Transoral Robotic Surgery Group Research Articles

Up-front and Salvage Transoral Robotic Surgery for Head and Neck Cancer: A Belgian Multicenter Retrospective Case Series.

We analyzed the functional and oncologic outcomes of primary and salvage transoral robotic surgery (TORS) procedures, performed in three Belgian institutions with a similar philosophy. A total of 86 patients who underwent TORS between 24-12-2009 and 25-09-2015 were retrospectively reviewed. Descriptive statistics, overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS; Kaplan-Meier), and the variation of these outcomes according to whether patients had primary or salvage TORS were evaluated (univariate log-rank analysis). Of 86 patients, 56 (65.1%) underwent TORS as a primary treatment and 30 (34.9%) as a salvage procedure for recurrent or second primary cancer. Tumor location was mainly oropharynx (N = 63; 73.3%) followed by supraglottic larynx (N = 11; 12.8%), hypopharynx (N = 11; 12.8%), and glottic larynx (N = 1; 1.2%). In the up-front TORS group, most tumors were classified as cT1 (N = 23; 41.1%)/pT1 (N = 24; 42.9%) or cT2 (N = 27; 48.2%)/pT2 (N = 27; 48.2%) and cN0 (N = 18; 32.1%), cN1 (N = 13; 23.2%), or cN2 (N = 25; 44.6%). In the salvage TORS group, most tumors were cT1-rT1 (N = 18; 60.0%)/pT1-rpT1 (N = 18; 60.0%) or cT2-rT2 (N = 12; 40.0%)/pT2-rpT2 (N = 7; 23.3%) and cN0 (N = 25; 83.3%). Neck dissection was performed in 87.5% of primary cases and 30.0% of salvage cases. In the up-front TORS group, patients were postoperatively submitted to follow-up (N = 13; 23.2%) or received adjuvant radiotherapy, either as single modality (N = 26; 46.4%) or with concomitant cisplatin (N = 15; 26.8%). On the other hand, most salvage TORS patients did not receive any adjuvant therapy (N = 19; 63.3%). Mean and median follow-up was 23.1 and 21.2 months, respectively. Functional results were excellent (no definitive tracheostomy, long-term tube feeding in 1.8% of primary cases, and 20% of salvage cases). In the up-front TORS group, estimated 2-year OS was 88.5% (SE = 5.0%), 2-year DSS was 91.8% (SE = 4.6%) and 2-year DFS was 86.1% (SE = 5.3%). In the salvage TORS group, estimated 2-year OS was 73.5% (SE = 10.9%), 2-year DSS was 93.3% (SE = 6.4%), and 2-year DFS was 75.8% (SE = 9.7%). Comparing outcome of primarily treated patients to salvage patients, a non-statistically significant trend toward better OS (p = 0.262) and DFS (p = 0.139) was observed. This retrospective study confirms favorable oncologic and functional outcomes of TORS for selected head and neck malignancies, both in the primary and in the salvage setting.

Oncologic outcomes and patient-reported quality of life in patients with oropharyngeal squamous cell carcinoma treated with definitive transoral robotic surgery versus definitive chemoradiation

It has been postulated that treatment outcomes are similar between transoral robotic surgery (TORS) and definitive chemoradiation (CRT) for oropharyngeal squamous cell carcinomas (OPSCC). We compared oncologic and quality of life (QOL) outcomes between definitive CRT and definitive TORS. An observational comparison study was performed on 92 patients treated with TORS±adjuvant therapy and 46 patients treated with definitive CRT between July 2005 and January 2016. The Kaplan Meier method was used for survival analyses, and the Mann-Whitney test was used to compare QOL scores between groups. All patients had T0-T2 and N0-N2 disease, although CRT patients had higher clinical staging (p<0.001). HPV+ disease was present in 79% (n=73) of TORS patients and 91% (n=19) of tested CRT patients. Median follow-up was 22.1months (range: 0.33-83.4). There were no significant differences in locoregional control or overall survival between CRT and TORS groups. Definitive TORS resulted in better saliva-related QOL than definitive CRT at 1, 6, 12, and 24months (p<0.001, p=0.025, p=0.017, p=0.011). Among TORS patients, adjuvant therapy was associated with worse QOL in the saliva domain at 6, 12, and 24months (p<0.001, p<0.001, p=0.007), and taste domain at 6 and 12months (p=0.067, p=0.008). Definitive CRT and definitive TORS offer similar rates of locoregional control, overall survival, and disease-free survival in patients with early stage OPSCC. TORS resulted in significantly better short and long-term saliva-related QOL, whereas adjuvant therapy was associated with worse saliva and taste-related QOL compared to TORS alone.

Survival and Gastrostomy Prevalence in Patients With Oropharyngeal Cancer Treated With Transoral Robotic Surgery vs Chemoradiotherapy.

Treatment of oropharyngeal squamous cell carcinoma (OPSCC) presents unique challenges and can be associated with significant morbidity. Transoral robotic surgery (TORS) has emerged as a treatment modality for OPSCC, but data comparing outcomes between patients treated with TORS-based therapy and nonsurgical therapy are limited. To compare survival and gastrostomy prevalence between patients with OPSCC treated with TORS-based therapy and those treated with nonsurgical therapy. This retrospective matched-cohort study identified patients with OPSCC treated at the University of Washington and University of Minnesota tertiary care medical centers from January 1, 2005, to December 31, 2013. Each patient treated with TORS-based therapy was matched by stage with as many as 3 patients treated with nonsurgical therapy. Final follow-up was completed on April 1, 2015. Disease-free survival, overall survival, and gastrostomy tube prevalence. One hundred twenty-seven patients met the study criteria (113 men [89.0%]; 14 women [11.0%]; median [interquartile range] age, 57 [52-63] years); 39 patients who underwent TORS were matched to 88 patients who underwent nonsurgical therapy. Compared with the nonsurgical group, more patients had p16-positive tumors in the TORS group (30 of 31 [96.8%] vs 30 of 37 [81.1%] among patients with known p16 status). No statistically significant difference in survival between treatment groups was found in multivariable analysis (disease-free survival hazard ratio, 0.22; 95% CI, 0.04-1.36; P = .10). Patients who received TORS-based therapy had lower gastrostomy tube prevalence after treatment (13 of 39 [33.3%] vs 74 of 88 [84.1%]) for a univariable relative risk of 0.43 (95% CI, 0.27-0.67; P < .001) and a multivariable relative risk of 0.43 (95% CI, 0.27-0.68; P < .001). Gastrostomy prevalence decreased by time after treatment for both groups (TORS group: 3 of 34 [9%] at 3 months to 1 of 33 [3%] at 12 months; nonsurgical group: 37 of 82 [45%] at 3 months to 7 of 66 [11%] at 12 months). Patients undergoing TORS for OPSCC have statistically indistinguishable survival but lower gastrostomy prevalence compared with patients undergoing nonsurgical therapy for stage-matched OPSCC. TORS offers promise for improved swallowing function in patients with OPSCC.

Tongue reduction for OSAHS: TORSs vs coblations, technologies vs techniques, apples vs oranges

Coblation tongue surgery and Trans-oral robotic surgery (TORS) proved to be the most published therapeutical options for the treatment of patients affected by obstructive sleep apneas (OSAHS). A systematic review of the literature and an analysis of the data are presented. The mean rates of failure were 34.4 and 38.5%, respectively in TORS and Coblation groups. Complications occurred in 21.3% of the patients treated with TORS and in 8.4% of the patients treated with Coblation surgery. TORS seems to give slightly better results, allowing a wider surgical view and a measurable, more consistent removal of lingual tissue. However, the higher rate of minor complication and the significant costs of TORS must also be considered. Moreover, both technologies may be applied to a wide range of surgical techniques, each of them with different effectiveness.

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.

Comparison of oncologic and functional outcomes after transoral robotic lateral oropharyngectomy versus conventional surgery for T1 to T3 tonsillar cancer

We performed transoral robotic surgery (TORS) or conventional surgery via a transoral or mandibulotomy approach in patients with tonsillar cancer and prospectively analyzed the oncologic outcomes and functional recovery of the 3 groups. Between May 2008 and October 2011, 57 patients were enrolled in this prospective study. Although there was no significant difference in the survival rate of the TORS group (100%) and the conventional surgery group (96.7%), a higher rate of margin negativity was observed in the TORS group, especially in cases in which the tumor extends inferiorly. Patients who received TORS or conventional transoral procedures showed more rapid recovery of swallowing, shorter hospitalization, and shorter operation time than the mandibulotomy group. Despite the weakness of this nonrandomized trial and the differences in T classification, TORS seemed to have distinct advantages over conventional transoral surgery and other conventional open surgery, but further studies are needed.

Transoral Robotic Surgery versus External Approach: Oncologic Results and Comparison of the Cost of Treatment

Objectives: Compare functional outcomes, oncologic outcomes and treatment costs between a group of consecutive patients operated by transoral robotic surgery (TORS) for squamous cell carcinoma of the upper aero-digestive tract (UADT) and a matched group of patients operated by CC. Methods: 21 patients who underwent TORS from December 18, 2008 to January 21, 2012, were matched on age, sex, TNM stage, tumor location, type of neck dissection realized and operator with 21 patients operated by CC from July 19, 2005 to May 22, 2008 (before the arrival of the robot in our center). Results: In each group there were 3 T1 tumors, 16 T2 and 2 T3. The number of tracheotomy was significantly lower in the TORS group (3 vs18, respectively 14 and 86%, P &lt; 0.001). The average length of feeding by NT and hospitalization were shorter in the TORS group (respectively, 9 vs 16 days, P = 0.01 and 11 vs 19 days, P = 0.001). There was no significant difference in the rate of recurrence-free survival at 3 years between the 2 groups (89% for the TORS group and 85% in the CC group, P = 0.76). The average treatment cost was reduced by 5488 euros for the TORS group ( P = 0.03). Conclusions: Robotic technology allows the treatment of T1-T2-T3 selected squamous cell carcinoma of the UADT, reducing morbidity and treatment costs while providing an equivalent cancer control at 3 years. Prospective and longitudinal studies could confirm these encouraging results.

Outcomes of Transoral Robotic Surgery: Initial Experience

Objectives: Transoral robotic surgery (TORS) has gained importance in the resection of head and neck tumors. The use of robotics in this field has provided surgeons with the ability to access anatomic locations that were previously only managed via open techniques. This has resulted in decreased overall morbidity, excellent functional results and the promise of equivalent oncologic outcomes. TORS provides access to the oropharynx, hypopharynx, larynx, oral cavity and parapharyngeal space vial the oral aperture. We aimed to assess the initial experience for TORS, as observed in the BNCI TORS group. Methods: Forty-four consecutive patients who were scheduled for TORS between March 2012 and January 2013 were included in this single institutional prospective cohort study. The operative times, conversion rates, morbidity, feeding tube rates, and tracheotomy were evaluated. Results: Most patients (55.5%) had squamous cell carcinoma of the tonsils, and 44.5% had SCC of the tongue base. Tumor resection with free margins was achieved in all cases. No patient needed conversion to an open approach. There were 6.8% postoperative hemorrhages and tracheotomy was performed in 9 patients. 43.2% of patients needed a feeding tube after TORS. The median setup and procedure times were 21 ± 18 and 61 ± 45 minutes, respectively. All patients underwent a neck dissection one week after TORS. The extent of neck dissection depended on neck nodes status. The average hospital stay was 4.5 days. Conclusions: Based on our initial experience, TORS appears to be safe and feasible, with minimal complications and favorable clinical and functional outcomes.

Transoral robotic surgery and transoral laser microsurgery for oropharyngeal squamous cell cancer.

The aim of our study was to compare transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) for primary resection of oropharyngeal squamous cell cancer (OPSCC). This was a retrospective chart analysis of 33 patients with OPSCC treated at one academic medical center with either TORS (n=17) or TLM (n=16) between July 2008 and December 2010. Six patients in the TLM group and seven patients in the TORS group had primary cancer of the tonsil; the remaining patients had base of tongue cancer. Two patients in the TORS group had Stage I or II disease; the other 31 patients had Stage III [1/16 (6%) TLM; 5/17 (29%) TORS] or Stage IV cancer [15/16 (94%) TLM; 10/17 (59%) TORS]. The intervention was transoral surgery for OPSCC, and the main outcome measures were perioperative variables and functional outcomes. Mean operative time was 170 versus 115min for TLM and TORS, respectively (p=0.057). One patient, in the TLM group, required a temporary tracheostomy. Perioperative feeding tubes were placed in 6/16 (38%) patients who underwent TLM and in 4/17 (24%) patients who underwent TORS (p=0.465). At a median follow-up of 14.5months, the average MD Anderson Dysphagia Inventory score was 65.2 for TLM and 70.8 for TORS (p=0.431). All TORS procedures were performed with a single oral retractor, while multiple laryngoscopes were required in 9/16 (56%) TLM cases (p=0.0003). The mean number of total specimens were 6.2 for TORS and 13.6 for TLM (p=0.002). These results demonstrate that TLM and TORS have comparable perioperative variables with no significant differences in functional outcomes. For a subset of patients, TORS reduced the spatial complexity of surgery, suggested by the decreased need for multiple laryngoscopes, fewer specimens, and shorter operative times, while larger tumors were more amenable to TLM.

Comparison study of transoral robotic surgery and radical open surgery for hypopharyngeal cancer

Conclusions: The oncologic outcome of transoral robotic surgery (TORS) was comparable to radical open surgery. The TORS group showed a better functional recovery and quality of life (QOL) than the radical surgery group. Therefore, TORS was a valid treatment option as a minimally invasive surgery for selected patients with hypopharyngeal cancer. Objectives: To affirm rapid functional recovery and improved QOL of patients who underwent TORS, which is a minimally invasive surgical technique. Methods: Between April 2008 and November 2011, 56 patients were enrolled in the study. During the study period, 30 patients underwent TORS and 26 patients underwent radical open surgery. Results: In the TORS and radical surgery groups, the 3-year overall survival rate was 85% and 78%, respectively, and disease-free survival was 81% and 76%, respectively. Significant differences were not observed in the overall survival and disease-free survival rates. As regards postoperative functional recovery, the TORS group showed statistically better results for decannulation, swallowing, and hospitalization compared with the radical surgery group. On the University of Washington (UW)-QOL, the TORS group showed better results than the radical open surgery group in the domains of pain, activity, recreation, swallowing, speech, anxiety, and health-related QOL.