“A shifting paradigm for patients with head and neck cancer: Transoral Robotic Surgery (TORS).”
Bhayani, M. K., F. C. Holsinger, et al. (2010).
The evolution of surgical oncologic technology has moved toward reducing patient morbidity without compromising oncologic resection. In head and neck surgery, organ-preserving techniques have paved the way for the development of transoral techniques that remove tumors of the upper aerodigestive tract without external incisions and potentially spare the patient adjuvant treatment. The introduction of transoral robotic surgery (TORS) improves upon current transoral techniques to the oropharynx and supraglottis. This review will report on the evolution of robotic-assisted surgery: We will cover its applications in head and neck surgery by examining early oncologic and functional outcomes, training of surgeons, costs, and future directions.
“Transoral minimally invasive robotic surgery for carcinoma of the pharynx and the larynx: a new approach.”
Ceruse, P., B. Lallemant, et al. (2010).
Partial laryngectomy is an old but well-accepted surgical treatment for selected carcinomas of the larynx. Actually, the transcervical approach remains the most popular even if the transoral laser approach is useful in some cases. Transoral robotic surgery is a new promising surgical procedure in head and neck oncology as an alternative to conventional surgery with decreased morbidity. The aim of this study is a description of the state of the art by a review of the literature. We emphasize limits and future prospects on this topic with a special focus on dependability.
“A shifting paradigm for patients with head and neck cancer: Transoral robotic surgery (TORS).”
Chen, A. Y. (2010).
Achieving optimal oncologic outcomes is always the priority for care of our head and neck cancer patients. Preserving functional status is equally important. Traditional surgical approaches to the oropharynx were extensive and unappealing to patients. This led to a surge in the use of chemoradiation for these patients[8,9]. However, these nonsurgical treatments often left the patients with long-term gastrostomy tubes and tracheotomies, and thus they did not achieve the goal of preserving functional status. TORS is a new approach to tried and true oncologic resections and has demonstrated comparable to improved oncologic and functional outcomes. Adding TORS to the multidisciplinary care of head and neck cancer patients, particularly those with oropharynx and larynx primaries, may allow our patients to achieve a cancer-free and highly functional life.
“Transoral robotic surgery and human papillomavirus status: Oncologic results.”
Cohen, M. A., G. S. Weinstein, et al. (2010).
Head and Neck.
BACKGROUND: Patients with oropharyngeal squamous cell carcinoma (OPSCC) have been shown to have distinct outcome profiles based on their human papillomavirus (HPV) status. The purpose of this study was to assess HPV-related outcomes after transoral robotic surgery (TORS) with adjuvant therapy as indicated. METHODS: This study consisted of a retrospective review of 50 patients with OPSCC within a prospective single-arm cohort study. Outcome measures included HPV status, margin status, relapse pattern, and survival. RESULTS: Thirty-seven patients were HPV-positive (74.0%) with 34 patients (91.9%) being serotype-16. Negative margins were achieved in 92.3% (HPV-negative) and 94.6% (HPV-positive). In the HPV-negative group, there were no local recurrences and 1 patient had both regional and distant recurrence (7.7%). In the HPV-positive group, there were no local or regional recurrences and 2 patients (5.4%) had distant recurrences. There were no statistically significant differences in survival between the 2 cohorts (overall survival, disease-specific survival, disease-free survival). CONCLUSION: TORS as a primary surgical modality, followed by adjuvant therapy as indicated, offers disease control in both HPV-negative and HPV-positive groups. We believe that multi-institutional studies are warranted to further evaluate this novel approach for patients who are HPV negative and HPV positive. (c) 2010 Wiley Periodicals, Inc. Head Neck, 2010.
“Robotics in head and neck cancer: Future opportunities.”
Harari, P. M. and G. K. Hartig (2010).
“Initial experience with robot-assisted modified radical neck dissection for the management of thyroid carcinoma with lateral neck node metastasis.”
Kang, S. W., S. H. Lee, et al. (2010).
BACKGROUND: Since the introduction of endoscopic techniques in thyroid surgery, several trials of endoscopic lateral neck dissection have been conducted with the aim of avoiding a long cervical scar, but these endoscopic procedures require more effort than open surgery, mainly because of the relatively nonsophisticated instruments used. However, the recent introduction of surgical robotic systems has simplified the operations and increased the precision of endoscopic techniques. We have described our initial experience with robot-assisted modified radical neck dissection (MRND) in thyroid cancer using the da Vinci S system. METHODS: From October 2007 to October 2009, 33 patients with thyroid cancer with lateral neck lymph node (LN) metastases underwent robot-assisted thyroidectomy and additional robotic MRND using a gasless, transaxillary approach. Clinicopathologic data were analyzed retrospectively. RESULTS: Mean patient age was 37 +/- 9 years and the gender ratio (male to female) was 7:26. The mean operating time was 281 +/- 41 minutes and mean postoperative hospital stay was 5.4 +/- 1.6 days. The mean tumor size was 1.1 +/- 0.5 cm and 20 cases (61%) had papillary thyroid microcarcinoma. The mean number of retrieved LNs was 6.1 +/- 4.4 in the central neck compartment and 27.7 +/- 11.0 in the lateral compartment. No serious postoperative complications, such as Horner’s syndrome or major nerve injury, occurred. CONCLUSION: Robot-assisted MRND is technically feasible, safe, and produces excellent cosmetic results. Based on our initial experience, robot-assisted MRND should be viewed as an acceptable alternative method in patients with low-risk, well-differentiated thyroid cancer with lateral neck node metastasis.
“Transoral Robotic Surgery (TORS): The natural evolution of endoscopic head and neck surgery.”
Kaplan, M. J. and E. J. Damrose (2010).
“Perspective on robotic surgery and its role in head and neck cancers.”
Kazi, R., A. Garg, et al. (2010).
Journal of Cancer Research and Therapeutics6(3): 237-238.
“Perioperative administration of pregabalin for pain after robot-assisted endoscopic thyroidectomy: A randomized clinical trial.”
Kim, S. Y., J. J. Jeong, et al. (2010).
Surgical Endoscopy and Other Interventional Techniques24(11): 2776-2781.
Background: Perioperative administration of pregabalin, which is effective for neuropathic pain, might reduce early postoperative and chronic pain. This randomized, double-blinded, placebo-controlled trial (Clinical Trials.gov ID NCT00905580) was designed to investigate the efficacy and safety of pregabalin for reducing both acute postoperative pain and the development of chronic pain in patients after robot-assisted endoscopic thyroidectomy. Methods: Ninety-nine patients were randomly assigned to groups that received pregabalin 150 mg or placebo 1 h before surgery, with the dose repeated after 12 h. Assessments of pain and side effects were performed 48 h postoperatively. The incidences of chronic pain and hypoesthesia in the anterior chest were recorded 3 months after surgery. Results: Ninety-four patients completed the study. Verbal numerical rating scale scores for pain and the need for additional analgesics were lower in the pregabalin group (n = 47) than the placebo group (n = 47) during 48 h postoperatively (P < 0.05). However, incidences of sedation and dizziness were higher in the pregabalin group (P < 0.05). There were no differences between the groups in the incidences of chronic pain and chest hypoesthesia at 3 months after surgery. Conclusions: Perioperative administration of pregabalin (150 mg twice per day) was effective in reducing early postoperative pain but not chronic pain in patients undergoing robot-assisted endoscopic thyroidectomy. Caution should be taken regarding dizziness and sedation. © 2010 Springer Science+Business Media, LLC.
“Robotic thyroid surgery: An initial experience with North American patients.”
Kuppersmith, R. B. and F. C. Holsinger (2010).
OBJECTIVE:: To review the initial experience of gasless transaxillary robot-assisted endoscopic thyroid surgery in a series of patients and describe modifications of the technique for the North American patients, selection criteria, and other issues related to this technology. METHODS:: Retrospective review of the first 31 consecutive cases at a single institution. RESULTS:: Thirty-one patients underwent robotic thyroid surgery. Twenty thyroid lobectomies and 11 total thyroidectomies were performed. Improvements in the length of time to perform components of the procedure were noted from the early group of cases to later group of cases. No major or permanent complications occurred. CONCLUSIONS:: Robotic thyroid surgery is feasible in North American patients and can be safely performed. The procedure has potential complications and a definite learning curve exists for both surgeons and operating room staff. Training methods need to be validated to ensure safe adoption. More studies need to be performed to further evaluate the relative benefits of this technique. Laryngoscope, 2010.
“Comparison of Endoscopic and Robotic Thyroidectomy.”
Lee, J., J. H. Lee, et al. (2010).
Annals of Surgical Oncology.
BACKGROUND: Endoscopic thyroidectomy is a technically challenging procedure. Robot-assisted thyroidectomy has been recently introduced and offers improved visualization and dexterity. The present study compared conventional endoscopic and robotic thyroidectomy for thyroid cancer patients in terms of perioperative outcomes and learning curve. All operations were performed by the same surgeon. MATERIALS AND METHODS: Between April 2007 and March 2010, 96 patients underwent endoscopic thyroidectomy (endoscopy group) and 163 patients underwent robotic thyroidectomy (robot group). A gasless transaxillary approach was used in both groups. The 2 groups were compared in terms of patient characteristics, perioperative clinical results, complications, and pathologic details. Learning curves for the 2 procedures were compared based on the number of cases required to reach a consistent operation time. RESULTS: Patient characteristics were similar for both groups. The mean total operation time for thyroidectomy with central compartment neck dissection was 142.7 +/- 52.1 min in the endoscopy group and 110.1 +/- 50.7 min in the robot group (P = .041). Both patient groups were similar in terms of pathological features including TNM stage, intraoperative blood loss, length of hospital stay, and complication rate. However, the mean number of retrieved central lymph nodes was 2.4 +/- 1.9 for the endoscopy group and 4.5 +/- 1.5 for the robot group (P = .004). The learning curve was 55-60 cases for endoscopic thyroidectomy and 35-40 cases for robotic thyroidectomy. CONCLUSION: Robotic thyroidectomy was found to be superior to endoscopic thyroidectomy in terms of operation time, lymph node retrieval, and learning curve. Complication rates and postoperative hospital stay were similar for the 2 procedures.
“Outcomes of 109 patients with papillary thyroid carcinoma who underwent robotic total thyroidectomy with central node dissection via the bilateral axillo-breast approach.”
Lee, K. E., H. Koo do, et al. (2010).
BACKGROUND: We developed the bilateral, axillo-breast approach (BABA) to endoscopic thyroidectomy and applied it to the da Vinci robotic surgical system in 2008. Herein, we have analyzed the immediate postoperative outcomes and 1-year follow-up results of robotic BABA total thyroidectomy with central node dissection (CND). METHODS: In 2008 and 2009, 109 patients with PTC underwent robotic BABA total thyroidectomy with CND. Clinicopathologic characteristics, short- and long-term complications, and postoperative thyroglobulin (Tg) level were obtained prospectively and analyzed. RESULTS: The mean age was 39 +/- 10 years and the male to female ratio was 1:5.8. The mean operation time was 206 +/- 36 minutes. Transient recurrent laryngeal nerve (RLN) palsy occurred in 17 cases (16%) and transient hypocalcemia in 21 cases (19%). The median follow-up was 12 months. There were 1 and 2 cases of permanent RLN palsy and permanent hypoparathyroidism, respectively. Postoperative radioactive iodine ablation was performed on 54 patients (50%). Their mean stimulated Tg level was 1.84 +/- 6.35 ng/mL and 76% had stimulated Tg levels <1.0 ng/mL. CONCLUSION: Robotic BABA total thyroidectomy with CND yields good postoperative outcomes. Given the excellent cosmetic outcomes, this technique may be a suitable operative alternative for low-risk patients with PTC.
“Robotic thyroidectomy: a framework for new technology assessment and safe implementation.”
Perrier, N. D., G. W. Randolph, et al. (2010).
Robotic thyroidectomy is a new approach to thyroid surgery that offers the benefit of eliminating the anterior neck incision utilized in traditional approaches. Although no level I evidence exists to strongly support a robotic approach to thyroid surgery, initial non-randomized reports of robotic surgical approaches, in a variety of surgical specialty areas such as cardiothoracic, urologic, gynecologic and head and neck surgery suggest possible advantages of robot assisted techniques. These include platform and instrument stability, tremor reduction, articulating end effectors, three-dimensional, magnified imaging, and improved surgeon ergonomics. Potential negatives associated with robotic surgery include its expense, the lack of haptic feedback, instrument limitations, and the implicit learning curve. Robotic thyroidectomy introduces new potential risks, not typically associated with thyroid surgery. These risks are related to a new approach to the surrounding anatomy and are also associated with the learning curve. The introduction of new technology to any surgery mandates a rational framework for initial assessment and safe implementation. A New Technology Task Force was convened to draft guiding principles which may serve as a framework for the safe implementation of emerging technologies in thyroid surgery. This document suggests initial minimum steps that surgeons should consider during initial implementation of robotic thyroidectomy.
“Head and neck squamous cell carcinoma: New translational therapies.”
Prince, A., J. Aguirre-Ghizo, et al. (2010).
Mount Sinai Journal of Medicine77(6): 684-699.
Head and neck squamous cell carcinoma includes cancers of the mouth, throat, larynx, and lymph nodes of the neck. Although early disease is amenable to single-modality treatment with surgery or radiation, patients with advanced disease have a dramatically worse prognosis, despite potentially morbid/toxic treatment regimens involving surgery, radiation, chemotherapy, or all 3 modalities. The present review seeks to provide an overview of current understanding and treatment of head and neck squamous cell carcinoma for the nonspecialist clinician or basic/translational researcher, followed by an overview of major translational approaches to the treatment of head and neck squamous cell carcinoma. Translational research topics addressed include targeted molecular therapy, immunotherapy, minimally invasive robotic surgery, and ablation of dormant/residual tumor cells. Despite the many potentially promising avenues of head and neck squamous cell carcinoma research, only 2 new treatment approaches (antiepidermal growth factor receptor therapy and robotic surgery) have been approved by the US Food and Drug Administration in the past 30 years. Focused research programs involving integrated teams of clinicians, basic scientists, and translational clinician-researchers have the potential to accelerate discovery and change treatment paradigms for patients with head and neck cancer. © 2010 Mount Sinai School of Medicine.
“Transoral robotic reconstruction of oropharyngeal defects: a case series.”
Selber, J. C. (2010).
Plastic and Reconstructive Surgery126(6): 1978-1987.
BACKGROUND: Large resections of oropharyngeal tumors in the absence of a mandibulotomy create a reconstructive challenge, because flaps are often necessary, and inset requires contouring and suturing in a confined space with limited line of sight. Transoral robotically assisted reconstruction is the logical solution. METHODS: The DaVinci Surgical System was used in five cases of oropharyngeal reconstruction. All oropharyngeal tumors were resected without a mandibulotomy, using either a transoral robotic approach or a lateral pharyngotomy. Robotic reconstruction was performed using a radial forearm, an anterolateral thigh flap, a facial artery myomucosal flap, and primary closure. The robot was also used to perform an arterial anastomosis. RESULTS: All cases were performed with an intact mandible. This resulted in complex oropharyngeal defects with limited access. The robot was used to inset free flaps or local flaps, or to close primarily by improving access and precision in the oropharynx. The robot was used to perform a microvascular anastomosis between two, 2-mm arteries without hand-sewn revision. There were no surgical complications, flap failures, take-backs, or fistulas. All patients have been decannulated and are tolerating an oral diet without tube feeding. CONCLUSIONS: Minimally invasive resections provide locoregional control without the morbidity of mandibulotomy or high-dose chemoradiation. Transoral robotic reconstruction allows access and precision within the oropharynx. It is safe and effective, and may expand minimally invasive resections where reconstruction is not possible through traditional approaches.
White, H. N., E. J. Moore, et al. (2010).
Archives of Otolaryngology–Head and Neck Surgery136(12): 1248-1252.
OBJECTIVE: To report 2-year survival outcomes for head and neck squamous cell carcinoma using transoral robotic-assisted resection. DESIGN: Prospective case study. SETTING: Two tertiary care centers. PATIENTS: Eighty-nine patients from 2 tertiary care centers (University of Alabama at Birmingham and the Mayo Clinic in Rochester, Minnesota) with head and neck squamous cell carcinoma of all stages and subsites, who underwent transoral robotic-assisted resection between March 2007 and December 2008, with a median follow-up time of 26 months. MAIN OUTCOME MEASURES: Disease-free survival, cancer recurrence, and gastrostomy tube dependence RESULTS: Seventy-one patients had T1 (n = 29) or T2 (n = 42) tumors while 18 patients had T3 (n = 8) or T4 (n = 10) tumors. There were 24 patients with overall stage I or II disease and 65 with stage III or IV disease. At the time of the last follow-up visit (median, 26 months), there had been a total of 11 patients with recurrent cancer: 3 with local; 7, regional (2 of whom also had distant metastases); and 1, distant. Seven patients were treated for recurrent disease. Eighty-two patients had no evidence of disease, 1 patient died of the disease, 2 died of other disease, and 4 were alive with disease at the last follow-up visit. Results of Kaplan-Meier survival analysis showed that the 2-year recurrence-free survival rate for the cohort was 86.5%. None of the patients were gastrostomy tube dependent at the last follow-up visit. CONCLUSION: The 2-year functional and oncologic results justify the continued treatment of select patients with head and neck squamous cell carcinoma with robotic-assisted surgical resection.