Transoral Robotic Surgery for Recurrent Tumors of the Upper Aerodigestive Tract (RECUT): An International Cohort Study.

BACKGROUND: Transoral robotic surgery (TORS) is an emerging minimally invasive surgical treatment for residual, recurrent, and new primary head and neck cancers in previously irradiated fields, with limited evidence for its oncological effectiveness. METHODS: A retrospective observational cohort study of consecutive cases performed in 16 high-volume international centers before August 2018 was conducted (registered at clinicaltrials.gov [NCT04673929] as the RECUT study). Overall survival (OS), disease-free survival, disease-specific survivals (DSS), and local control (LC) were calculated using Kaplan-Meier estimates, with subgroups compared using log-rank tests and Cox proportional hazards modeling for multivariable analysis. Maximally selected rank statistics determined the cut point for closest surgical resection margin based on LC. RESULTS: Data for 278 eligible patients were analyzed, with median follow-up of 38.5 months. Two-year and 5-year outcomes were 69.0% and 62.2% for LC, 71.8% and 49.8% for OS, 47.2% and 35.7% for disease-free survival, and 78.7% and 59.1% for disease-specific survivals. The most discriminating margin cut point was 1.0 mm; the 2-year LC was 80.9% above and 54.2% below or equal to 1.0 mm. Increasing age, current smoking, primary tumor classification, and narrow surgical margins (≤1.0 mm) were statistically significantly associated with lower OS. Hemorrhage with return to theater was seen in 8.1% (n = 22 of 272), and 30-day mortality was 1.8% (n = 5 of 272). At 1 year, 10.8% (n = 21 of 195) used tracheostomies, 33.8% (n = 66 of 195) used gastrostomies, and 66.3% (n = 53 of 80) had maintained or improved normalcy of diet scores. CONCLUSIONS: Data from international centers show TORS to treat head and neck cancers in previously irradiated fields yields favorable outcomes for LC and survival. Where feasible, TORS should be considered the preferred surgical treatment in the salvage setting.

Robotic-Assisted Tubular Transoral Parapharyngeal Approach to the Ventral Craniovertebral Junction.

BACKGROUND: Transoral robotic surgery (TORS) has become a routine technique for treating benign and malignant lesions of the oropharynx with the advantage of reducing morbidity compared to open surgical techniques. However, TORS has not been used routinely for accessing lesions of the spine. OBJECTIVE: To describe how TORS can be used to access spinal lesions. METHODS: We describe our technique of accessing the parapharyngeal space using the robotic technique, and then dissecting the prevertebral muscles to expose the ventral craniovertebral junction. Tubular retraction with endoscopic visualization is then employed for surgical resection. We then report a case of a 14-yr-old competitive athlete who presented with an osseous lesion of C1, which underwent resection using this novel TORS approach. RESULTS: Our patient underwent successful resection of a lateral C1 osteoid osteoma utilizing a combined TORS/endoscopic approach. She tolerated soft diet immediately and was discharged on postoperative day 2. Postoperative imaging revealed complete resection of the lesion, and she returned to competitive athletics within 6 wk. CONCLUSION: Utilizing this novel, robotic-assisted approach can definitively treat osseous cervical spine lesions while reducing morbidity, allowing for early return to normal diet and minimizing overall length of hospital stay.

Transoral robotic parapharyngeal approach to the submandibular space.

The aim of the study was to demonstrate a novel transoral parapharyngeal approach to the submandibular space. The method used was the clinical case of a patient presenting with an anteriorly based tumor in the left submandibular space. The video shows the transoral robotic technique for access to the submandibular space through the parapharyngeal space for removal of the tumor. This approach allows for high definition visibility and complete access to structures in the submandibular space including the submandibular gland. For robotic head and neck surgeons performing lateral oropharyngectomies, the anatomy is familiar, and the technique avoids potential access issues with traditional floor of mouth incisions. Furthermore, it provides a novel technique for identification of the hypoglossal nerve for potential preservation in oropharyngeal malignancy. The transoral robotic parapharyngeal approach to the submandibular space is safe, reproducible, and avoids unnecessary cervical incisions.

A novel surgeon credentialing and quality assurance process using transoral surgery for oropharyngeal cancer in ECOG-ACRIN Cancer Research Group Trial E3311.

PURPOSE: Understanding the role of transoral surgery in oropharyngeal cancer (OPC) requires prospective, randomized multi-institutional data. Meticulous evaluation of surgeon expertise and surgical quality assurance (QA) will be critical to the validity of such trials. We describe a novel surgeon credentialing and QA process developed to support the ECOG-ACRIN Cancer Research Group E3311 (E3311) and report outcomes related to QA. PATIENTS AND METHODS: E3311 was a phase II randomized clinical trial of transoral surgery followed by low- or standard-dose, risk-adjusted post-operative therapy with stage III-IVa (AJCC 7th edition) HPV-associated OPC. In order to be credentialed to accrue to this trial, surgeons were required to demonstrate active hospital credentials and technique-specific surgical expertise with ≥20 cases of transoral resection for OPC. In addition, 10 paired operative and surgical pathology reports from the preceding 24 months were reviewed by an expert panel. Ongoing QA required <10% rate of positive margins, low oropharyngeal bleeding rates, and accrual of at least one patient per 12 months. Otherwise surgeons were placed on hold and not permitted to accrue until re-credentialed using a new series of transoral resections. RESULTS: 120 surgeons trained in transoral minimally invasive surgery applied for credentialing for E3311 and after peer-review, 87 (73%) were approved from 59 centers. During QA on E3311, positive final pathologic margins were reported in 19 (3.8%) patients. Grade III/IV and grade V oropharyngeal bleeding was reported in 29 (5.9%) and 1 (0.2%) of patients. CONCLUSIONS: We provide proof of concept that a comprehensive credentialing process can support multicenter transoral head and neck surgical oncology trials, with low incidence of positive margins and *grade III/V oropharyngeal bleeding.

Anatomical-based classification for transoral lateral oropharyngectomy.

PURPOSE: The aim of the study is proposing a classification of different transoral lateral oropharyngectomy procedures in order to ensure better definitions of post-operative results. METHODS: The classification resulted from the consensus of the different authors and was based on anatomical-surgical principles. RESULTS: The classification comprises three types of lateral oropharyngectomy: type 1 is the resection of the palatine tonsil deep to the pharyngobasilar fascia; type 2 is performed by removing the entire palatine tonsil, the palatoglossus muscle, the palatopharyngeal muscle and the superior constrictor muscle; type 3 is performed by removing the entire palatine tonsil, the palatoglossus muscle, the palatopharyngeal muscle, the superior constrictor muscle, the buccopharyngeal fascia with extension to the pterygoid muscle and parapharyngeal space fat content. Based on the extension of the dissection we can use the suffix A (soft palate), B (posterior pharyngeal wall), C (base of tongue) and D (retromolar trigone). CONCLUSION: The proposed classification introduces a simple and easy to use categorization of transoral lateral oropharyngectomies into three classes. Resection extensions are easily described using suffixes.

A Next-Generation Single-Port Robotic Surgical System for Transoral Robotic Surgery: Results From Prospective Nonrandomized Clinical Trials.

IMPORTANCE: Transoral endoscopic head and neck surgery now plays an important role in the multidisciplinary management of oropharyngeal carcinoma. Previous generations of robotic surgical systems used a multiport system with a rigid stereo-endoscope and 2 wristed instruments that facilitated transoral robotic surgery. OBJECTIVE: To evaluate a new single-port robotic surgical system in head and neck surgery prospectively through concurrent nonrandomized clinical trials. DESIGN, SETTING, AND PARTICIPANTS: Two prospective clinical trials were conducted from December 16, 2016, to December 26, 2017, to assess the safety, feasibility, and performance of a flexible single-port robotic surgical system in 4 institutions, including 3 in the United States and 1 in Hong Kong. A total of 47 patients with tumors of the oropharynx were enrolled and underwent surgery. All patients were classified as having American Society of Anesthesiologists class I to III status and Eastern Cooperative Oncology Group status 0 to 1. An initial cohort of 7 patients underwent staging and endoscopic procedures for benign disease. The remaining 40 patients all had malignant tumors of the oropharynx. MAIN OUTCOMES AND MEASURES: Safety was measured by the incidence of device-related serious adverse events. Feasibility and performance were measured by the conversion rate from the use of the single-port robotic surgical system to either open surgery or the use of any other transoral technology required to complete the planned procedure. Secondary end points of swallowing function and surgical margins were also measured. RESULTS: All 47 patients (8 women and 39 men; mean [SD] age, 61 [8] years) safely underwent transoral resection with the single-port robotic surgical system without conversion to open surgery, laser surgery, or multiport robotic surgery. There were no intraoperative complications or device-related serious adverse events. Mean (SD) estimated intraoperative blood loss per procedure was 15.4 (23.9) mL; no patients received a transfusion. Two patients underwent a planned tracheotomy owing to medical comorbidity (previous chemoradiotherapy; obesity and severe sleep apnea). Two patients (4%) had grade III or IV postoperative hemorrhage, requiring a return to the operating room; however, both patients had medical comorbidities requiring the use of antithrombotic medication. The incidence of positive margins for patients with oropharyngeal malignancy was 3% (1 of 40). Within 30 days, 45 patients (96%) were eating by mouth and without the need for a percutaneous endoscopic gastrostomy tube. CONCLUSIONS AND RELEVANCE: This study describes the results of phase 2 clinical testing of a next-generation, robotic surgical system using a single-port architecture. The use of the device appears to be feasible, safe, and effective for transoral robotic surgery of oropharyngeal tumors. TRIAL REGISTRATION: ClinicalTrials.gov identifiers: NCT03010813 and NCT03049280.

Hemostatic Options for Transoral Robotic Surgery of the Pharynx and Base of Tongue.

Surgery with transoral robotic surgery (TORS) offers significant advantages compared with traditional open surgical approaches and potentially minimizes the long-term side effects of organ preservation therapy with chemoradiation. Angled telescopes and wristed instruments allow visualization and access to areas of the pharynx that are difficult to reach with line-of-sight instrumentation. Although the application of TORS in head and neck surgery has expanded considerably, there are still only limited data available on the postoperative complications and their management. As further data become available, it is likely that further risk factors and treatment strategies will become available.

Robotics in otolaryngology and head and neck surgery: Recommendations for training and credentialing: A report of the 2015 AHNS education committee, AAO-HNS robotic task force and AAO-HNS sleep disorders committee.

Training and credentialing for robotic surgery in otolaryngology - head and neck surgery is currently not standardized, but rather relies heavily on industry guidance. This manuscript represents a comprehensive review of this increasingly important topic and outlines clear recommendations to better standardize the practice. The recommendations provided can be used as a reference by individuals and institutions alike, and are expected to evolve over time. © 2016 Wiley Periodicals, Inc. Head Neck 38: E151-E158.

Oncologic Outcomes After Transoral Robotic Surgery: A Multi-institutional Study.

IMPORTANCE: Large patient cohorts are necessary to validate the efficacy of transoral robotic surgery (TORS) in the management of head and neck cancer. OBJECTIVES: To review oncologic outcomes of TORS from a large multi-institutional collaboration and to identify predictors of disease recurrence and disease-specific mortality. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of records from 410 patients undergoing TORS for laryngeal and pharyngeal cancers from January 1, 2007, through December 31, 2012, was performed. Pertinent data were obtained from 11 participating medical institutions. INTERVENTIONS: Select patients received radiation therapy and/or chemotherapy before or after TORS. MAIN OUTCOMES AND MEASURES: Locoregional control, disease-specific survival, and overall survival were calculated. We used Kaplan-Meier survival analysis with log-rank testing to evaluate individual variable association with these outcomes, followed by multivariate analysis with Cox proportional hazards regression modeling to identify independent predictors. RESULTS: Of the 410 patients treated with TORS in this study, 364 (88.8%) had oropharyngeal cancer. Of these 364 patients, information about post-operative adjuvant therapy was known about 338: 106 (31.3) received radiation therapy alone, and 72 (21.3%) received radiation therapy with concurrent chemotherapy. Neck dissection was performed in 323 patients (78.8%). Mean follow-up time was 20 months. Local, regional, and distant recurrence occurred in 18 (4.4%), 15 (3.7%), and 10 (2.4%) of 410 patients, respectively. Seventeen (4.1%) died of disease, and 13 (3.2%) died of other causes. The 2-year locoregional control rate was 91.8% (95% CI, 87.6%-94.7%), disease-specific survival 94.5% (95% CI, 90.6%-96.8%), and overall survival 91% (95% CI, 86.5%-94.0%). Multivariate analysis identified improved survival among women (P = .05) and for patients with tumors arising in tonsil (P = .01). Smoking was associated with worse overall all-cause mortality (P = .01). Although advanced age and tobacco use were associated with locoregional recurrence and disease-specific survival, they, as well as tumor stage and other adverse histopathologic features, did not remain significant on multivariate analysis. CONCLUSIONS AND RELEVANCE: This large, multi-institutional study supports the role of TORS within the multidisciplinary treatment paradigm for the treatment of head and neck cancer, especially for patients with oropharyngeal cancer. Favorable oncologic outcomes have been found across institutions. Ongoing comparative clinical trials funded by the National Cancer Institute will further evaluate the role of robotic surgery for patients with head and neck cancers.

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 versus open surgical approaches to oropharyngeal squamous cell carcinoma by human papillomavirus status.

OBJECTIVES: (1) Investigate oncologic survival outcomes and (2) analyze the impact of human papillomavirus status on prognosis in patients with oropharyngeal squamous cell carcinoma treated with transoral robotic versus open surgery. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary care referral center, University of Alabama at Birmingham Hospital. SUBJECTS: One hundred thirty total (65 per treatment arm) with primary oropharyngeal squamous cell carcinoma (OPSCC). METHODS: Patients treated for primary oropharyngeal squamous cell carcinoma with either transoral robotic (TORS) or open surgery plus standard of care adjuvant therapy between October 2004 and March 2012 were matched based on TNM staging before a retrospective chart review was performed. Carcinoma tissue was stained both prospectively and retrospectively with CINtec p16-INK4a kits for surrogate human papillomavirus typing. Recurrence-free survival was used to evaluate the impact of human papillomavirus tumor status and method of surgical intervention on prognosis. RESULTS: As a whole, patients treated with transoral robotic surgery survived more frequently (94%, 91%, 89% at 1, 2, 3 years, respectively) than those treated with open surgery (85%, 75%, 73% at 1, 2, 3 years, correspondingly) (P = .035). The subgroup of patients with human papillomavirus-negative malignancies treated with open surgery survived without recurrence less frequently at 1, 2, and 3 year rates of 58%, 25%, 25%, respectively (P < .01). CONCLUSION: These retrospective data suggest that oncologic outcomes are not being sacrificed when patients with OPSCC are treated with TORS instead of open surgery regardless of tumor human papillomavirus immunohistochemical staining.

Transoral robotic sleep surgery: the obstructive sleep apnea-hypopnea syndrome.

Nocturnal upper airway collapse is often multi-level in nature but typically will involve some degree of obstruction at the level of the tongue-base. Several surgical procedures have been developed in recent years to address this area in patients resistant to continuous positive airway pressure. This article outlines a novel way to treat obstructive sleep apnea lingual obstruction using the da Vinci robotic surgical system. This technique offers significant potential advantages over other established approaches and it should be included in the surgical armamentarium of sleep surgeons.

Harmonic Scalpel versus electrocautery and surgical clips in head and neck free-flap harvesting.

We sought to determine the safety and utility of Harmonic Scalpel-assisted free-flap harvesting as an alternative to a combined electrocautery and surgical clip technique. The medical records of 103 patients undergoing radial forearm free-flap reconstruction (105 free flaps) for head and neck surgical defects between 2006 and 2008 were reviewed. The use of bipolar electrocautery and surgical clips for division of small perforating vessels (n = 53) was compared to ultrasonic energy (Harmonic Scalpel; Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) (n = 52) free-tissue harvesting techniques. Flap-harvesting time was reduced with the use of the Harmonic Scalpel when compared with electrocautery and surgical clip harvest (31.4 vs. 36.9 minutes, respectively; p = 0.06). Two patients who underwent flap harvest with electrocautery and surgical clips developed postoperative donor site hematomas, whereas no donor site complications were noted in the Harmonic Scalpel group. Recipient site complication rates for infection, fistula, and hematoma were similar for both harvesting techniques (p = 0.77). Two flap failures occurred in the clip-assisted radial forearm free-flap harvest group, and none in the Harmonic Scalpel group. Median length of hospitalization was significantly reduced for patients who underwent free-flap harvest with the Harmonic Scalpel when compared with the other technique (7 vs. 8 days; p = 0.01). The Harmonic Scalpel is safe, and its use is feasible for radial forearm free-flap harvest.

Hardware removal after osseous free flap reconstruction.

OBJECTIVE: Identifying risk factors for hardware removal in patients undergoing mandibular reconstruction with vascularized osseous free flaps remains a challenge. The purpose of this study is to identify potential risk factors, including osteocutaneous radial forearm versus fibular flap, for need for removal and to describe the fate of implanted hardware. STUDY DESIGN: Case series with chart review Setting Academic tertiary care medical center. SUBJECTS AND METHODS: Two hundred thirteen patients undergoing 227 vascularized osseous mandibular reconstructions between the years 2004 and 2012. Data were compiled through a manual chart review, and patients incurring hardware removals were identified. RESULTS: Thirty-four of 213 evaluable vascularized osseous free flaps (16%) underwent surgical removal of hardware. The average length of time to removal was 16.2 months (median 10 months), with the majority of removals occurring within the first year. Osteocutaneous radial forearm free flaps (OCRFFF) incurred a slightly higher percentage of hardware removals (9.9%) compared to fibula flaps (6.1%). Partial removal was performed in 8 of 34 cases, and approximately 38% of these required additional surgery for removal. CONCLUSION: Hardware removal was associated with continued tobacco use after mandibular reconstruction (P = .03). Removal of the supporting hardware most commonly occurs from infection or exposure in the first year. In the majority of cases the bone is well healed and the problem resolves with removal.

Intraluminal negative pressure wound therapy for optimizing pharyngeal reconstruction.

IMPORTANCE: Pharyngocutaneous fistula formation after pharyngeal reconstruction is one of the most common and challenging problems to manage. Despite many advances in management, the published success rates indicate a role for any adjuvant therapy that could potentially decrease this complication. OBJECTIVE: To describe the use of intraluminal negative pressure dressings (NPDs) in pharyngeal reconstruction. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case series at a tertiary care academic hospital. Twelve laryngectomy patients underwent pharyngeal reconstruction augmented by placement of an intrapharyngeal NPD in combination with the introduction of vascularized tissue from August 2011 to May 2012. All patients had potential risk factors for compromised wound healing defined as previous radiation therapy, hypothyroidism, diabetes mellitus, compromised nutrition, or established pharyngocutaneous fistula. INTERVENTIONS: An NPD was placed in an intraluminal position spanning the length of the pharyngeal defect as part of the reconstructive procedure. The negative pressure sponge was attached to a standard nasogastric tube to which negative pressure was applied. External closure of the pharynx was then achieved with regional or free tissue transfer. MAIN OUTCOMES AND MEASURES: Pharyngeal closure rates, timing until return to oral diet, identification of wound healing risk factors, and adverse events related to use of the device. RESULTS: Eleven of 12 patients (92%) achieved pharyngeal closure with reconstruction using negative pressure wound therapy. All patients had at least 1 potential risk factor for compromised wound healing, with 11 of 12 (92%) having 2 or more. Seven patients had an established pharyngocutaneous fistula, and 5 patients underwent primary reconstruction after laryngopharyngectomy. In 6 of these 7 patients undergoing fistula repair, pharyngeal closure was achieved, and they resumed an oral diet at 1 week postoperatively. The other had successful leak repair initially, but 1 week later developed a separate area of wound breakdown and a second fistula. All 5 patients in whom an intraluminal NPD was placed at the time of initial vacularized tissue reconstruction were able to resume an oral diet by 3 weeks postoperatively, with 3 of them eating by mouth at 1 week postoperatively. No serious adverse events could be attributed to the use of intraluminal NPDs. CONCLUSIONS AND RELEVANCE: Intraluminal negative pressure wound therapy is feasible and safe. Future research should be conducted to determine its potential in optimizing pharyngeal reconstruction in high-risk patients.

Negative pressure wound therapy in head and neck surgery.

IMPORTANCE Negative pressure wound therapy has been shown to accelerate healing. There is a paucity of literature reporting its use as a tool to promote wound healing in head and neck reconstruction. OBJECTIVE To review 1 institution's experience with negative pressure dressings to further describe the indications, safety, and efficacy of this technique in the head and neck. DESIGN, SETTING, AND PARTICIPANTS Retrospective case series at a tertiary care academic hospital. One hundred fifteen patients had negative pressure dressings applied between April 2005 and December 2011. Data were gathered, including indications, details of negative pressure dressing use, adverse events, wound healing results, potential risk factors for compromised wound healing (defined as previous radiation therapy, hypothyroidism, or diabetes mellitus), and wound characteristics (complex wounds included those with salivary contamination, bone exposure, great vessel exposure, in the field of previous microvascular free tissue transfer, or in the case of peristomal application in laryngectomy). EXPOSURE Negative pressure wound therapy utilized after head and neck reconstruction. MAIN OUTCOMES AND MEASURES Indications for therapy, length and number of dressing applications, identification of wound healing risk factors, classification of wound complexity, wound healing results, and adverse events related to the use of the device. RESULTS Negative pressure wound therapy was used primarily for wounds of the neck (94 of 115 patients [81.7%]) in addition to other head and neck locations (14 of 115 patients [12.2%]), and free tissue transfer donor sites (7 of 115 patients [6.1%]). The mean (SD) wound size was 5.6 (5.0) cm. The mean number of negative pressure dressing applications was 1.7 (1.2), with an application length of 3.7 (1.4) days. Potential risk factors for compromised wound healing were present in 82 of 115 patients (71.3%). Ninety-one of 115 patients (79.1%) had complex wounds. Negative pressure dressings were used in wounds with salivary contamination (n = 64), bone exposure (n = 40), great vessel exposure (n = 25), previous free tissue transfer (n = 55), and peristomal application after laryngectomy (n = 32). Adverse events occurred in 4 of 115 patients (3.5%). CONCLUSIONS AND RELEVANCE Negative pressure wound therapy in head and neck surgery is safe and has potential to be a useful tool for complex wounds in patients with a compromised ability to heal. LEVEL OF EVIDENCE 4.

Robotic surgery for primary head and neck squamous cell carcinoma of unknown site.

IMPORTANCE: Identification of the primary site in head and neck squamous cell carcinoma (HNSCC) is crucial because it improves the patient's prognosis and minimizes morbidity from treatment. OBJECTIVES: To determine the efficacy of transoral robotic surgery (TORS) in identifying unknown primary sites of head and neck squamous cell carcinoma. DESIGN, SETTING, AND PARTICIPANTS: Retrospective, multi-institutional case series from January 1, 2010, to February 28, 2013, in which data were pooled from the following 6 institutions: University of Washington Medical Center, The University of Texas MD Anderson Cancer Center, University of Alabama-Birmingham Hospital, The University of Texas Medical School at Houston, Johns Hopkins Hospital, and Oregon Health Sciences University. All patients diagnosed as having HNSCC of an unknown primary site who underwent TORS to identify the primary site were included in the study. We excluded those with recurrent disease, a history of radiation therapy to the head and neck, or evidence of a primary tumor site based on previous biopsy results. MAIN OUTCOME AND MEASURE: Identification of the primary tumor site. RESULTS: Forty-seven patients were eligible for the study. The tumor site was identified by TORS in 34 of 47 patients (72.3%). The primary site was located in the base of tongue for 20 patients (58.8%) and the palatine tonsil for 13 patients (38.2%), with 1 patient having a primary site in both the base of tongue and the palatine tonsil. Suspicious physical examination findings were present in 23 of 47 patients (48.9%), with positive and negative predictive values of 56.5% and 25.0%, respectively. Of those who underwent any imaging, 16 patients had suspicious findings, with positive and negative predictive values of 50.0% and 16.7%, respectively. In 18 of 47 patients (38.3%), both preoperative radiographic and physical examination failed to suggest a primary site. Of these 18 patients, 13 (72.2%) were identified after undergoing TORS. CONCLUSIONS AND RELEVANCE: We demonstrate that TORS is a useful approach to identify and treat the primary site in patients with HNSCC who present with an unknown primary site.

Salvage surgery for recurrent cancers of the oropharynx: comparing TORS with standard open surgical approaches.

IMPORTANCE: Surgical salvage may be the only viable treatment option for recurrent tumors of the oropharynx. To our knowledge, there have been no published reports directly comparing the oncologic and functional outcomes of patients with recurrent oropharyngeal squamous cell carcinoma (SCC) treated with transoral robotic-assisted surgery (TORS) with those treated with traditional open surgical approaches. OBJECTIVE: To compare the oncologic and functional outcomes of patients with recurrent oropharyngeal SCC treated with TORS with those treated with traditional open surgical approaches. DESIGN: Retrospective multi-institutional case-control study; study dates, March 2003 through October 2011. SETTING: Four tertiary care institutions (University of Alabama at Birmingham; M. D. Anderson Cancer Center, Houston, Texas; Mayo Clinic, Rochester, Minnesota; and Henry Ford Hospital, Detroit, Michigan). PARTICIPANTS Sixty-four patients who underwent salvage TORS for recurrent oropharyngeal SCC were matched by TNM stage to 64 patients who underwent open salvage resection. INTERVENTION OR EXPOSURE: Salvage TORS for recurrent SCC of the oropharynx. MAIN OUTCOME AND MEASURES: Patient demographics, operative data, functional, and oncologic outcomes were recorded and compared with a similarly TNM-matched patient group that underwent salvage surgical resection by traditional open surgical approaches. RESULTS Patients treated with TORS were found to have a significantly lower incidence of tracheostomy use (n = 14 vs n = 50; P < .001), feeding tube use (n = 23 vs n = 48; P < .001), shorter overall hospital stays (3.8 days vs 8.0 days; P < .001), decreased operative time (111 minutes vs 350 minutes; P < .001), less blood loss (49 mL vs 331 mL; P < .001), and significantly decreased incidence of positive margins (n = 6 vs n = 19; P = .007). The 2-year recurrence-free survival rate was significantly higher in the TORS group than in the open approach group (74% and 43%, respectively) (P = .01). CONCLUSIONS AND RELEVANCE: This study demonstrates that TORS offers an alternative surgical approach to recurrent tumors of the oropharynx with acceptable oncologic outcomes and better functional outcomes than traditional open surgical approaches. This adds to the growing amount of clinical evidence to support the use of TORS in selected patients with recurrent oropharyngeal SCC as a feasible and oncologically sound method of treatment.

Learning curve for transoral robotic surgery: a 4-year analysis.

IMPORTANCE: As new institutions incorporate transoral robotic surgery (TORS) into their everyday practice, it is helpful to have a timeline reference of expected goals to follow as their experience increases. This article evaluates a single tertiary care academic institution's experience with TORS for head and neck tumors and reports its 4-year learning curve. OBJECTIVE: To evaluate a single institution's experience with TORS over a 4-year period and report treatment trends and clinical outcomes. DESIGN: Prospective case study. SETTING: A single tertiary care academic institution. PARTICIPANTS: A total of 168 patients underwent TORS for tumors of the head and neck at University of Alabama at Birmingham between March 2007 and September 2011. The total group was subdivided into 4 consecutive groups (42 patients each). Patients were monitored throughout their hospital stay and up to 4.5 years postoperatively (mean follow-up duration, 14 months). INTERVENTION: Transoral robotic surgery. MAIN OUTCOMES AND MEASURES: Data points were collected and compared over time, including feasibility, operative time, tumor type, stage, subsite, length of intubation, need for tracheostomy, feeding tube use, hospital stay, margin status, neck dissection performed, and postoperative complications. RESULTS: Significant decreases in operative time, length of intubation, and hospital stay were seen as TORS experience increased. Overall, the mean operative time decreased by 47% (group 4, 86 minutes; group 1, 183 minutes). Total mean intubation time decreased by 87% (group 1, 12.9 hours; group 4, 1.7 hours) and mean hospital stay decreased from 3.0 days to 1.4 days. There was not a significant difference between groups in number of cases unable to be performed robotically (7-9 per group), tumor stage (majority T1/T2), tumor subsite (majority oropharynx), positive margin status (2-5 per group), number of salvage cases performed (7-9 per group), and number of tracheostomies (2-4 per group) or feeding tubes (22-25 per group) required. CONCLUSIONS AND RELEVANCE: This is the first multiyear prospective study to document a single institution's TORS experience over time and demonstrate particular areas of expected improvement as case number increases.

Hemorrhage after transoral robotic-assisted surgery.

OBJECTIVE: An increasing number of head and neck surgeons have begun using transoral robotic-assisted surgery. Our objective was to examine the postoperative bleeding complications we have encountered to determine risk factors and to discuss the topic of hemorrhage control. STUDY DESIGN: Case series with chart review. METHODS: Medical records were reviewed in 147 consecutive patients undergoing transoral robotic-assisted surgery for any indication at one tertiary academic medical center between March 2007 and September 2011. RESULTS: Eleven of 147 (7.5%) patients undergoing transoral robotic-assisted surgery experienced some degree of postoperative hemorrhage, with 9 patients requiring reoperation for examination and/or control of bleeding. Bleeding occurred at a mean of 11.1 ± 9.2 days after initial operation. Eight of 11 (72%) patients who bled were on antithrombotic medication (anticoagulants or antiplatelet agents) for other medical comorbidities. The postoperative hemorrhage rate in patients taking antithrombotic medication (8/48 patients = 17%) was significantly higher than in those not taking antithrombotics (3/99 patients = 3%), P = .0057. While the bleeding rate in salvage surgery (3/29 = 10.3%) was slightly higher than in primary surgery (8/118 = 6.8%), this difference did not reach statistical significance. CONCLUSION: Potential for postoperative bleeding in association with antithrombotic medications in patients undergoing transoral robotic-assisted surgery should be recognized. Various effective techniques for management of these patients without robotic assistance were demonstrated.