Transoral Robotic Surgery for Head and Neck Cancer: Advances and Residual Knowledge Gaps

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TL;DR

Transoral robotic surgery (TORS) is a minimally invasive approach for head and neck cancer that offers comparable oncologic outcomes to conventional treatments, with potential benefits in functional recovery. Its use is expanding to oropharyngeal, laryngeal, hypopharyngeal, and parapharyngeal tumors, but evidence gaps remain regarding cost-effectiveness, long-term functional outcomes, and optimal patient selection. The review emphasizes that TORS should be applied cautiously, guided by high-level evidence to ensure safety and efficacy.

Full summary

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**Background:** Head and neck cancer (HNC) is the eighth most common cancer worldwide, with approximately 900,000 cases yearly. Traditional treatments include surgery, radiotherapy, and chemotherapy, but these can impair quality of life. Transoral robotic surgery (TORS) using the Da Vinci system gained FDA approval in 2009 for T1–T2 malignancies of the oral cavity, oropharynx, and larynx. Its wristed instruments and 3D visualization improve surgical access to remote areas. This narrative review assesses the current evidence-based role of TORS in HNC and identifies knowledge gaps.

**Methods:** The authors conducted a narrative review of the literature, summarizing evidence on TORS for various HNC subsites, including oropharyngeal, laryngeal, hypopharyngeal, and parapharyngeal cancers, as well as carcinomas of unknown primary. They evaluated preoperative considerations, eligibility criteria, oncologic outcomes, functional outcomes, complications, and technological advances.

**Key Results:** For oropharyngeal squamous cell carcinoma (SCC), TORS is primarily used for T1–T2 tumors, with selected T3–T4a cases possible but with higher positive margin rates (13% for T1, 17.1% for T2, 28.2% for T3, 45.9% for T4a). A multicenter cohort of 410 patients reported 3-year overall survival (OS) of 87.1% and disease-specific survival (DSS) of 94.5%. The ORATOR trial showed comparable swallowing-related quality of life between TORS + neck dissection and definitive (chemo)radiotherapy, though trismus was more common in the TORS arm (26% vs. 3%). For supraglottic laryngectomy, a systematic review of 422 patients found 2-year local control >94.3% and OS ranging 66.7–88.0%. Positive margins occurred in 5.4% of cases. For hypopharyngeal SCC, a study of 57 patients reported 4-year OS of 66% and DFS of 50%. Postoperative hemorrhage is the most dreaded complication, occurring in 1.5–18.5% of cases, with major bleeding requiring intervention in 2.9%. Prophylactic ligation of external carotid artery branches reduces major hemorrhage risk for oropharyngectomy but not for supraglottic laryngectomy. Airway complications occur in 4.92% of supraglottic laryngectomies, with emergent tracheostomy in 3.38%.

**Clinical Implications:** TORS offers a minimally invasive alternative for selected HNC patients, with oncologic outcomes comparable to standard treatments and potential functional benefits. However, evidence gaps remain, including cost-effectiveness, long-term functional outcomes, and optimal patient selection criteria. The review highlights the need for high-level evidence, particularly randomized controlled trials, to guide clinical practice. Technological advances, such as the single-port Da Vinci SP system, may expand indications and improve outcomes. Surgeons should consider patient-specific factors, including tumor extension, surgical exposure, and comorbidities, when selecting candidates for TORS.