell carcinoma (OPSCC) in patients undergoing transoral robotic surgery (TORS) and selective neck dissection (SND) followed by observation, radiation, or concurrent chemoradiation. A prospective, phase I, single-arm study was conducted. All OPSCC patients who voluntarily participated in a surgical trial with TORS and SND at an academic tertiary referral center from May 2005 to July 2007 were included. Thirty-one patients with previously untreated OPSCC undergoing TORS and SND (29 unilateral and two bilateral) were included. There were 29 males and two females, with ages ranging from 36 to 76 years (median = 55 years) with one palate, one lateral wall, 17 tonsil, 11 base of tongue, and one vallecula primary tumor classified as follows: T1 (n = 9, 29%), T2 (n = 15, 48.4%), T3 (n = 7, 22.6%), N0 (n = 6, 19.4%), N1 (n = 15, 48.4%), N2b (n = 10, 32.3%), and N2c (n = 1, 3.2%). There were three stage I (9.7%), two stage II (6.5%), 15 stage III (48.4%) and 11 stage IVa (35.5%) patients. Twenty-two patients were treated postoperatively with adjuvant therapy (12 radiation alone and 12 combined radiation and chemotherapy). Primary outcome measured was regional recurrence rate. There was one regional recurrence on the contralateral, non-operated neck and one distant recurrence among the 31 patients who underwent SND. SND after TORS resection of primary OPSCC enables the use of selective and deintensified adjuvant therapy to reduce regional recurrence rates.