Transoral robotic surgery - time for consensus on pain assessment. A review.

BACKGROUND: In Head and Neck surgery Transoral Robotic Surgery (TORS) is evolving as a key treatment option for benign and malignant lesions in the oropharynx. Even so, postoperative pain is one of the primary early complaints following TORS. Well established evidence-based procedure specific pain treatment guidelines are available for a variety of other surgical specialties. However, there are no guidelines for TORS. AIM: This review describes the available data of early pain intensity following TORS during rest and procedure related activity. METHODS: Literature concerning pain in the immediate postoperative phase following TORS were obtained from two literature databases. RESULTS: Most data on pain intensity following TORS are based upon a numeric rating scale, e.g. the Visual Analogue Scale and/or analgesic demands. Only one randomized clinical trial is available reflecting that the literature is mainly based on retrospective and a few prospective studies. Only one study analyzed pain during relevant functionality, i.e. swallowing. Overall, the studies suffer from a non-standardized approach and there is a need for transparent information concerning the timing of pain ratings and methodology. CONCLUSIONS: The evidence for optimal pain control is limited, particularly during surgical relevant activity. Postoperative pain rating during activity is a fundamental element in pain trials in order to enhance recovery thereby calling for future consensus on assessment methodology.

Treatment of supraglottic squamous cell carcinoma with advanced technologies: observational prospective evaluation of oncological outcomes, functional outcomes, quality of life and cost-effectiveness (SUPRA-QoL).

BACKGROUND: Over the past decade, therapeutic options in head and neck supraglottic squamous cell carcinoma have constantly evolved. The classical total laryngectomy has been partially replaced by alternative organ- and function-sparing techniques with the same prognosis but less morbidity, such as Radiotherapy, Transoral Laser Microsurgery (TLM) and Trans-Oral Robotic Surgery (TORS). Up to now, a prospective comparison of these innovant techniques has not been conducted. METHODS/DESIGN: We will conduct an original international multicentric prospective nonrandomized clinical trial to compare the efficacy between these treatments (Arm 1: Radiotherapy ± chemotherapy; Arm 2: TLM and Arm 3: TORS) with 4 classes of outcomes: quality of life (QoL), oncological outcomes, functional outcomes and economic resources. The population will include cT1-T2 /cN0-N1/M0 supraglottic squamous cell carcinoma. The primary outcome is a Clinical Dysphagia QoL evaluation assessed by the MD Anderson Dysphagia questionnaire. Secondary outcomes include others QoL evaluation, oncological and functional measures and cost parameters. The sample size needs to reach 36 patients per arm (total 108). DISCUSSION: In the current literature, no prospective head-to-head trials are available to compare objectively these different treatments. With the increase of highly efficient treatments and the increase of oncological survival, it is imperative also to develop management strategies that optimize QoL and functional results. We will conduct this innovate prospective trial in order to obtain objective data in these two main issues. TRIAL REGISTRATION: NCT05611515 posted on 10/11/2022 (clinicaltrial.fgov).

Assessment of stress response due to C-Mac D-blade guided videolaryngoscopic endotracheal intubation and docking of da Vinci surgical robot using perfusion index in patients undergoing transoral robotic oncosurgery.

Clinical utility of perfusion index (PI) has entered a new realm as a non-invasive, quantitative index of stress response to endotracheal intubation. Transoral robotic surgery (TORS) involves F-K retractor aided docking of the surgical robot producing haemodynamic and stress responses akin to laryngoscopy. We compared the stress response to videolaryngoscopy with that due to docking of da Vinci surgical robot using PI, heart rate and mean arterial pressure evaluated at specific time points post-laryngoscopy and post-docking. Twenty-six adult patients, scheduled for TORS under general endotracheal anaesthesia were included in this prospective, observational, single-centric cohort study. Statistical analysis included paired samples t-test, dotted box-whisker plots, trendlines and correlograms for comparative analysis of two stressors, laryngoscopy and docking. Baseline PI was 4.14. PI values increased post-midazolam (4.23), 1 min (5.69) and 3 min (6.25) post anaesthetic-induction, plummeted at laryngoscopy (3.24), remained low at 1 min (3.68), 3 min (4.69) thereafter, and were highest at 10 min (6.17) post-laryngoscopy and predocking (6.84). Docking witnessed a fall in PI (4.1), which remained low at 1 min (4.02), 3 min (4.31) and 10 min (4.79) post-docking. PI was significantly higher at laryngoscopy compared with PI at docking (p = 0.0044). At 1 min and 3 min post-laryngoscopy and post-docking, respectively, the differences in PI were statistically insignificant. PI at 10 min post-laryngoscopy was significantly lower than PI at 10 min post-docking (p < 0.0001). As non-invasively quantified by PI, videolaryngoscopic stress response is more intense but shorter-lived versus that due to docking. PI displays a negative correlation with haemodynamic variables. PI at laryngoscopy is a good predictor of PI at docking, enabling pre-emptive measures (fentanyl bolus; deepening of volatile anaesthesia from MAC-maintenance to MAC-intubation) anticipating the docking-induced stress response.Trial registration http://ctri.nic.in ; Identifier: CTRI/2019/11/022091.

Job market in head and neck surgery: A survey and analysis of recent fellowship graduates.

OBJECTIVE: Recent years have seen increase in individuals pursuing postgraduate fellowships in head and neck (HN) surgery. This has presented concerns about insufficient jobs where graduates can apply their scope of specialized training. METHODS: Data was collected in two manners- a survey and a manual online search of American Head and Neck Society (AHNS) fellowship graduates. A 25-question survey was sent in 2021 to approximately 400 HN fellows who graduated between 2010 and 2020. The AHNS list of graduates from the same years were searched online to collect information including gender, graduation year, fellowship training, and current job practice. RESULTS: Of the 78 survey responses, 64.1 % were male and 34.6 % female. 96.2 % reported ablative, 84.6 % microvascular, and 82.1 % TORS training. Mean number of interviews was 4 with most interviewing during the 3rd quarter (January to March). Majority reported being in academic and university-based practices (79.6 %). Online search was done on 393 graduates. Since 2010 the number of graduates almost doubled. There was a statistically significant increase in females by year (p = 0.022). There was a significant decrease (p = 0.022) in graduates with additional fellowship training from that of their AHNS fellowship. There was also a statistically significant increase in graduates being in academic practices (p = 0.022). CONCLUSION: Despite growing numbers, there appears to be more graduates entering an academic practice, although the definition of an academic HN practice may be evolving. These results provide guidance on how to approach the job search in a select market. LEVEL OF EVIDENCE: II.

The impact of socioeconomic and geographic factors on access to transoral robotic/endoscopic surgery for early stage oropharyngeal malignancy.

OBJECTIVE: To evaluate the role of social and geographic factors on the likelihood of receiving transoral robotic surgery (TORS) or non-robotic transoral endoscopic surgery treatment in early stage oropharyngeal squamous cell carcinoma (OPSCC). MATERIALS AND METHODS: The National Cancer Database was queried to form a cohort of patients with T1-T2 N0-N1 M0 OPSCC (AJCC v.7) who underwent treatment from 2010 to 2016. Demographics, tumor characteristics, treatment type, social, and geographic factors were all collected. Univariate analysis and multivariate logistic regression were then performed. RESULTS: Among 9267 identified patients, 1774 (19.1%) received transoral robotic surgery (TORS), 1191 (12.9%) received transoral endoscopic surgery, and 6302 (68%) received radiation therapy. We found that lower cancer stage, lower comorbidity burden and HPV- positive status predicted a statistically significant increased likelihood of receiving surgery. Patients who reside in suburban or small urban areas (>1 million population), were low-to- middle income, or rely on Medicaid were less likely to receive surgery. Patients that reside in Medicaid-expansion states were more likely to receive TORS (p > .0001). Patients that reside in states that expanded Medicaid January 2014 and after were more likely to receive non-robotic transoral endoscopic surgery (p > .0001). CONCLUSIONS: Poorer baseline health, lower socioeconomic status and residence in small urban areas may act as barriers to accessing minimally invasive transoral surgery while residence in a Medicaid-expansion state may improve access. Barriers to accessing robotic surgery may be greater than accessing non-robotic surgery.

Cost-utility of two minimally-invasive surgical techniques for operable oropharyngeal cancer: transoral robotic surgery versus transoral laser microsurgery.

BACKGROUND: In the past few decades, a re-evaluation of treatment paradigms of head and neck cancers with a desire to spare patients the treatment-related toxicities of open surgery, has led to the development of new minimally invasive surgical techniques to improve outcomes. Besides Transoral Laser Microsurgery (TLM), a new robotic surgical technique namely Transoral Robotic Surgery (TORS) emerged for the first time as one of the two most prominent and widely used minimally invasive surgical approaches particularly for the treatment of oropharyngeal cancer, a sub-entity of head and neck cancers. Recent population-level data suggest equivalent tumor control, but different total costs, and need for adjuvant chemoradiation. A comparative analysis of these two techniques is therefore warranted from the cost-utility (C/U) point of view. METHODS: A cost-utility analysis for comparing TORS and TLM was performed using a decision-analytical model. The analyses adopted the perspective of a Swiss hospital. Two tertiary referral centers in Lausanne and Zurich provided data for model quantificantion. RESULTS: In the base case analysis TLM dominates TORS. This advantage remains robust, even if the costs for TORS reduce by up to 25%. TORS begins to dominate TLM, if less than 59,7% patients require adjuvant treatment, whereby in an interval between 55 and 62% cost effectiveness of TORS is sensitive to the prescription of adjuvant chemoradiation therapy (CRT). Exceeding 29% of TLM patients requiring a revision of surgical margins renders TORS more cost-effective. CONCLUSION: Non-robotic endoscopic surgery (TLM) is more cost-effective than robotic endoscopic surgery (TORS) for the treatment of oropharyngeal cancers. However, this advantage is sensitive to various parameters, i.e.to the number of re-operations and adjuvant treatment.

Voice Assessment in Patients With Obstructive Sleep Apnea Syndrome After Transoral Robotic Surgery.

Objectives: Removal of part of the tongue base, in combination with uvulopharyngopalatoplasty via transoral robotic surgery (TORS), for treating obstructive sleep apnea syndrome (OSAS) results in enlargement of the oropharynx and hypopharynx and change in the size of the resonance chamber. These procedures may also alter the laryngeal-hyoid bone complex, which is linked to vocal fold tension. Thus, there is the potential for change in phonation and pitch after surgery. Study Design: Prospective, nonrandomized, institutional board-approved study. Methods: From January to August 2018, 15 patients with OSAS receiving TORS underwent voice and pitch sampling. The multi-dimensional voice program (MDVP) was applied to the evaluation of preoperative sound parameters. Highest pitch and lowest pitch were obtained with real-time pitch software, with pitch synchronized to electronic organ or tuner. Subjects also completed the Voice Handicap Index-10 scale (VHI-10), to assess their subjective perception and to detect factors affecting the VHI-10 score. The relevant parameters were analyzed again 3 months after the operation. Results: There was an increase in VHI-10 score 3 months after operation that did not reach statistical significance. There were also no significant differences in sound parameters. Increases in highest pitch (353.18 Hz shift to 387.99 Hz), highest semitone ( F 5 # shift to F 5 # ), lowest pitch (117.45 Hz shift to 131.42 Hz), and lowest semitone (C3 shift to C3) did not reach statistical significance. The increase in the lowest semitone was significantly related to change in VHI-10 score (r = -0.808, P = 0.028). Conclusion: Patients with OSA undergoing TORS showed a negative correlation coefficient over 0.8 with change in VHI-10 score. That is, increase in the lowest semitone after operation correlated with increase in VHI-10 score which may cause perceive changes in subjective pronunciation.

Insurance Status as a Predictor of Treatment in Human Papillomavirus Positive Oropharyngeal Cancer.

OBJECTIVES: The link between human papillomavirus (HPV) and oropharyngeal cancer (OPC) is well known. Locally advanced, HPV-positive OPC (HPV OPC) can be treated with either chemoradiation or primary surgery with or without adjuvant therapy. Head and neck cancer patients with government insurance or uninsured have been shown to have worse prognosis than similar patients with private insurance. In this study, we aimed to determine if insurance status would predict treatment modality in patients with HPV OPC. STUDY DESIGN: A retrospective analysis using the National Cancer Database (NCDB). METHODS: The National Cancer Database was used to identify patients with HPV OPC who underwent primary surgery or primary chemoradiation from 2010-2015. Insurance status was categorized as government, private, or no insurance. The relationship between insurance status and treatment was investigated using Chi square and multivariate regression models. Kaplan-Meier analyses were performed comparing overall survival (OS) by insurance status. RESULTS: There were 10,606 patients were included. There was a statistically significant correlation between insurance status and primary treatment modality for HPV OPC (P < .001). Patients with government insurance were 19.3% less likely to undergo surgery and uninsured patients were 36.9% less likely to undergo primary surgery when compared to those with private insurance (P < .001), even after correcting for TNM stage in multivariate analysis. There was an improved 5-year OS for patients with private insurance (86.6%) versus both government insurance (68.4%) and no insurance (69.9%) (P < .001). CONCLUSIONS: Patients with private insurance are more likely to undergo primary surgery in HPV OPC and have improved overall survival. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:776-781, 2021.

Radical Tonsillectomy and Superior Pharyngeal Constrictor Anatomy: A Cadaveric and Oncologic Specimen Assessment.

INTRODUCTION: The rise in primary surgical management of oropharyngeal squamous cell carcinoma has led to varying interpretations of the histopathologic evaluation following a radical tonsillectomy. The oncologic margin may be significantly influenced by the morphologic relations and anatomic dimensions of the palatine tonsil and superior pharyngeal constrictor (SPC) muscle. OBJECTIVE: The aim of this study was to characterize the gross and histologic anatomic features of the palatine tonsil and SPC muscle following an en bloc radical tonsillectomy. METHODS: Radical tonsillectomy specimens were collected from cadaveric and oncologic subjects. Specimens were processed using standard histopathologic techniques and were analyzed by a board-certified head and neck pathologist. The thickness of the SPC muscle and relationship to the tonsillar carcinoma were assessed. RESULTS: Six cadaveric and 10 oncologic specimens were analyzed. The mean minimum SPC width for all cadaveric specimens was 1.02 ± 0.50 mm. The mean minimum width for oncologic specimens was 0.76 ± 0.46 mm. The mean distance from tonsil carcinoma to the lateral specimen margin was 1.79 ± 1.39 mm. CONCLUSION: Due to the limited width of the SPC muscle, a margin in excess of 2 mm may not be attainable in a transoral radical tonsillectomy. Margin status may be ideally determined by the integrity of the SPC muscle in future oncologic studies, rather than an adequate distance measurement.

Comparative cost of transoral robotic surgery and radiotherapy (IMRT) in early stage tonsil cancer.

PURPOSE: To compare treatment costs and cost-effectiveness for transoral robotic surgery (TORS) and definitive intensity-modulated radiotherapy (IMRT) in managing early stage tonsil cancer. MATERIALS AND METHODS: Direct treatment costs for surgery and IMRT were calculated from SEER-Medicare data for a cohort with clinically early stage (cT1/2N0) p16+ tonsillar squamous cell carcinoma from Kaiser Permanente Southern California Health Plan between 2012 and 2017. A Markov decision tree model with a 5-year time horizon was then applied to the cohort which incorporated costs associated with treatment, surveillance, and recurrence. RESULTS: IMRT cost up to $19,000 more (35%) than TORS in direct treatment costs. When input into the Markov model, TORS dominated IMRT with lower cost and better effectiveness over a range of values. CONCLUSION: TORS is a more cost-effective treatment method than IMRT in early stage (cT1/2N0) tonsil cancer.

A cost effective custom dental guard for transoral robotic surgery.

There has been an increasing use of transoral robotic surgery (TORS) as studies have demonstrated its effectiveness for treating a variety of conditions. Postoperative complications of TORS include hemorrhage, tooth injury, dehydration, aspiration pneumonia, and prolonged percutaneous endoscopic gastrostomy (PEG) tube dependency. Dental injury has not been adequately discussed although it has been reported to be a common complication in multiple studies, with repair costs ranging from $700 to $3000 and average time spent to address the injury estimated to be 2.6 h. The incidence of this injury is likely due to the standard dental guard, which is not customizable to the patient's teeth, therefore, not optimal for dental protection. Many alternative dental guards have been proposed to reduce the rate of dental injury. However, the previously presented alternatives are high cost, not time efficient, or have the potential for molding error rendering them less effective. We propose a guard that is cheap, time efficient, and effective in preventing dental injury. A retrospective study of 124 patients who underwent TORS over a period of 6 years with the proposed dental guard was conducted. No dental complications were observed in any of these cases. A cost analysis showed that this guard saved $4526.64 for our relatively small patient cohort. This guard can save money, time, and stress for both the patient and the surgeon, as well as reduce the number and severity of medico-legal claims related to perioperative dental injury.

Finding/identifying primaries with neck disease (FIND) clinical trial protocol: a study integrating transoral robotic surgery, histopathological localisation and tailored deintensification of radiotherapy for unknown primary and small oropharyngeal head and neck squamous cell carcinoma.

INTRODUCTION: Carcinomas of unknown primary site (CUP) of the head and neck have historically been worked up and managed heterogeneously. Failure to identify a primary site may result in large radiotherapy mucosal volumes. Transoral approaches such as Transoral Robotic Surgery (TORS) may improve the yield of identifying hidden primaries. We aim to assess the oncological and functional outcomes of a combined treatment approach with TORS and tailored radiotherapy. METHODS AND ANALYSIS: Twenty-five patients with metastatic squamous cell carcinoma to the neck without clinical or radiographic evidence of a primary site will be enrolled in a phase II trial. Patients will undergo a diagnostic or therapeutic approach with TORS based on specific algorithms incorporating tailored radiotherapy according to the location and laterality of the primary tumour. The primary outcome is to evaluate the out-of-field failure rate over a 2-year period. Secondary outcomes include identification rates, survival outcomes, patient reported outcomes and functional swallowing outcomes. ETHICS AND DISSEMINATION: The University Health Network Research Ethics Board approved this study (ID 15-9767). The results will be published in an open access journal. TRIAL REGISTRATION NUMBER: NCT03281499.

Cost comparison of treatment for oropharyngeal carcinoma.

OBJECTIVES/HYPOTHESIS: Based on current guidelines, surgical and nonsurgical therapies are viable frontline treatment for patients with locoregional oropharyngeal carcinoma (OPC). We sought to compare financial parameters between chemoradiation and transoral robotic surgery (TORS) in this patient population. STUDY DESIGN: Case-control study. METHODS: In this study we identified patients with selected American Joint Committee on Cancer 7th Edition stage II to IVa OPC treated with TORS between January 2013 and December 2014. Fifteen patients who underwent TORS were stage matched with 15 patients treated with chemoradiation. Total charges and cost data for each patient were analyzed at 4-month and 1-year time points; functional and oncologic outcomes were assessed. RESULTS: There were no significant differences in functional and oncologic outcomes. Patients undergoing TORS had a longer inpatient hospital stay, and most required a nasogastric tube for an average of 3.5 days. There were no local or regional recurrences. Across all time points, the TORS group had lower charges and costs compared to the chemoradiation group, with 14% lower costs at 1 year. In the chemoradiation group, nearly two-thirds of costs came from radiation therapy and pharmacy expenses. Chemotherapy accounted for most pharmacy costs. The costs of operating the surgical robot accounted for a about half of surgical costs. CONCLUSIONS: Selected patients with stage II to IVa oropharyngeal carcinoma treated with TORS may incur lower costs than those treated nonsurgically. With rising healthcare spending, the financial impact of treatment might be considered for those patients eligible for treatment regimens with comparable functional and oncologic outcomes. LEVEL OF EVIDENCE: 3b Laryngoscope, 129:1604-1609, 2019.

Development and Assessment of a Transoral Robotic Surgery Curriculum to Train Otolaryngology Residents.

PURPOSE OF THE STUDY: (1) To develop a multifaceted didactic and hands-on curriculum to prepare otolaryngology residents to perform transoral robotic surgery (TORS) and safely transition to the operating room. (2) To assess the effectiveness of the TORS curriculum. PROCEDURES: Learning objectives were developed and a curriculum was formulated utilizing five unique modalities: focused didactic reading, online training modules, backpack console simulations, videos of TORS cases, and hands-on cadaveric dissections with the robotic surgical system in a simulated operating room. The trainees completed a nine-item self-assessment of their skill level using a Likert scale. RESULTS: Five senior otolaryngology residents completed the TORS curriculum. Before and after the cadaveric dissections, there was improvement in each of the nine items assessed. Composite scores were calculated and there was significant improvement from predissection (15.2 ± 2.2) to postdissection (31.4 ± 1.9) (p = 0.002). CONCLUSIONS: The current study demonstrates the feasibility of implementing a multifaceted TORS curriculum which incorporates robotic cadaveric dissection for otolaryngology residents. Residents demonstrate marked improvement in skills with the TORS curriculum. A TORS curriculum which includes robotic cadaveric dissection can improve surgical skills and serve as a key component of residency TORS education.

Early assessment of feasibility and technical specificities of transoral robotic surgery using the da Vinci Xi.

The latest generation Da Vinci® Xi™ Surgical System Robot released has not been evaluated to date in transoral surgery for head and neck cancers. We report here the 1-year results of a non-randomized phase II multicentric prospective trial aimed at assessing its feasibility and technical specificities. Our primary objective was to evaluate the feasibility of transoral robotic surgery using the da Vinci® Xi™ Surgical System Robot. The secondary objective was to assess peroperative outcomes. Twenty-seven patients, mean age 62.7 years, were included between May 2015 and June 2016 with tumors affecting the following sites: oropharynx (n = 21), larynx (n = 4), hypopharynx (n = 1), parapharyngeal space (n = 1). Eighteen patients were included for primary treatment, three for a local recurrence, and six for cancer in a previously irradiated field. Three were reconstructed with a FAMM flap and 6 with a free ALT flap. The mean docking time was 12 min. "Chopsticking" of surgical instruments was very rare. During hospitalization following surgery, 3 patients experienced significant bleeding between day 8 and 9 that required surgical transoral hemostasis (n = 1) or endovascular embolization (n = 2). Transoral robotic surgery using the da Vinci® Xi™ Surgical System Robot proved feasible with technological improvements compared to previous generation surgical system robots and with a similar postoperative course. Further technological progress is expected to be of significant benefit to the patients.

Cost-effectiveness of transoral robotic surgery versus (chemo)radiotherapy for early T classification oropharyngeal carcinoma: A cost-utility analysis.

BACKGROUND: The present study is an economic evaluation comparing transoral robotic surgery (TORS) to (chemo)radiotherapy for the management of early T-classification oropharyngeal cancer. METHODS: A societal perspective was adopted. Treatment for TORS and (chemo)radiotherapy were modeled using decision analysis and recurrences were modeled over a 10 year horizon with a Markov model. Model parameters were derived from systematic review. Deterministic and probabilistic sensitivity analyses were used to test model robustness. RESULTS: TORS demonstrated a cost savings of $1366 and an increase of 0.25 quality-adjusted life years (QALYs) per case in comparison to (chemo)radiotherapy. TORS was sensitive to variations in adjuvant therapy, costs, utilities, complications, and recurrence rates in deterministic and probabilistic sensitivity analysis. In two-way sensitivity analysis, with increasing adjuvant therapy for TORS and decreasing concurrent chemotherapy for radiotherapy, TORS is decreasingly cost-effective. CONCLUSION: TORS is cost-effective for treatment of early oropharyngeal cancer. Case selection to minimize adjuvant therapy ensures cost-effective treatment.

Making a case for high-volume robotic surgery centers: A cost-effectiveness analysis of transoral robotic surgery.

OBJECTIVE: To evaluate the cost-effectiveness of transoral robotic surgery (TORS) compared to intensity-modulated radiotherapy (IMRT) for early stage (T1-2, N0, M0) oropharyngeal squamous cell carcinoma (OPSCC). PATIENTS AND METHODS: A Markov decision tree model with a 5-year time horizon was developed. Comparative groups were: i) TORS with concurrent ipsilateral neck dissection +/- adjunctive IMRT, and ii) primary IMRT. Primary outcome was cost/quality adjusted life year (QALY). Perspective was the United States third party payer. Costs and effects were discounted at a rate of 3.5%. A threshold and probabilistic sensitivity analysis were performed. RESULTS: TORS strategy cost $30,992 and provided 4.81 QALYs/patient. The IMRT strategy cost $26,033 and provided a total of 4.78 QALYs/patient. The incremental cost effectiveness ratio for TORS vs. IMRT in the reference case was $165,300/QALY. The probability that TORS is cost-effective compared to IMRT at a maximum willingness-to-pay threshold of $50,000/QALY is 42%. CONCLUSION: An IMRT strategy for management of early stage OPSCC is more likely to be cost-effective compared to TORS. To improve the value of TORS for early stage OPSCC, consolidating TORS procedures to create high-volume centers of excellence may be a potential strategy to increase incremental effectiveness and reduce incremental costs. J. Surg. Oncol. 2015 111:155-163. © 2015 Wiley Periodicals, Inc.

Transoral robotic surgery for oropharyngeal and tongue cancer in the United States.

OBJECTIVES/HYPOTHESIS: To compare the clinical and cost outcomes of transoral robotic surgery (TORS) versus open procedures following the U.S. Food and Drug Administration approval in December 2009. STUDY DESIGN: Retrospective analysis of the Nationwide Inpatient Sample from 2008 to 2011. METHODS: Elective partial pharyngectomies and partial glossectomies for neoplasm were identified by International Classification of Diseases, 9th Revision, Clinical Modification code. RESULTS: TORS represented 2.1% in 2010 and 2.2% in 2011 of all transoral ablative procedures. Patients undergoing open partial pharyngectomy for oropharyngeal neoplasms (n = 1426) had more severe illness compared to TORS (n = 641). However, after controlling for minor-to-moderate severity of illness, open partial pharyngectomy was associated with longer hospital stay (5.2 vs. 3.7 days, P < 0.001), higher charge ($98,228 vs. $67,317, P < 0.001), higher cost ($29,365 vs. $20,706, P < 0.001), higher rates of tracheostomy and gastrostomy tube placement, and more wound and bleeding complications. TORS was associated with a higher rate of dysphagia (19.5% vs. 8.0%, P < 0.001). The lower cost of TORS remained significant in the major-to-extreme severity of illness group but was associated with higher complication rates when compared to open cases of the same severity of illness. A similar analysis of TORS partial glossectomy for base of tongue tumors had similar cost and length of stay benefits, whereas TORS partial glossectomy for anterior tongue tumors revealed longer hospital stays and no benefit in charge or cost compared to open. CONCLUSIONS: Early data demonstrate a clinical and cost benefit in TORS partial pharyngectomy and partial glossectomy for the base of tongue but no benefit in partial glossectomy of the anterior tongue. It is likely that anatomic accessibility and extent of surgery factor into the effectiveness of TORS.

Transoral Robotic Surgery and the Unknown Primary: A Cost-Effectiveness Analysis.

OBJECTIVE: To evaluate the cost-effectiveness of transoral robotic surgery (TORS) for the diagnosis and treatment of cervical unknown primary squamous cell carcinoma (CUP). STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic hospital. SUBJECTS AND METHODS: A retrospective chart review was performed on patients with new occult primary squamous cell carcinoma of the head and neck with nondiagnostic imaging and/or endoscopy who were treated with TORS at a tertiary hospital between 2009 and 2012. Direct costs were obtained from the hospital's billing system, and national data were used for inpatient hospital costs and physician fees. The proportion of tumors found in 3 strategies was used as effectiveness to calculate the incremental cost-effectiveness ratio. RESULTS: In total, 206 head and neck robotic cases were performed at our institution between December 2009 and December 2012. Three surgeons performed TORS on 22 patients for occult primary squamous cell carcinoma. The primary tumor was located in 19 of 22 patients (86.4%). The incremental cost-effectiveness ratio for sequential and simultaneous examination under anesthesia with tonsillectomy (EUA) and TORS base of tongue resection was $8619 and $5774 per additional primary identified, respectively. CONCLUSION: Sequential EUA followed by TORS is associated with an incremental cost-effectiveness ratio of $8619 compared with traditional EUA alone. Bilateral base of tongue resection should be considered in the workup of these patients, particularly if the palatine tonsils have already been removed.

The effect of transoral robotic surgery on short-term outcomes and cost of care after oropharyngeal cancer surgery.

OBJECTIVES/HYPOTHESIS: Transoral surgery is an increasingly frequent treatment modality for tumors of the upper aerodigestive tract. This is in large part related to the introduction of transoral robotic surgery (TORS) for oropharyngeal cancer resection, which has demonstrated excellent oncologic and functional outcomes. There is limited data, however, on how TORS compares to traditional open surgery in overall costs and length of hospitalization. With increasing pressure to contain and reduce the costs of medical care, we sought to evaluate the impact of TORS on a national sample of patients undergoing surgery for oropharyngeal cancer. STUDY DESIGN: Retrospective cross-sectional study. METHODS: A cross-sectional analysis of 9,601 patients who underwent an extirpative procedure for a malignant oropharyngeal neoplasm in 2008 to 2009 was performed using discharge data from the Nationwide Inpatient Sample. RESULTS: TORS was performed in 116 (1.2%) of cases. TORS patients had a lower rate of gastrostomy tube placement (0% vs. 19%), tracheotomy tube placement (0% vs. 36%), and nonroutine discharge (0% vs. 44%) compared to patients undergoing non-TORS procedures. After controlling for all other variables, including comorbidity, extent of surgery, and teaching hospital status, TORS was associated with significantly decreased length of hospitalization (mean, -1.5 days) and hospital-related costs (mean, -$4,285). CONCLUSIONS: TORS is becoming an increasingly frequent technique to treat tumors of the upper aerodigestive tract. These data demonstrate that TORS is associated with a decreased length of hospitalization and hospital-related costs compared to other surgical techniques.