Archives of Head and Neck Surgery
Archives of Head and Neck Surgery
Original Article Miscellaneous

Experience with the introduction of Transoral Robotic Surgery (TORS) at an oncologic hospital of the Brazilian Unified Public Health System (SUS)

Ruy Gomes Neto, Fernando Luiz Dias, Roberto Rêgo Monteiro de Araújo Lima, Ullyanov Bezerra Toscano, Emilson Queiroz de Freitas, Terence Pires de Farias, Izabella Costa Santos, Bernardo Cacciari Peryasssu, Bruno Alburquerque Sousa, Julia Mattos Levi

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Introduction: Transoral Robotic Surgery (TORS) has emerged for treatment of oropharyngeal and supraglottic larynx tumors due to the increase of oropharyngeal cancer caused by HPV. Objective: To demonstrate the oncological results achieved with this technology. Methods: The study was retrospective, with 132 cases of patients submitted to TORS at our institution – 101 men and 31 women; 114 malignant. 65 patients in the malignant group received TORS as first-line treatment, and 44, as salvage treatment; 5 patients were excluded due to another treatment option. 10.61% of patients presented complications – the most common was bleeding. However, only 3 patients had to be reoperated. The mean time of enteral tube use was 14.2 days, and the mean time of tracheotomy was 29.77 days. By the end of the study, all patients had been dependent on enteral tube and tracheotomy. The mean time of hospitalization was 4.5 days; the mean total time of surgery was 65.4 minutes – 19.6 for docking and set-up, and 45.8 for console operation. Results: Among a total of 132 surgeries, our complication rate was of 10.61%, whereas 3 patients required reoperation. All patients had the enteral catheter and tracheotomy removed. The overall survival of patients submitted to TORS as first-line treatment was 86.2%, and disease-free survival, 83.0%. Among patients undergoing robotic surgery as salvage therapy, the overall survival was of 51.5%, and disease-free survival in the same period, of 42.2%. Conclusion: TORS is safe and it is usually possible to obtain negative surgical margins for malignant oropharyngeal and supraglottic larynx tumors. Use of this treatment was successfully introduced in a public hospital in Brazil.


head and neck neoplasms; oropharynx; oropharyngeal neoplasms; robotics.


1. Kwoh YS, Hou J, Jonckheere EA, Hayati S. A robot with improved absolute positioning accuracy for CT guided stereotactic brain surgery. IEEE Trans Biomed Eng. 1988;35(2):153-60. PMid:3280462.

2. Davies B. A review of robotics in surgery. Proc Inst Mech Eng H. 2000;214(1):129-40. PMid:10718057.

3. Hockstein NG, Nolan JP, O’Malley BW Jr, Woo YJ. Robotic microlaryngeal surgery: a technical feasibility study using the daVinci surgical robot and an airway mannequin. Laryngoscope. 2005;115(5):780-5. PMid:15867639.

4. Weinstein GS, O’Malley BW Jr, Hockstein NG. Transoral robotic surgery: supraglottic laryngectomy in a canine model. Laryngoscope. 2005;115(7):1315-9. PMid:15995528.

5. O’Malley BW Jr, Weinstein GS, Snyder W, Hockstein NG. Transoral robotic surgery (TORS) for base of tongue neoplasms. Laryngoscope. 2006;116(8):1465-72. PMid:16885755.

6. Hockstein NG, O’Malley BW Jr, Weinstein GS. Assessment of intraoperative safety in transoral robotic surgery. Laryngoscope. 2006;116(2):165-8. PMid:16467698.

7. American Cancer Society. Cancer facts and figures 2009. Atlanta: American Cancer Society; 2009.

8. Machtay M, Perch S, Markiewicz D, Thaler E, Chalian A, Goldberg A, Kligerman M, Weinstein G. Combined surgery and postoperative radiotherapy for carcinoma of the base of radiotherapy for carcinoma of the base of tongue: analysis of treatment outcome and prognostic value of margin status. Head Neck. 1997;19(6):494-9.<494::AIDHED6>3.0.CO;2-U. PMid:9278757.

9. Moore EJ, Henstrom DK, Olsen KD, Kasperbauer JL, McGree ME. Transoral resection of tonsillar squamous cell carcinoma. Laryngoscope. 2009;119(3):508-15. PMid:19235742.

10. Boudreaux BA, Rosenthal EL, Magnuson JS, Newman JR, Desmond RA, Clemons L, Carroll WR. Robot-assisted surgery for upper aerodigestive tract neoplasms. Arch Otolaryngol Head Neck Surg. 2009;135(4):397-401. PMid:19380364.

11. Genden EM, Desai S, Sung CK. Transoral robotic surgery for the management of head and neck cancer: a preliminary experience. Head Neck. 2009;31(3):283-9. PMid:18972413.

12. Parsons JT, Mendenhall WM, Stringer SP, Amdur RJ, Hinerman RW, Villaret DB, Moore-Higgs GJ, Greene BD, Speer TW, Cassisi NJ, Million RR. Squamous cell carcinoma of the oropharynx: surgery, radiation therapy, or both. Cancer. 2002;94(11):2967-80. PMid:12115386.

13. Steiner W, Fierek O, Ambrosch P, Hommerich CP, Kron M. Transoral laser microsurgery for squamous cell carcinoma of the base of the tongue. Arch Otolaryngol Head Neck Surg. 2003;129(1):36-43. PMid:12525192.

14. Holsinger FC, McWhorter AJ, Ménard M, Garcia D, Laccourreye O. Transoral lateral oropharyngectomy for squamous cell carcinoma of the tonsillar region: I. Technique, complications, and functional results. Arch Otolaryngol Head Neck Surg. 2005;131(7):583-91. PMid:16027280.

15. Laccourreye O, Hans S, Ménard M, Garcia D, Brasnu D, Holsinger FC. Transoral lateral oropharyngectomy for squamous cell carcinoma of the tonsillar region, II: an analysis of the incidence, related variables, and consequences of local recurrence. Arch Otolaryngol Head Neck Surg. 2005;131(7):592-9. PMid:16027281.

16. Weinstein GS, O’Malley BW Jr, Magnuson JS, Carroll WR, Olsen KD, Daio L, Moore EJ, Holsinger FC. Transoral robotic surgery: a multicenter study to assess feasibility, safety, and surgical margins. Laryngoscope. 2012;122(8):1701-7. PMid:22752997.

17. Moore EJ, Olsen KD, Kasperbauer JL. Transoral robotic surgery for oropharyngeal squamous cell carcinoma: a prospective study of feasibility and functional outcomes. Laryngoscope. 2009;119(11):2156-64. PMid:19824067.

18. Grant DG, Salassa JR, Hinni ML, Pearson BW, Perry WC. Carcinoma of the tongue base treated by transoral laser microsurgery, part one: untreated tumors, a prospective analysis of oncologic and functional outcomes. Laryngoscope. 2006;116(12):2150-5. f0. PMid:17146388.

19. Weinstein GS, Quon H, Newman HJ, Chalian JA, Malloy K, Lin A, Desai A, Livolsi VA, Montone KT, Cohen KR, O’Malley BW. Transoral robotic surgery alone for oropharyngeal cancer: an analysis of local control. Arch Otolaryngol Head Neck Surg. 2012;138(7):628-34. PMid:22801885.

20. Kelly K, Johnson-Obaseki S, Lumingu J, Corsten M. Oncologic, functional and surgical outcomes of primary Transoral Robotic Surgery for early squamous cell cancer of the oropharynx: a systematic review. Oral Oncol. 2014;50(8):696-703. PMid:24917389.

21. Nichols AC, Kneuertz PJ, Deschler DG, Lin DT, Emerick KS, Clark JR, Busse PW, Rocco JW. Surgical salvage of the oropharynx after failure of organ-sparing therapy. Head Neck. 2011;33(4):516-24. PMid:20652974.

22. White H, Ford S, Bush B, Holsinger FC, Moore E, Ghanem T, Carroll W, Rosenthal E, Sweeny L, Magnuson JS. Salvage surgery for recurrent cancers of the oropharynx: comparing TORS with standard open surgical approaches. JAMA Otolaryngol Head Neck Surg. 2013;139(8):773-8. PMid:23949352.

23. Machtay M, Moughan J, Trotti A, Garden AS, Weber RS, Cooper JS, Forastiere A, Ang KK. Factors associated with severe late toxicity after concurrent chemoradiation for locally advanced head and neck cancer: an RTOG analysis. J Clin Oncol. 2008;26(21):3582-9. PMid:18559875.

24. Olsen SM, Moore EJ, Laborde RR, Garcia JJ, Janus JR, Price DL, Olsen KD. Transoral surgery alone for human-papillomavirus-associated oropharyngeal squamous cell carcinoma. Ear Nose Throat J. 2013;92(2):76-83. PMid:23460216.

25. Mercante G, Ruscito P, Pellini R, Cristalli G, Spriano G. Transoral robotic surgery (TORS) for tongue base tumours. Acta Otorhinolaryngol Ital. 2013;33(4):230-5. PMid:24043909.

26. Sinclair CF, McColloch NL, Carroll WR, Rosenthal EL, Desmond RA, Magnuson JS. Patient-perceived and objective functional outcomes following transoral robotic surgery for early oropharyngeal carcinoma. Arch Otolaryngol Head Neck Surg. 2011;137(11):1112-6. PMid:22106235.

27. Almeida JR, Li R, Magnuson JS, Smith RV, Moore E, Lawson G, Remacle M, Ganly I, Kraus DH, Teng MS, Miles BA, White H, Duvvuri U, Ferris RL, Mehta V, Kiyosaki K, Damrose EJ, Wang SJ, Kupferman ME, Koh YW, Genden EM, Holsinger FC. Oncologic outcomes after transoral robotic surgery: a multi-institutional study. JAMA Otolaryngol Head Neck Surg. 2015;141(12):1043-51. PMid:26402479.

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