OBJECTIVE: Robotic transoral mucosectomy of the base of tongue was introduced as a diagnostic procedure in patients treated for head and neck cancer with unknown primary (CUP), increasing the identification rate of the primary tumour. For the treatment of CUP, a considerable percentage of patients require adjuvant (chemo)radiation. The aim of this study was to investigate swallowing outcomes among CUP patients after TORS and adjuvant treatment.
METHODS: A systematic review was carried out on studies investigating the impact of TORS and adjuvant treatment on swallowing-related outcomes among CUP patients In addition, a cross-sectional study was carried out on swallowing problems (measured using the SWAL-QOL questionnaire) among CUP patients in routine care who visited the outpatient clinic 1-5 years after TORS and adjuvant treatment.
RESULTS: The systematic review (6 studies; n = 98) showed that most patients returned to a full oral diet. The cross-sectional study (n = 12) showed that all patients were able to return to a full oral diet, nevertheless, 50% reported swallowing problems in daily life (SWAL-QOL total score ≥14).
CONCLUSIONS: Although after TORS and adjuvant treatment for CUP a full oral diet can be resumed, patients still experience problems with eating and drinking in daily life.

BACKGROUND: Head and neck carcinoma of unknown primary (CUP) represents a challenging diagnostic process when standard work-up fails to identify the primary tumour site. The aim of this systematic review and meta-analysis was to evaluate the diagnostic utility and complication profile of transoral robotic surgery (TORS) tongue base mucosectomy (TBM) in the management of CUP.
METHODS: An electronic database search was performed in the EMBASE, MEDLINE, PubMed and Cochrane databases. A meta-analysis of proportions was performed to obtain an estimate of the overall proportion for the detection and complication rates.
RESULTS: Nine studies representing 235 patients with CUP who had TORS TBM were included in the final analysis. The overall pooled tumour detection rate was 66.2% [95% confidence interval (CI) 56.1-75.8]. The incidence of tumour detection in human papilloma virus (HPV)-positive cases (81.5%, 95% CI 60.8-96.4) was significantly higher than HPV-negative cases (2.3%, 95% CI 0.00-45.7). Weighted overall complication rate was 11.4% (95% CI 7.2-16.2). The majority were grade I or II (80%) according to the Clavien-Dindo classification.
CONCLUSIONS: This meta-analysis suggests TORS to be safe and effective in localising the primary tumour site in patients with CUP. While the current data supports the use of TORS in patients who are HPV positive, larger numbers of HPV-negative cases are required to determine the true diagnostic effect with TORS before any valid conclusions can be inferred in this particular subgroup. Further research should focus on high quality prospective trials with stringent methodological work-up to minimise heterogeneity and allow for more accurate statistical analysis.

Transoral robotic surgery (TORS) is a minimally invasive surgical technique that has recently gained popularity. This involves the use of a robotic system to access and operate on hard-to-reach areas of the body, such as the base of tongue and pharynx. General anesthesia is the technique of choice in TORS as this procedure poses unique challenges due to the patient\'s airway anatomy, the need for precise surgical movements, and the potential for postoperative complications. Awake fiberoptic intubation (AFOI) is the gold standard for an anticipated difficult airway. This case report describes the anesthetic management for a patient undergoing TORS for a tongue base mass.

OBJECTIVE: Continuum manipulators (CMs) show great potential in transoral laryngeal surgery due to their flexibility. However, CMs for transoral surgery face several issues: large size, which reduces practicality; intersegment coupling, which causes undesired deflection; and a lack of versatility that limits their applicability across different patient groups.
METHODS: This work combines a rod-driven proximal segment and a cable-driven distal segment to achieve piecewise stiffness, alleviating the issue of intersegment coupling. A rigid constraint tube is integrated into the proximal segment to diversify its bending behavior. Preliminary experiments are conducted to validate the design concept.
RESULTS: The proposed CM has an overall diameter of only 6.5 mm. The proximal segment can achieve a 90° bending with various curvatures. At the working configuration, the coupling error between the proximal segment and the distal segment is less than 1 mm. The effectiveness of the proposed CM is successfully validated using a human model.
CONCLUSIONS: The proposed continuum manipulator possesses the desirable characteristics of small size, low coupling, and high versatility, indicating its great potentialities for the diagnosis and treatment of laryngeal lesion.

We present a cohort review of TORS resection for HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) and its associated oncological outcomes spanning a 10-year period. A retrospective case series review was performed of patients undergoing primary surgical treatment for HPV-associated OPSCC through the St. Vincent\'s Head and Neck Cancer service from 2011 to 2022. The primary outcomes were to investigate complete resection of the primary tumour, rates of recurrence, and survival analysis. Secondary outcomes included complications, rates of adjuvant therapy, sites of recurrence and rates of percutaneous endoscopic gastrostomy (PEG). 184 patients underwent TORS-based therapy with neck dissection, and guideline-directed adjuvant therapy for HPV-associated OPSCC. Our median follow-up was 46 months. The positive margin rate on final histopathology analysis was 10.9%. Adjuvant therapy was indicated in 85 patients (46%). The local recurrence rate was 10.9% with the majority (80%) of patients recurring in the first 3 years since treatment. The disease-specific survival at 3 years was 98.6% and at 5 years was 94.4%. The 3-year and 5-year OS for the cohort was 96.7% and 92.5%, respectively. The presence of extranodal extension and positive margins were associated with increased risk of recurrence, whereas adjuvant therapy was found to be a protective factor for both overall recurrence and survival. Major complications occurred in 12 patients (6.5%), resulting in one death. This study has demonstrated that primary surgical therapy for HPV-associated OPSCC is a safe and effective treatment modality with low local recurrence and complication rates, and overall survival benefits.

This study aimed to develop and validate a Computed Tomography (CT)/Magnetic Resonance Imaging (MRI)-compatible polymer oral retractor system to enable intraoperative image guidance for transoral robotic surgery (TORS). The retractor was designed based on standard-of-care metallic retractors and 3D (three-dimensional) printed with carbon fiber composite and nylon. The system was comprehensively evaluated in bench-top and cadaveric experiments in terms of its ability to enable intraoperative CT/MR images during TORS, functionality including surgical exposure and working volume, usability, compatibility with da Vinci surgical systems, feasibility for disinfection or sterilization, and robustness over an extended period of time. The polymer retractor system enabled the acquisition of high-resolution and artifact-free intraoperative CT/MR images during TORS. With an inter-incisive distance of 42.55 mm and a working volume of 200.09 cm3, it provided surgical exposure comparable to standard-of-care metallic retractors. The system proved intuitive and compatible with da Vinci S, Xi, and Single Port systems, enabling successful mock surgical tasks performed by surgeons and residents. The retractor components could be effectively disinfected or sterilized for clinical use without significant compromise in material strength, with STERRAD considered the optimal method. Throughout a 2 h mock procedure, the retractor system showed minimal displacements (<1.5 mm) due to surrounding tissue deformation, with insignificant device deformation. The 3D-printed polymer retractor system successfully enabled artifact-free intraoperative CT/MR imaging in TORS for the first time and demonstrated feasibility for clinical use. This breakthrough opens the door to surgical navigation with intraoperative image guidance in TORS, offering the potential to significantly improve surgical outcomes and patients\' quality of life.

BACKGROUND: Transoral Robotic Surgery (TORS) and radiotherapy are considered oncologically equivalent primary treatment options for early-stage HPV-positive oropharyngeal squamous cell carcinoma (OPSCC). Quality of Life (QoL) and Patient Reported Outcome Measures (PROMs) are therefore imperative in supporting clinical decision-making and optimising patient-centred care. The aim of this article is to evaluate how these primary treatment modalities compare in terms of QoL.
METHODS: Systematic review and meta-analysis of studies comparing primary TORS and primary radiotherapy for OPSCC using validated QoL tools. Swallowing and global QoL were the primary endpoints with secondary endpoints including all other QoL domains. An inverse variance random-effects model was employed to calculate the weighted estimate of the treatment effects across trials.
RESULTS: A total of six studies collectively reporting on 555 patients were included (n = 236 TORS and n = 319 radiotherapy). Meta-analysis showed no significant difference for swallowing (mean difference = -0.24, p = 0.89) and global QoL (mean difference = 4.55, p = 0.14). For the remaining QoL domains (neck/shoulder impairment, neurotoxicity, voice, xerostomia, speech, and distress), the scarcity of data did not permit meta-analysis. However, the existing data showed no significant difference for any except for xerostomia where TORS appears favourable in the sole study reporting on this.
CONCLUSIONS: TORS and radiotherapy appear to be comparable primary treatment options for early stage OPSCC when it comes to QoL. However, a substantial proportion of patients in the TORS group received adjuvant (chemo)radiotherapy rendering it difficult to establish the \'true\' QoL outcomes following surgery alone. There are also minimal studies reporting QoL outcomes beyond swallowing and global QoL. Further research is therefore needed, including more randomised trials adequately powered to detect differences in QoL outcomes.

OBJECTIVE: Transoral robotic surgery (TORS) is a challenging procedure due to its small workspace and complex anatomy. Ultrasound (US) image guidance has the potential to improve surgical outcomes, but an appropriate method for US probe manipulation has not been defined. This study evaluates using an additional robotic (4th) arm on the da Vinci Surgical System to perform extracorporeal US scanning for image guidance in TORS.
METHODS: A stereoscopic imaging system and da Vinci-compatible US probe attachment were developed to enable control of the extracorporeal US probe from the surgeon console. The prototype was compared to freehand US by nine operators in three tasks on a healthy volunteer: (1) identification of the common carotid artery, (2) carotid artery scanning, and (3) identification of the submandibular gland. Operator workload and user experience were evaluated using a questionnaire.
RESULTS: The robotic US tasks took longer than freehand US tasks (2.09x longer; p = 0.001 ) and had higher operator workload (2.12x higher; p = 0.004 ). However, operator-rated performance was closer (avg robotic/avg freehand = 0.66; p = 0.017 ), and scanning performance measured by MRI-US average Hausdorff distance provided no statistically significant difference.
CONCLUSIONS: Extracorporeal US scanning for intraoperative US image guidance is a convenient approach for providing the surgeon direct control over the US image plane during TORS, with little modification to the existing operating room workflow. Although more time-consuming and higher operator workload, several methods have been identified to address these limitations.

BACKGROUND: Transoral surgical resectability (TOS) is a prognostic factor for patients with HPV+ T1-2 oropharyngeal squamous cell carcinoma (OPSCC) disease undergoing radiotherapy (RT), but it is unclear whether this holds for HPV-negative (HPV-) patients. We aimed to compare outcomes of potential TOS-candidates vs. non-TOS candidates, among patients who underwent RT/CRT for early T-stage HPV- OPSCC.
METHODS: For patients treated with RT/CRT for early T-stage HPV-negative OPSCC between 2014 and 2021, pretreatment imaging was reviewed by four head-and-neck surgeons, masked to clinical outcomes, to assess primary-site suitability for TOS. Extracapsular extension (ECE) was assessed by a head-and-neck neuroradiologist. We compared outcomes based on surgical resectability relating to: (1) the primary site tumor alone, and (2) the primary site plus the absence/presence of ECE (overall assessment). Kaplan-Meier curves for overall survival (OS), disease-specific survival (DSS), and progression-free survival (PFS) were compared using the log-rank test.
RESULTS: Seventy patients were included in the analysis. The primary site was TOS-favorable in 46/70 (66%). Based on the overall assessment, 41/70 (58.6%) were TOS-favorable. The 3-year OS, DSS and PFS for primary site TOS-favorable versus unfavorable were OS: 76.9% versus 37.4%; DSS: 78.1% versus 46.2%, PFS: 69.9% versus 41.3%, (log-rank test = 0.01, 0.03, 0.04; respectively). Additionally, patients with an overall assessment of TOS favorability demonstrated better survival outcomes compared with TOS-unfavorable patients (OS: 77.3% vs. 46.2%; DSS: 78.2% vs. 56.5%, PFS: 72.3% vs. 42.1%, log-rank test = 0.01, 0.04, 0.01; respectively).
CONCLUSIONS: Patients with TOS-favorable HPV-negative early T-stage OPSCC have superior survival outcomes than TOS-unfavorable patients.

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