|LETTER TO EDITOR
|Year : 2016 | Volume
| Issue : 2 | Page : 86-88
Robotic surgery in oropharyngeal cancers: A brief narrative
Department of Cancer Epidemiology and Biostatistics, Dr. B. Borooah Cancer Institute; Department of Otolaryngology - Head and Neck Surgery, Max Life Medicos, Guwahati, Assam, India
|Date of Web Publication||20-Dec-2016|
Room 2, OPD Block, Dr. B. Borooah Cancer Institute, Gopinath Nagar, Guwahati - 781 016, Assam
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Krishnatreya M. Robotic surgery in oropharyngeal cancers: A brief narrative. J Head Neck Physicians Surg 2016;4:86-8
The first robotic surgery was performed in the year 1985 by a team of neurosurgeons in the US to improve computed tomography-guided stereotactic brain biopsies. Despite its growing popularity as a tool of surgical precision, the use of this new technology was limited in the head and neck region till the recent past. The ports and early instruments were designed for use in cavities, such as the abdomen or the pelvis. The instruments were bulky and not well designed for the anatomic constraints of the head and neck. With the passage of time, newer instruments were developed to adapt to operating in the head and neck region or for otolaryngologic use in particular. It was not until 2005 that the first robotic surgery in the head and neck region was performed. McLeod and Melder performed the first trans-oral robotic-assisted procedure when they used the da Vinci surgical robot to excise a vallecular cyst. 
One of the difficult regions to perform surgery in the head and neck anatomical region is the oropharynx. This is mostly due to its difficult surgical access and maneuverability of instruments in that area. Incidentally, in India, the relative proportions of oropharyngeal cancers among all cancer sites are high. Cancers of the tonsil and base of tongue constitute more than 80% of oropharyngeal cancers. One of the major risk factors for oropharyngeal cancers is human papillomavirus (HPV) infection, and HPV-related oropharyngeal cancers are more common in younger patients and are more likely to occur in nonsmokers and nondrinkers. A study from the northeastern part of India has shown that alcohol, tobacco, and high-risk HPV infection act synergistically or complement each other in the process of head and neck cancer development including oropharyngeal cancers.  The best part, however, is HPV-positive tumors have better survival than negative ones.  Management of oropharyngeal cancers generally involves a combination of radiation and chemotherapy. Moreover, radiation with or without chemotherapy has remained as the main modality in early and late oropharyngeal cancers. Traditional surgical procedure for oropharyngeal cancers is seldom performed in our settings. This is mainly because of very morbid surgical incisions and these surgical procedures require extensive soft tissue excision to remove even smaller tumors. Furthermore with traditional surgical approaches, the cure rates were low, complication rates were high, and quality of life was worse. In 2007, it was Weinstein et al. who recognized the potential for trans-oral robotic surgery (TORS) as an oncologically sound and function-preserving tool for treating oropharyngeal cancers.  The introduction of TORS has allowed an increase in the ability to manage oropharyngeal cancers through primary minimally invasive surgery.  This has opened a new vista in the management of this group of head and neck cancers. TORS was subsequently approved by the US Food and Drug Administration in January 2010 for removal of benign and malignant tumors of oropharynx, hypopharynx, larynx, and thyroids.
The advantages of using TORS to manage oropharyngeal cancers are better oncologic, technical, and functional outcomes. Primary surgical excision with TORS, as opposed to primary chemoradiation, allows the tumors to be accurately staged, as surgical staging differs from clinical staging in about 40% of cases, which can subsequently affect further management and the need for adjuvant therapy in early oropharyngeal cancers.  In addition, TORS uses camera, which allows visualization of an anatomic location that is typically poorly visualized using conventional headlights or lamps. In TORS, the operating field is visualized in three dimensions with ten times magnification. The robotic arms also filter tremors, allowing precision with microscopic movements. Compared to endoscopic tools, the robotic instruments also have more freedom of articulation and eliminate the fulcrum effect.  The disadvantages are lack of tactile feedback, high costs, and prolonged anesthesia, to name a few.
Retrospective data have shown that oncologic outcomes are not being compromised when patients with oropharyngeal cancers are treated with TORS.  TORS is a rapidly evolving technique in the management of oropharyngeal cancers, especially base of tongue and tonsillar cancers. In the backdrop of the rising prevalence of HPV infections in oropharyngeal cancers in India, the role of TORS seems to assume greater significance in not too distant future. Olsen et al. found that TORS alone, without adjuvant therapy, may be an adequate treatment modality for HPV-positive oropharyngeal cancers.  In the absence of randomized controlled studies comparing TORS alone to chemoradiation in the management of HPV-positive cancers,  it may be too early to draw far-reaching conclusions on better efficacy of TORS in the treatment of oropharyngeal cancers. So far, TORS has definitely shown better efficacy by lesser blood loss during surgery, no visible scarring or disfigurement in primary surgeries for oropharyngeal cancers, and early return of normal speech and swallowing compared to traditional open surgery. Upfront TORS for early oropharyngeal cancers is a promising area for head and neck surgeons who are willing to devote the time and energy to take this up.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
McLeod IK, Melder PC. Da Vinci robot-assisted excision of a vallecular cyst: A case report. Ear Nose Throat J 2005;84:170-2.
Kumar R, Rai AK, Das D, Das R, Kumar RS, Sarma A, et al.
Alcohol and tobacco increases risk of high risk HPV infection in head and neck cancer patients: Study from North-East region of India. PLoS One 2015;10:e0140700.
Joseph AW, D'Souza G. Epidemiology of human papillomavirus-related head and neck cancer. Otolaryngol Clin North Am 2012;45:739-64.
Weinstein GS, O'Malley BW Jr., Snyder W, Sherman E, Quon H. Transoral robotic surgery: Radical tonsillectomy. Arch Otolaryngol Head Neck Surg 2007;133:1220-6.
Li RJ, Richmon JD. Transoral endoscopic surgery: New surgical techniques for oropharyngeal cancer. Otolaryngol Clin North Am 2012;45:823-44.
Walvekar RR, Li RJ, Gooding WE, Gibson MK, Heron D, Johnson JT, et al.
Role of surgery in limited (T1-2, N0-1) cancers of the oropharynx. Laryngoscope 2008;118:2129-34.
Oliveira CM, Nguyen HT, Ferraz AR, Watters K, Rosman B, Rahbar R. Robotic surgery in otolaryngology and head and neck surgery: A review. Minim Invasive Surg 2012;2012:286563.
Ford SE, Brandwein-Gensler M, Carroll WR, Rosenthal EL, Magnuson JS. Transoral robotic versus open surgical approaches to oropharyngeal squamous cell carcinoma by human papillomavirus status. Otolaryngol Head Neck Surg 2014;151:606-11.
Olsen SM, Moore EJ, Laborde RR, Garcia JJ, Janus JR, Price DL, et al.
Transoral surgery alone for human-papillomavirus-associated oropharyngeal squamous cell carcinoma. Ear Nose Throat J 2013;92:76-83.
Shah S, Goldenberg D. Robotic surgery for oropharyngeal cancer. Rambam Maimonides Med J 2014;5:e0014.