Robot-Assisted Surgery Feasible for Head and Neck Cancer

Roxanne Nelson

April 30, 2009

April 30, 2009 — Robot-assisted surgery appears feasible for resection of select upper aerodigestive tract tumors, according to a study published in the April issue of Archives of Otolaryngology — Head & Neck Surgery. Researchers found that the surgical robot had several advantages over traditional endoscopic and open approaches, such as 3-dimensional visualization, tremor filtration, and greater freedom of instrument movement.

"Robotic surgery in head and neck patients is still considered investigational," said senior author William Carroll, MD, associate professor of surgery and otolaryngology at the University of Alabama in Birmingham. "The procedure is under consideration by the [US Food and Drug Administration] for an approved indication."

The key message from this study is that this technology could prove useful for the surgical management of select patients with head and neck cancers. "We hope to see similar or improved cure rates with fewer side effects and quicker return to function," he told Medscape Oncology.

Since they were introduced a decade ago, robot-assisted surgeries have become widely accepted in the United States, especially for cardiac, gynecologic, and urologic procedures. The authors note that in 2007, about 60% of all radical prostatectomies were performed with robot assistance, and that robot-assisted cardiac and urological procedures can result in less blood loss and fewer complications than standard open approaches. In addition, the use of robots in cardiac surgery has had a favorable effect on operative time, length of stay in intensive care units, and length of overall inpatient care days, compared with open procedures.

For head and neck surgery, there are a number of theoretic advantages, explained Dr. Carroll. These include less morbidity than standard open surgery, shorter hospital stay, and the potential for less late toxicity from higher radiation doses.

"It also may allow targeted surgery and less radiation with better functional outcomes than existing chemoradiation protocols," he said. "This hypothesis is just being evaluated in a multicenter study."

For patients with upper aerodigestive tract tumors, surgery commonly requires a transcervical approach, including mandibulotomy and lip-splitting incision, and this can result in poor cosmesis and alterations in speech and the ability to swallow. Preclinical experimental studies, the authors write, have demonstrated the technical feasibility of transoral application of the robot, and subsequent clinical trials in patients have shown both the feasibility and the safety of robot-assisted resection of upper aerodigestive tract tumors.

Technically Feasible, Promising Results

In this study, Dr. Carroll and colleagues assessed the utility of using robot-assisted surgery for the excision of upper aerodigestive tract neoplasms and characterized patient and clinical predictors of successful robotic resection and functional outcome.

The prospective nonrandomized study involved 36 patients who presented with upper aerodigestive tract neoplasms from March 2007 to May 2008 at the University of Alabama. Within this cohort, 8 patients had undergone previous treatment for head and neck cancer.

Transoral resection using the robot was successfully performed in 29 patients (81%), and negative margins were obtained in all 29. Within this group, 11 patients (2 with oral-cavity lesions, 9 with oropharyngeal lesions) underwent simultaneous selective neck dissection, and 6 patients (5 with oropharyngeal lesions, 1 with laryngeal lesions) underwent selective neck dissection performed during a staged operation.

Patient blood loss ranged from 2 to 150 mL, and none of the patients required a transfusion. Nearly three quarters (n = 21, 72%) of the patients were able to be safely extubated before leaving the operating room. The mean hospital stay for patients who underwent robot-assisted resection was 2.9 days (range, 1 - 13 days); 1 patient who was hospitalized for 13 days had a second primary lesion that was detected intraoperatively, and opted to undergo a second surgery during this time period.

The researchers also noted that oral nutrition was tolerated by 16 of the 29 patients (55%) prior to discharge; in fact, oral nutrition was started on the day of surgery in 5 patients, on the first postoperative day in 10 patients, and on postoperative day 2 in 1 patient.

Postoperative complications that occurred within 30 days of the procedure included dehydration (n = 4), aspiration pneumonia (n = 1), delayed postoperative bleeding (n = 2), and airway edema requiring reintubation (n = 2). These complications, write the authors, were consistent with transoral excision by any method and not considered to be directly associated with the use of a surgical robot.

The researchers also observed that several factors were associated with successful robotic resection. These included lower T classification (P = .01) and edentulism (P = .07); factors associated with gastrostomy-tube dependence were advanced age (P = .02), tumor location in the larynx (P < .001), and higher T classification (P = .02).

Comparisons Not Yet Available

"Compared with open surgical procedures, the hospitalization is shorter and the return to function quicker," said Dr. Carroll. However, he emphasized that this comparison is based on historic information only.

"There was no direct group for comparison in this feasibility study," he said. "We don't want to overstate the functional benefits until we have better data. We are participating in a multicenter study comparing the outcomes of robotic resection [and] chemoradiation. Open surgery is so morbid that most patients are treated instead with chemoradiation currently."

Thus far, clinical guidelines have not been established for robot-assisted resection of head and neck tumors, but the technology is widely available. This project only assessed the feasibility of robot-assisted surgery in this population, conclude the researchers, and the study does not confirm oncologic or functional superiority to any standard method of treatment. More research is needed to define the indications, advantages, limitations, and outcomes of robotic surgery for patients with head and neck cancer.

The researchers have disclosed no relevant financial relationships.

Arch Otolaryngol Head Neck Surg. 2009;135:397-401. Abstract

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