The Future of Robotic Surgery in Otolaryngology

For patients with oropharyngeal cancers, the days of morbid surgical outcomes, often leading to facial disfigurement, are gone after the switch nearly 20 to 30 years ago from early generation open surgery to high-dose radiation (RT) and chemotherapy (CT) as the dominant first-line treatment approach.

Now, for select patients, surgery once again plays a major role as a first-line treatment. Transoral robotic surgery (TORS), a minimally invasive surgery using optics that now allow surgeons to see far into the oropharynx to target and excise cancerous tissue with flexible robotic arms, offers an efficacious and safe way to treat throat cancer and, importantly, reduce the long-term side effects of high-dose radiation that can drastically curtail quality of life for many patients.

“Transoral robotic surgery has brought surgery back into the armamentarium for treatment of oropharynx cancer,” said Eric Moore, MD, a head and neck surgeon in the department of otolaryngology–head and neck surgery at the Mayo Clinic in Rochester, Minn., who explained that robotic surgery allows for faster and easier removal of tumors through the mouth compared to other transoral approaches. It also allows surgeons to perform transoral surgery on tumors that otherwise would need to be excised using more extensive surgical techniques.

Benefits for HPV-Related Cancers

The benefits of this approach are expanding as the population of patients who would benefit from TORS grows and changes. (See the sidebar on page 17 for contraindications to TORS.) Unlike the majority of oropharyngeal cancers, which were once seen primarily in older men who were heavy smokers and drinkers, many oropharyngeal cancers diagnosed today are appearing in younger adults and are associated with the human papilloma virus (HPV).

“The epidemic of HPV-related throat cancers is forcing us to innovate and rethink how we used to do things,” said F. Chris Holsinger, MD, professor and chief of head and neck surgery at Stanford University, Palo Alto, Calif., noting that this group may account for as many as 20,000 patients with oropharyngeal cancers each year. “Diagnosis-and-radiate is really now a thing of the past,” he added.

It’s the younger age of these patients that’s driving the need to reduce the late effects of radiation-induced side effects, according to Dr. Holsinger. For these patients, the benefits of robotic surgery are unquestioned.

Greg Weinstein, MD, professor and vice chair of the department of otorhinolaryngology–head and neck surgery and co-chair of the Center for Head and Neck Cancer at the University of Pennsylvania Perelman School of Medicine in Philadelphia, who with his colleagues at the University of Pennsylvania in 2004 developed and later refined TORS, said that the development of TORS coincided with the rise in HPV-related oropharyngeal cancer. “It became evident in the early 2000s that high-dose chemoradiation, a technique developed for smoking-related squamous cell carcinoma, was leading to far too much toxicity in terms of damage to normal tissues and associated problems with radiation soft tissue damage and swallowing dysfunction for the healthy, younger population suffering from HPV-related cancer,” he said.

In 2009, the U.S. Food and Drug Administration (FDA) approved the use of the da Vinci Surgical System for TORS in patients with T1/T2 oropharyngeal cancer tumors as well as benign oropharyngeal lesions. Since then, evidence has shown that both oncologic and functional outcomes associated with TORS are positive, the latter due in part to the lower doses or the elimination of radiation therapy through TORS as the first-line treatment (Cancer Manag Res. 2018;10:839-846).

“Transoral robotic surgery results have shown good oncologic tumor control for selected oropharyngeal cancers, but the functional (swallowing) results, length of hospital stay, complication rates, and patient satisfaction for transoral robotic surgery have been shown to be superior to open surgical techniques for the same tumors, and often superior to chemotherapy and radiation therapy alone,” said Dr. Moore.