Can robotic thyroidectomy be performed safely in thyroid carcinoma patients?

Transoral robotic thyroidectomy: Lessons learned from consecutive series of 1,000 patients

BACKGROUND

Transoral robotic thyroidectomy has gained popularity as a promising approach for thyroid surgery owing to its improved cosmetic outcomes. The objective of this retrospective study was to describe the surgical and safety outcomes of 1,000 consecutive transoral robotic thyroidectomy cases.

METHODS

1,000 consecutive patients who underwent transoral robotic thyroidectomy for thyroid disease were reviewed at a large metropolitan tertiary hospital (Seoul, Korea) between September 2012 and March 2022.

RESULTS

The study comprised 1,000 patients (815 women), with 891 cancer cases. Lobectomy was the most common procedure (89.4%), followed by total thyroidectomy (9.8%) and isthmusectomy (0.8%), and their respective mean total operative times were 173.8 ± 36.2, 236.8 ± 50.5, and 107.5 ± 19.8 minutes. An obvious learning curve was noted. The respective postoperative pain scores on postoperative days 0, 1, and 2 were 4.6 ± 1.3, 3.1 ± 0.8, and 2.5 ± 0.8. The mean postoperative hospital stay duration was 2.6 ± 0.9 days. Complications occurred in 3.6% of cases, including oral wound infection, skin flap burn, bleeding, chyle leakage, transient and permanent mental nerve injury, and transient and permanent recurrent laryngeal nerve injury. Transient hypoparathyroidism occurred in 4.1% of total thyroidectomy cases. Thirty-seven patients (4.2%) underwent additional radioactive iodine therapy. The median follow-up period was 39 months, and there were no cases of recurrence.

CONCLUSIONS

Under the expertise of an experienced surgeon, transoral robotic thyroidectomy results in favorable cosmetic outcomes, tolerable postoperative pain, and acceptable complication rates in carefully selected patients.

Transoral endoscopic thyroidectomy vestibular approach vs. transoral robotic thyroidectomy: systematic review and meta-analysis

This study aimed to conduct a systematic review and meta-analysis to compare the surgical outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transoral robotic thyroidectomy (TORT). We carried out a systematic literature search of PubMed, Web of Science, Cochrane Library, and Google Scholar on studies comparing TOETVA and TORT until January 2023. A total of five articles published between 2018 and 2023 that matched the inclusion criteria were included in the systematic review and meta-analysis. The studies included 641 patients (394 TOETVA patients and 247 TORT patients). TOETVA group was associated with a significantly shorter operative time with a mean difference of 60.08 min [95% confidence interval (CI) - 83.95 to - 36.20; P < 0.001). Transient recurrent laryngeal nerve palsy was more common in the TOETVA group than the TORT group (OR 3.00; 95% CI 1.14-7.88; P = 0.03). There were no significant differences in the other outcomes, including the length of hospital stay, postoperative pain scores, number of central lymph nodes retrieved, permanent recurrent laryngeal nerve injuries, and transient and permanent hypoparathyroidism. The TOETVA group was associated with shorter operative time and more transient recurrent laryngeal nerve palsy than the TORT group. Each procedure has its benefits and limitations. The surgical approach should be determined by considering the patient's characteristics and preferences, as well as the surgeon's preference and area of expertise.

Bilateral axillo-breast approach robotic thyroidectomy (BABA-RT) versus transoral robotic thyroidectomy (TORT): a systematic review and meta-analysis

The aim of this study is to conduct a systematic review and meta-analysis of all comparative studies that evaluated the surgical outcomes between bilateral axillo-breast approach-robotic thyroidectomy (BABA-RT) and transoral robotic thyroidectomy (TORT). The Cochrane Central Register of Controlled Trials, PubMed, Scopus, and Web of Science databases were screened until July 2022. The Risk of Bias in Non-Randomized Studies for Interventions (ROBINS-I) tool was used to evaluate study quality. The data were summarized as mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI) in a fixed-effects or random-effects model. Five comparative observational studies met the inclusion criteria comprising 923 patients (TORT = 408 and BABA-RT = 515). The study quality varied and included low (n = 4) and moderate (n = 1) risk of bias. There was no significant difference between both groups regarding the mean operative time (MD = 19.98 min, 95% CI [-11.33, 51.28], p = 0.21), mean hospital stay (MD = -0.14 days, 95% CI [-0.66, 0.38], p = 0.60), mean number of retrieved lymph nodes (MD = 0.42, 95% CI [-0.16, 0.99], p = 0.16), and rate of recurrent laryngeal nerve injury (RR = 0.39, 95% CI [0.13, 1.19], p = 0.10). However, the TORT group had significantly reduced mean postoperative pain score (MD = -0.39, 95% CI [-0.51, -0.26], p < 0.001) and lower rate of hypocalcemia (RR = 0.08, 95% CI [0.02, 0.26], p < 0.001) than the BABA-RT group. TORT and BABA-RT have comparable surgical outcomes. Both methods are largely safe and effective when patients are carefully chosen. However, TORT appears to offer better results regarding postoperative pain and hypocalcemia. Further clinical trials with extended follow-up periods are needed to confirm our findings.

Comparison of surgical completeness in patients operated on conventional open total thyroidectomy (OT) or trans-axillary robot-assisted total thyroidectomy (RATT) by a single axillary approach

Trans-axillary robot-assisted total thyroidectomy (RATT) is nowadays worldwide accepted but the completeness obtained by RATT is still debated. The Aim of this study was to compare the completeness and safety of RATT with conventional open thyroidectomy (OT). We enrolled patients with nontoxic multinodular goiter, cytologically indeterminate nodules and well differentiated thyroid cancer without local and/or distant metastasis. In all cases the biggest nodule should be < 6 cm. The surgical completeness was evaluated by means of serum thyroglobulin (hs-Tg) and neck ultrasound (nUS) performed three months postoperatively. 100 patients underwent either RATT or OT. The type of surgical procedure was chosen by patients. They were then divided in two subgroups based on benign or malignant histology. There were no significant differences in the postoperatively values of hs-Tg in patients operated with RATT or OT, both in benign and malignant subgroups. The post-operative thyroid remnant volume estimated by nUS was not significantly different between the two groups, both in benign and malignant subgroups. We also analyzed the difference of the volume of the thyroid remnant ipsilateral to the axillary access vs that of the remnant on the contralateral side and there was not significantly difference in both subgroups. RATT was demonstrated to determine a comparable surgical completeness as OT, both in benign and malignant thyroid diseases, with no differences in the prevalence of surgical complications. In our hands the surgical completeness of RATT by a single trans-axillary was satisfying.

Comparative surgical outcomes of transoral endoscopic and robotic thyroidectomy for thyroid carcinoma: a propensity score-matched analysis

BACKGROUND

Surgical outcomes of patients with thyroid carcinoma who underwent transoral endoscopic thyroidectomy vestibular approach (TOETVA) versus transoral robotic thyroidectomy (TORT) were compared.

METHODS

Patients who underwent TOETVA or TORT between July 2016 and February 2022 were retrospectively analyzed. TOETVA and TORT groups were propensity score-matched (1:1) based on age, sex, body mass index, surgical extent, tumor size, and presence of thyroiditis.

RESULTS

A total of 185 patients underwent transoral thyroidectomy (142 TOETVA and 43 TORT). Final diagnoses consisted of 135 papillary and seven follicular thyroid carcinomas in the TOETVA group and 43 papillary thyroid carcinomas in the TORT group (p = 0.138). Mean operative time was shorter for the TOETVA group than the TORT group (106.3 vs. 158.9 min, p < 0.001), whereas mean hospital stay was longer for the TOETVA group than the TORT group (2.2 vs. 1.9 days, p = 0.031). After 1:1 propensity score matching, each group included 43 patients. Mean operative time was shorter in the TOETVA group than the TORT group (106.2 vs. 158.9 min, p < 0.001), whereas mean hospital stay was longer in the TOETVA group (2.3 vs. 1.9 days, p = 0.031). There was no significant difference in vocal cord palsy incidences between the groups (one transient, one permanent in the TOETVA group vs. none in the TORT group, p = 0.359). The learning curve was 71 cases for TOETVA and 25 cases for TORT.

CONCLUSION

TOETVA had shorter mean operative time, and TORT had shorter learning curve and shorter mean hospital stay. Surgeons should be familiar with the advantages and disadvantages of each procedure.

Current Advances in Robotics for Head and Neck Surgery-A Systematic Review

Background. In the past few years, surgical robots have recently entered the medical field, particularly in urology, gynecology, and general surgery. However, the clinical effectiveness and safety of robot-assisted surgery (RAS) in the field of head and neck surgery has not been clearly established. In this review, we evaluate to what extent RAS can potentially be applied in head and neck surgery, in which fields it is already daily routine and what advantages can be seen in comparison to conventional surgery. Data sources. For this purpose, we conducted a systematic review of trials published between 2000 and 2021, as well as currently ongoing trials registered in clinicaltrials.gov. The results were structured according to anatomical regions, for the topics "Costs," "current clinical trials," and "robotic research" we added separate sections for the sake of clarity. Results. Our findings show a lack of large-scale systematic randomized trials on the use of robots in head and neck surgery. Most studies include small case series or lack a control arm which enables a comparison with established standard procedures. Conclusion. The question of financial reimbursement is still not answered and the systems on the market still require some specific improvements for the use in head and neck surgery.

[Robot-assisted head and neck surgery]

Robot-assisted surgery (RAS) has already been approved for several clinical applications in head and neck surgery. In some Anglo-American regions, RAS is currently the common standard for treatment of oropharyngeal diseases. Systematic randomized studies comparing established surgical procedures with RAS in a large number of patients are unavailable so far. Experimental publications rather describe how to reach poorly accessible anatomical regions using RAS, or represent feasibility studies on the use of transoral robotic surgery (TORS) in established surgical operations. With general application of RAS in clinical practice, the question of financial reimbursement arises. Furthermore, the technical applications currently on the market still require some specific improvements for routine use in head and neck surgery.

Transoral Endoscopic Thyroidectomy by Vestibular Approach with Central Lymph Node Dissection for Thyroid Microcarcinoma

Background: The transoral endoscopic thyroidectomy by vestibular approach (TOETVA) has been developed for thyroid microcarcinoma (TMC) treatment worldwide, with low rate of complications and excellent oncological results. However, this approach has still not been routinely performed. Thus, in this study, we aim to demonstrate the feasibility and safety of this technique in the clinical practice. Methods: In this prospective cohort study, 29 patients diagnosed TMC and clinically node negative underwent thyroidectomy and prophylactic central lymph node dissection by TOETVA. The clinicopathologic characteristics, surgical outcomes, and cosmetic results were evaluated. Results: The mean age was 34.7 ± 8.5 years. Three patients had underlying Grave's disease. Thyroid lobectomy with isthmusectomy was performed in the majority of cases (72.4%). All patients underwent prophylactic central node dissection. The mean number of retrieved central node was 7.8 ± 3.7 (3-19). Seven patients (24.1%) had lymph node metastasis in postoperative pathology. Among them, the mean number of metastatic lymph nodes was 2.1 ± 1.7 (1-5). The mean operative time was 121.2 ± 22.6 minutes. Four patients experienced transient hoarse and 1 patient had hematoma. Visual analog scale score on first postoperative day was 2.8 ± 1.4 (0-5). Most of patients were satisfied with cosmetic outcome. Conclusions: The TOETVA is new technique for TMC in Vietnam. The initial results of oncology, postoperative complications, and cosmetic supported the application of TOETVA in TMC.

Institutional experience of 200 consecutive papillary thyroid carcinoma patients in transoral robotic thyroidectomy surgeries

BACKGROUND

We evaluated the outcomes of patients with papillary thyroid carcinoma (PTC) who underwent transoral robotic thyroidectomy (TORT).

METHODS

We retrospectively analyzed the perioperative outcomes of 200 patients (170 women and 30 men) with PTC who underwent TORT at a single center between March 2016 and February 2018.

RESULTS

There were 182 and 13 cases of lobectomy and total thyroidectomy, respectively, with corresponding mean operative times of 200.6 ± 31.2 and 265.7 ± 63.0 minutes. On average, 5.6 ± 3.45 lymph nodes were retrieved per patient. There were 12 cases of perioperative morbidity. No conversion to endoscopic or conventional open surgery was noted. In a subgroup analysis for predictors of difficult TORT, patient sex was the only factor showing a significant operative time difference between a difficult and a nondifficult thyroidectomy.

CONCLUSION

TORT can be performed safely in patients with PTC without serious complications.

Transoral Robotic Thyroidectomy for Papillary Thyroid Carcinoma: Perioperative Outcomes of 100 Consecutive Patients

BACKGROUND

Endoscopic transoral thyroidectomy is a recently introduced technique of remote access thyroidectomy. We previously reported the feasibility of the robotic approach (TORT). Nevertheless, experience to date is limited, with scant data on outcomes in patients with papillary thyroid carcinoma (PTC).

METHODS

This was a retrospective analysis of prospectively collected data. Patients with PTC, who underwent TORT at a single center between March 2016 and February 2017, were analyzed.

RESULTS

There were a total of 100 patients (85 women, 15 men) with a mean age of 40.7 ± 9.8 years, and a mean tumor size of 0.8 ± 0.5 cm. Nine patients underwent a total thyroidectomy, and 91 underwent a lobectomy. The operative time for a total thyroidectomy and lobectomy was 270.0 ± 9.3 and 210.8 ± 32.9 min, respectively. Ipsilateral prophylactic central neck compartment dissection was performed routinely with retrieval of 5.0 ± 3.6 lymph nodes. Perioperative morbidity was present in nine patients including transient recurrent laryngeal nerve palsy (n = 1), postoperative bleeding requiring surgical intervention (n = 1), zygomatic bruising (n = 2), chin flap perforation (n = 1), oral commissure tearing (n = 2), and chin dimpling (n = 2). There was no conversion to endoscopic or conventional open thyroid surgery.

CONCLUSION

In this study, TORT could be safely performed in a large series of patients with PTC without serious complications. In selected patients, TORT by experienced surgeons could be considered an alternative approach for remote access thyroidectomy.

Robotic Thyroidectomy Decreases Postoperative Pain Compared With Conventional Thyroidectomy

BACKGROUND

This retrospective study compared postoperative pain between patients undergoing open thyroidectomy (OT) and bilateral axillo-breast approach (BABA) robotic thyroidectomy (RT).

MATERIALS AND METHODS

We analyzed the electronic medical records of 1269 patients who underwent OT or RT at Chung-Ang University Hospital between January 1, 2010 and April 30, 2016. On the basis of the surgical procedure performed, patients were categorized into an OT (n=1128) and a BABA RT (BRT) group (n=141). On the basis of covariates, patients in these groups were matched using propensity score matching (n=86 in each group).

RESULTS

After propensity score matching, no intergroup differences were observed in the covariates. The visual analogue scale scores for pain on postoperative day 0 were lower in the BRT than in the OT group (2.57±0.95 vs. 2.28±0.95, P=0.040). However, no statistically significant differences were observed in the use of rescue analgesics, the numerical rating scale score for nausea, and the use of rescue antiemetics.

CONCLUSIONS

Pain on postoperative day 0 was lesser in the BRT than in the OT group. Similarly, the severity of nausea was lesser in the BRT group, despite longer operation time and broad dissection performed for docking the robotic arms.

Robotic-assisted modified radical neck dissection using a bilateral axillo-breast approach (robotic BABA MRND) for papillary thyroid carcinoma with lateral lymph node metastasis

BACKGROUND

Although safe in patients with papillary thyroid carcinoma (PTC), robotic thyroidectomy using a bilateral axillo-breast approach (BABA) has not been frequently performed in patients with advanced PTC. This study describes surgical outcomes in patients with PTC and lymph node metastasis (LNM) in lateral neck compartment who underwent robotic-assisted modified radical neck dissection with BABA (robotic BABA MRND).

METHODS

The medical records of patients with PTC and lateral LNM who underwent robotic BABA MRND from March 2010 to July 2016 were retrospectively reviewed.

RESULTS

Fifteen patients, 14 women and 1 man, of mean age 37.1 ± 9.3 years, were enrolled. Mean operation time was 272.7 ± 33.8 min. A mean 20.7 ± 7.2 lymph nodes were retrieved from the lateral neck compartment, with a mean 5.3 ± 4.4 lymph nodes being metastatic. The rates of transient and permanent hypocalcemia were 46.7 and 0%, respectively, and the rates of transient and permanent vocal cord palsy were 6.7 and 0%, respectively. Fourteen patients (93.3%) had stimulated thyroglobulin concentrations below 2 ng/mL after the first treatment with radioactive iodine.

CONCLUSIONS

Robotic BABA MRND could be safely performed and may be a good surgical option in selected patients with PTC and lateral LNM.

[Robotic Surgery - Who is The Boss?]

In the head and neck region, great potential is seen in robot-assisted surgery (RAS). Mainly in cancer surgery, the use of robotic systems seems to be of interest. Until today, two robotic systems (DaVinci® und FLEX®) have gained approval for clinical use in the head and neck region, and multiple other systems are currently in pre-clinical testing. Although, certain groups of patients may benefit from RAS, no unbiased randomized clinical studies are available. Until today, it was not possible to satisfactorily prove any advantage of RAS as compared to standard procedures. The limited clinical benefit and the additional financial burden seem to be the main reasons, why the comprehensive application of RAS has not been realized so far.This review article describes the large variety of clinical applications for RAS in the head and neck region. In addition, the financial and technical challenges, as well as ongoing developments of RAS are highlighted. Special focus is put on risks associated with RAS and current clinical studies. We believe, that RAS will find its way into clinical routine during the next years. Therefore, medical staff will have to increasingly face the technical, scientific and ethical features of RAS.

[Experience of transaxillary endoscopic thyroid surgery]

AIM

To compare the outcomes after open and endoscopic interventions on thyroid gland.

MATERIAL AND METHODS

We have retrospectively analyzed 158 interventions on thyroid gland for the period March 2014 - January 2016. Herewith, 21 interventions were performed endoscopically with transaxillary removal of specimen.

RESULTS

The study was designed in 2 groups - main (endoscopic surgery) and control (open surgery). There were 2 complications in the main group: intraoperative injury of cricoid cartilage by harmonic scalpel and unilateral subcutaneous emphysema of the neck and face. In the control group one patient had transient hypocalcemia.

CONCLUSION

Endoscopic thyroid surgery is technically feasible in certain patients, adequate technical equipment and sufficient experience of surgical team.

Surgical safety and oncological completeness of robotic thyroidectomy for thyroid carcinoma larger than 2 cm

BACKGROUND

The safety of robotic thyroidectomy (RT) for small-sized thyroid carcinomas has been well established. The surgical outcomes of bilateral axillo-breast approach RT for thyroid carcinomas larger than 2 cm were evaluated and compared with those of open thyroidectomy (OT).

METHODS

The medical records of patients who underwent total thyroidectomy or hemithyroidectomy followed by completion thyroidectomy for differentiated thyroid carcinomas measuring 2-4 cm were retrospectively reviewed.

RESULTS

The study included 86 patients who underwent RT (n = 21) or OT (n = 65) with mean ages of 30.8 and 51.6 years, respectively. The mean tumor size was 2.8 cm in both groups. There were no significant differences between the RT and OT groups in vocal cord palsy rate (transient, 19.0 vs. 9.2 %; permanent, 0 vs. 1.5 %), postoperative hypoparathyroidism rate (transient, 19.0 vs. 33.8 %; permanent, 4.8 vs. 1.5 %), and the number of retrieved central lymph nodes in papillary thyroid carcinoma patients (6.4 ± 3.5 vs. 6.1 ± 3.9, respectively). The proportion of the patients with serum stimulated thyroglobulin level of <1.0 ng/ml at the initial radioactive iodine treatment was 64.7 % (11/17) for RT group and 66.0 % (35/53) for OT group (p = 0.920). There were three patients (1 RT and 2 OT) who had a biochemical incomplete response, and there was no case of anatomical recurrence or mortality during the median follow-up period of 40.2 months.

CONCLUSION

RT is a safe and oncologically sound treatment option for differentiated thyroid carcinomas measuring 2-4 cm in a selected group of patients. The role of RT should be evaluated in correlation with technological advances and increased experience.

Ethical issues in robotic-assisted transaxillary thyroidectomy

Like many new techniques in surgery, the use of robotic-assisted transaxillary thyroidectomy is an innovative approach to a common surgical treatment. However, the increased risks associated with the operation along with the increased costs make robotic-assisted transaxillary thyroidectomy an ethically problematic procedure to be utilized in contemporary health systems.

The evolution of image-guided lumbosacral spine surgery

Techniques and approaches of spinal fusion have considerably evolved since their first description in the early 1900s. The incorporation of pedicle screw constructs into lumbosacral spine surgery is among the most significant advances in the field, offering immediate stability and decreased rates of pseudarthrosis compared to previously described methods. However, early studies describing pedicle screw fixation and numerous studies thereafter have demonstrated clinically significant sequelae of inaccurate surgical fusion hardware placement. A number of image guidance systems have been developed to reduce morbidity from hardware malposition in increasingly complex spine surgeries. Advanced image guidance systems such as intraoperative stereotaxis improve the accuracy of pedicle screw placement using a variety of surgical approaches, however their clinical indications and clinical impact remain debated. Beginning with intraoperative fluoroscopy, this article describes the evolution of image guided lumbosacral spinal fusion, emphasizing two-dimensional (2D) and three-dimensional (3D) navigational methods.