Unilateral transoral robotic surgery for patients with human papillomavirus–positive tonsillar squamous cell carcinoma was associated with fewer postoperative complications and comparable survival outcomes vs. bilateral surgery, according to a retrospective cohort study of 158 patients treated from June 2016 to July 2023.
The study population included 139 men and 18 women (mean age, 60 years). Of the 158 patients, 106 underwent unilateral transoral robotic surgery (TORS), defined as ipsilateral radical tonsillectomy, and 52 underwent bilateral TORS, which included removal of the clinically uninvolved contralateral tonsil. All patients had biopsy-confirmed human papillomavirus–positive tonsillar squamous cell carcinoma and underwent at least unilateral neck dissection. The decision to proceed with unilateral vs. bilateral TORS was determined by the treating surgeon.
Key Findings
The primary outcome was postoperative oropharyngeal hemorrhage. This occurred in eight of 106 patients (8%) in the unilateral group and eight of 52 patients (15%) in the bilateral group. Among patients undergoing bilateral TORS, one hemorrhage originated from the contralateral tonsil, three from the ipsilateral side, and four had unknown sources.
Within 30 days following surgery, the emergency department visit or hospitalization rate was 10 of 106 patients (9%) in the unilateral group and 11 of 52 patients (21%) in the bilateral group. More visits in the bilateral group were due to pain and dehydration (three of 52 patients [6%] vs. one of 106 patients [1%] in the unilateral group).
The median hospital stay was two days (range, zero to 21 days) for the unilateral group and three days (range, one to 36 days) for the bilateral group. The median time to nasogastric tube removal was two days (range, zero to 33 days) in both groups. At discharge, 23 of 91 patients (25%) in the unilateral group and eight of 38 patients (21%) in the bilateral group retained a nasogastric tube.
Gastrostomy tube use within one year following surgery was observed in 13 of 106 patients (12%) in the unilateral group and nine of 52 patients (17%) in the bilateral group. Long-term gastrostomy tube dependence at last follow-up was similar between groups (nine of 106 patients [8%] in the unilateral group; four of 52 patients [8%] in the bilateral group).
Swallowing function, assessed in a subset of patients using the MD Anderson Dysphagia Inventory, showed no statistically significant differences in dysphagia-related quality-of-life scores prior to and following surgery between groups. Mean preoperative scores were 90 in the unilateral group and 88 in the bilateral group; postoperative scores were 73 and 76, respectively.
Survival outcomes were comparable. Among patients in the unilateral group, two-year overall survival was 94% and five-year overall survival was 88%. In the bilateral group, two-year overall survival was 89% and five-year overall survival was 74%. Five-year disease-free survival was 83% in the unilateral group and 73% in the bilateral group.
Contralateral second primary tumors were rare. In the unilateral group, two of 106 patients (2%) developed metachronous contralateral tonsil tumors at nine and 23 months following surgery. In the bilateral group, one of 52 patients (2%) had a synchronous tumor detected during surgery. All patients with second primary tumors were without evidence of disease at last follow-up.
Study Limitations
Limitations of the study include its retrospective design, surgeon-dependent assignment to unilateral or bilateral TORS, and the potential for selection bias. Median follow-up for the cohort was 31 months (range, zero to 90 months).
Conclusion
Omission of prophylactic contralateral extracapsular tonsillectomy among patients with unilateral human papillomavirus–positive tonsillar squamous cell carcinoma was associated with lower rates of posttonsillectomy hemorrhage, shorter hospital stay, and fewer postoperative emergency department visits vs. bilateral surgery, without compromising survival outcomes. The researchers concluded that unilateral transoral robotic surgery is a safe approach for patients with human papillomavirus–positive tonsillar squamous cell carcinoma with unilateral disease and recommended against routine prophylactic contralateral tonsillectomy. Further prospective studies are needed to evaluate long-term outcomes and recurrence risk.
The researchers reported no conflicts of interest.
