Transoral Robotic Surgery using the Thulium-YAG Laser: A Prospective Study
Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, 200 First Street SW, Rochester, MN 55905, USA. Archives of otolaryngology--head & neck surgery
(Impact Factor: 2.33).
02/2012; 138(2):158-66. DOI: 10.1001/archoto.2011.1199
To compare thulium:YAG laser-assisted transoral robotic surgery (TY:TORS) and conventional electrocautery-equipped TORS (EC:TORS) in patients undergoing transoral resection of upper aerodigestive tract malignant neoplasms.
Prospective matched cohort study.
Tertiary academic referral center.
Fifteen patients undergoing TY:TORS were matched on the basis of tumor site, clinical T stage, sex, and age with 30 control subjects undergoing EC:TORS.
The primary outcome was a comparison between the feasibility of TY:TORS compared with EC:TORS. The secondary outcome was a comparison between the safety and functional outcome of TY:TORS compared with EC:TORS in patients undergoing resection of upper aerodigestive tract malignant neoplasms.
All the tumors underwent complete excision with negative margins. Estimated blood loss was minimal (<150 mL) for 87% of TY:TORS patients (13 of 15) and 63% of EC:TORS controls (19 or 30). Intraoperative pharyngotomy was reported in 8% of TY:TORS patients (1 of 13) and 42% of EC:TORS controls (11 of 30) (P = .03). Postoperative pain was greater in EC:TORS compared with TY:TORS (P = .02). No statistically significant differences were noted in hemostasis, postoperative bleeding rates, or other complications.
Compared with EC:TORS, TY:TORS seems feasible and safe. In addition, TY:TORS resulted in fewer intraoperative pharyngotomies and less postoperative pain than did EC:TORS, which may be because of decreased collateral thermal damage, improved visualization, and finer cutting using the thulium laser.
Available from: Raul Pellini
- "One of the objectives of this study is to evaluate whether acceptable overall functional outcomes in case of tongue base tumours are obtained using TORS. Most reports describe the use of TORS in radical tonsillectomy 5
11 and partial laryngectomy 12. Few authors have focused on tongue base neoplasms, most likely due to the difficulty to recruit eligible cases 6
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ABSTRACT: In recent years, transoral robotic surgery (TORS) has been used for the removal of pharyngeal and laryngeal cancers with the objective to improve functional and aesthetic outcomes without worsening the survival. This prospective single-centre cohort study described TORS in selected tumours of the tongue base in order to assess safety, efficacy and functional outcome of the procedure. From October 2010 to February 2012, TORS was performed in 13 consecutive patients affected by T1-T2 tumours of the base of the tongue. This procedure was applicable in all cases. The clinical stage demonstrated 8 T1 tumours and 5 T2 tumours. Neck node metastases were clinically evident in 6 cases (7 N0, 1 N1, 4 N2b and 1 N2c). The final pathology report confirmed malignancy in all cases (11 squamous cell carcinoma and 2 mucoepidermoid carcinoma). Negative-margin resections were obtained in all cases but one with close margins. Synchronous lymph node neck dissections were performed in 7 cases (6 monolateral, 1 bilateral). Patients underwent temporary tracheostomies for a mean time of 6 days. A naso-gastric feeding tube was positioned in 10/13 (76.9%) patients for a mean time of 7.5 days. The average time to carry out the TORS procedure was 95 min (set-up time 25 min; TORS 70 min). No deaths occurred. Surgical complications were observed in 4 cases (postoperative bleedings in 3 cases and intraoperative anaphylactic shock in 1 case). Median hospital stay was 9 days. All patients had good functional outcomes. Adjuvant treatment was indicated in 5/13 cases (35.4%). TORS represents a good tool for staging and treating neoplasm of the base of the tongue. The transoral removal is safe and can radically remove limited oropharyngeal tumours of the tongue base with good functional outcomes. The operating costs can be relatively high but they are related to the number of procedures per year, although the advantages to patients seem to justify the procedure. TORS can represent the definitive treatment in selected T1-T2 cases of base of the tongue tumours without adverse features and allow the possibility for the deintensification of adjuvant treatments.
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Within the last years transoral robotic surgery (TORS) has gained importance in the resection of head and neck tumors, especially in North America. In contrast only few groups in Germany have studied this system so far. In respect to potential future developments in surgical robotic systems it seems reasonable to deal with this system.
Material and methods:
17 patients with tumors of the oropharynx, the base of tongue or the supraglottic area were treated with TORS in our clinic, between May 2011 and June 2012. In a prospective study we analyzed the exposure, visualization and resectability of these tumors using the da Vinci-system. In addition, set up and operation time, as well as costs were evaluated.
All neoplasms of the oropharynx (n=9) and the tongue base (n=5) could be well exposed, visualized and resected. In the supraglottic area (n=3) 2 tumors could not be properly exposed and therefore resection was converted to a transoral microscopic laser approach. Resection with the cautery spatula tip or the Tm:YAG-laser fibre caused wide coagulation zones, but resulted in good hemostasis. The costs for the medical equipment and the leasing rate were 6280 € per case at our institution.
Tumors of the tongue base and oropharynx could be easily visualized with help of the da Vinci-system. The resection of supraglottic tumors can be challenging, due to the arrangement of the robotic-arms and the narrow anatomic conditions. Despite its high costs, the da Vinci-system is a potentially interesting supplementation to existing surgical techniques.
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