Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Importance: Transoral robotic surgery (TORS) has emerged as the primary surgical option for locoregional control of oropharyngeal squamous cell carcinoma and certain early stage glottic tumors. However, the timing of neck dissection remains variable amongst surgeon preference and institution.
Objective: To review and perform a meta-analysis on complication rates, oncologic outcomes, and economical factors when considering staged or concurrent neck dissection during TORS.
Data Sources: PubMed, Embase, and Web of Science databases were reviewed through October 2024 without date or language restrictions
Study Selection: A systematic review following PRISMA guidelines was performed. Included studies were prospective or retrospective cohort studies that reported on outcomes of staged or concurrent neck dissection during TORS. The timing of neck dissection was categorized into three broad categories: before, concurrently, and after TORS. Case studies, non-English studies, or studies with patients who required free flap reconstruction were excluded.
Main Outcomes and Measures: Primary outcomes include intraoperative and postoperative pharyngeal fistula formation rates, postoperative hemorrhage rates, and length of stay data (defined as the total hospital stay of TORS and neck dissection). Secondary outcomes include other operative complications, recurrence rates, disease free survival, need for reoperation or readmission. Demographic and staging data were also collected.
Results: Out of 423 articles screened, 11 met the inclusion criteria, encompassing 1,123 patients who underwent TORS and neck dissection (805 concurrent, 318 staged). Reported intraoperative fistula rates were significantly higher for the concurrent neck dissection cohort (0.5% vs 12.6%, p < 0.001), but postoperative fistula rates were similar (3.2% vs 4.9%, p = 0.23). Hemorrhage rates did not significantly differ between patient cohorts (5.1% vs 6.8%, p = 0.30). Total length of hospital stay was longer for patients undergoing staged procedures (6.92 days vs 3.33 days). Random effects and subset analysis is pending individual data from their respective authors.
Conclusions: This systematic review and meta-analysis finds staged neck dissection reduces the rate of intraoperative but not postoperative pharyngeal fistula formation. This is at the cost of a longer hospital length of stay. The data is limited primarily to retrospective cohort studies, which may introduce bias and heterogeneity in reported outcomes. Future studies should aim to consistently report pharyngeal fistula formation and hemorrhage rates, as these are the most common complications associated with TORS and neck dissection.