SM13: Transoral Surgery Valuable Tool in Treatment of Oropharyngeal Cancer

SCOTTSDALE, Ariz.—As the use of robotic machines for oropharyngeal cancer surgery becomes more common, surgeons have to consider which method is best, transoral robotic surgery (TORS) or transoral laser microsurgery (TLM).

There are advantages to each method, but some doctors regard one approach more highly than the other, as two experts showed in a debate session here on Jan. 24 at the Triological Society Combined Sections Meeting. The discussion was part of a session that also included presentations on whether image-guided surgery can be considered the standard of care.

TORS vs. TLM

William Armstrong, MD, professor of clinical otolaryngology in the department of head and neck surgery at the University of California Irvine, said open surgical procedures have significant morbidity, and chemoradiation protocols have become more popular. These protocols have very high morbidity, however, with up to 20 percent incidence of gastrostomy tube dependence two years after treatment. This has led to renewed interest in less invasive surgical options.

Arguing in favor of TORS, Dr. Armstrong said learning to use a “robot” is easier than learning how to perform the surgery. “I have personal experience with both TLM and TORS, and I found the learning curve to be quicker with the transoral robotic than the TLM,” he said. “I think the TLM is a more difficult operation.”

The dual console option on the robotic system provides a great opportunity for the master surgeon to work alongside someone who is learning, in a type of “driver’s ed” model, Dr. Armstrong said. “The master surgeon can let the assistant work, but if they’re doing something they don’t like, they can immediately take over the controls,” he said. “I think this would be helpful in teaching.”

He acknowledged, though, that TLM is the more versatile method, because it is more customizable and can be used in more types of cases.

Sunnyvale, Calif.-based Intuitive Surgical dominates the TORS market, but Dr. Armstrong said other systems are being developed, including the Raven Surgical Robotic System, from the University of Washington and the University of California Santa Cruz, as well as other ventures. “I think the future’s going to hold change,” he said. “And I think that will be really good for the industry, because it really needs competition for innovation.”

Michael Hinni, MD, associate professor of otolaryngology head and neck surgery at the Mayo Clinic in Arizona, said that TLM has advantages: There has been far more human experience with that method, and more cases can be performed using it. “I know that TLM is a little bit hard to master because there are more variables, but that doesn’t mean that it’s not better,” he said.