Help or Hoopla?: Surgical robots can benefit otolaryngology

“There is a pandemic of HPV-related cancer in the United States right now,” Dr. Weinstein said. “The number of HPV-related oropharyngeal cancers is increasing and it’s occurring in younger patients. Also, 70 percent of all oropharyngeal cancer now is T1 or T2, which is a perfect indication for robotic surgery.”

Research results suggest that TORS may offer advantages over traditional surgery. “The transoral surgery has significant benefits to the patient,” said Scott Magnuson, MD, associate professor of surgery in the division of otolaryngology–head and neck surgery at the University of Alabama at Birmingham. “They have a faster recovery, lesser use of feeding tubes, lesser use of tracheotomy tubes and shorter hospital stays.”

In the first study of patients to undergo TORS for oropharyngeal cancer, 26 of 27 patients (96 percent) were swallowing without the use of a gastrostomy tube at the last follow-up visit (Arch Otolaryngol Head Neck Surg. 2007;133:1220-1226.) Additional studies show similar results.

In a study of TORS for primary or recurrent cancer, 80 percent of patients (12 of 15) who underwent robotic surgery for primary cancer were tolerating oral intake by hospital discharge. All patients were eating normally by two months post-discharge. Estimated blood loss averaged less than 200 ml, and length of stay was decreased (Curr Opin Otolaryngol Head Neck Surg. 2009;17:126-131).

Other studies suggest that patients who undergo TORS require less medical intervention than those who undergo traditional surgery. In one study comparing robotic surgery for a primary neoplasm, robotic salvage surgery and open salvage surgery, none of the patients who underwent the robotic procedure, either primary or salvage, required a tracheostomy, while all of the patients who had an open resection required one (Arch Otolaryngol Head Neck Surg. 2010;136(4);380-384). Less medical intervention may translate into shorter hospital stays. Dr. Weinstein and colleagues report stays of five to seven days; Dr. Magnuson and others report stays of less than two days (Arch Otolaryngol Head Neck Surg. 2010;136(4):380-384; Curr Opin Otolaryngol Head Neck Surg. 2009;17:126-131).

Reported complications of TORS include transoral bleeding, wound infection, exacerbation of previous sleep apnea by postoperative swelling and postoperative hematomas (Arch Otolaryngol Head Neck Surg. 2010;136(4):380-384; Curr Opin Otolaryngol Head Neck Surg. 2009;17:126-131).

“I think it’s very clear that there’s an advantage to using transoral surgery to resect tumors of the oropharynx,” Dr. Genden said.

Drs. Magnuson and Weinstein also suspect that TORS may offer advantages over chemoradiation, which is often touted as the treatment of choice for oropharyngeal carcinoma, especially for patients with HPV-positive cancers. “Everyone is making a hoopla about the fact that HPV-related cancers do really well with chemoradiation. But chemoradiation leaves patients with a long-term stomach tube at a much higher rate than TORS. TORS only has a 2 percent gastrostomy tube dependency rate,” Dr. Weinstein said. Dr. Magnuson is currently collecting data to compare outcomes, complications and quality-of-life determinants for TORS and chemoradiation.