20 Years of Transoral Robotic Surgery

Gregory S. Weinstein, MD, on behalf of the History and Archives Committee

When I look back on the past two decades of Transoral Robotic Surgery (TORS), I am struck less by the technology itself than by the people who believed in it, challenged it, and ultimately carried it forward. What began as a simple idea—that we might treat head and neck cancers through the mouth with less harm to patients—has grown into a global practice. I remain humbled that I was able to play a role in its journey.

In 2004, at the University of Pennsylvania, Bert W. O'Malley, Jr., MD, Neil Hockstein, MD, and I began with little more than curiosity and determination. Traditional open surgeries for oropharyngeal cancer often leave patients with significant morbidity, while chemoradiation, though preserving organs, frequently compromised function. We wondered if robotics, already proving useful in other specialties, could be adapted to the narrow and complex anatomy of the throat. Our first experiments were modest: mannequins, cadavers, and canine models. Each step taught us something new, and each success inspired us to continue.

Then, in May 2005, Dr. O’Malley and I launched the first Institutional Review Board (IRB)‑approved human study of TORS. I still remember the weight of that moment—the responsibility to our patients, the skepticism from colleagues, and the hope that we might offer something better. The da Vinci Surgical System was not designed for head and neck surgery, yet with careful adaptation, it allowed us to perform precise resections through the mouth. Patients recovered more quickly, retained the ability to swallow and speak, and had outstanding cancer outcomes.

Gregory S. Weinstein, MD, and Bert W. O'Malley, Jr, MD, taught TORS to colleagues at the First TORS Research Workshop in October 2006 in Sunnyvale, California, October 2006. From right to left: Eric Gendon, Jan Kastenbauer, William Carole, John Salassa, Greg Grillone, Enver Ozer, Bert O’Malley, Jr, Christopher Holsinger, Gregory Weinstein, Frank Civantos, Richard Smith, Catherine Moore, Christopher Rassekh, and Ho Sheng-Lin.

The timing was significant. Incidences of HPV‑related oropharyngeal cancers were rising rapidly, and these patients often had excellent prognoses. The goal was to find treatments that were less toxic and could achieve survival outcomes comparable to primary chemoradiation. TORS offered a way to reduce reliance on high‑dose chemoradiotherapy. In December 2009, the U.S. Food and Drug Administration (FDA) cleared TORS for clinical use—a milestone that validated years of translational research.

Adoption did not happen overnight. We needed to train others, share what we had learned, and listen to their experiences. Workshops, simulation platforms, cadaver labs, and proctorship programs became essential. Our first workshop was to encourage TORS research by our peers (see photo). After gaining FDA clearance, we trained over 500 head and neck surgeons in the TORS techniques in our lab at the University of Pennsylvania. Today, approximately 75% of HPV‑positive oropharyngeal cancer patients treated surgically at high‑volume academic centers undergo TORS.

The journey of TORS ultimately converged with an important clinical investigation: the ECOG‑ACRIN E3311 trial.¹ This study was the first prospective, multi‑institutional effort to rigorously evaluate transoral surgery followed by risk‑based adjuvant therapy in HPV‑associated oropharyngeal cancer. Sixty-eight surgeons did transoral surgery on 495 patients (90% TORS). As the lead for surgical credentialing and quality assurance, I am proud to have helped ensure the integrity of the surgical component across dozens of centers.

The most important finding was that intermediate‑risk patients could safely be treated with 50 Gy (5000 rads) of postoperative radiation without chemotherapy, achieving excellent outcomes. Long‑term results confirmed the durability of this approach: At 54 months, overall survival was 97.1% for patients treated with TORS alone, 97.9% for those treated with TORS plus reduced‑dose radiation, 95.1% for those receiving standard‑dose radiation, and 92.5% for high‑risk patients requiring adjuvant chemoradiation. For me, E3311 stands as a landmark accomplishment—not only validating the vision of TORS and the feasibility of avoiding chemotherapy and reducing the dose of postoperative radiation but also demonstrating the power of collaborative science to transform care and quality of life for patients worldwide.

Reference

1. Burtness B, Flamand Y, Quon H, Weinstein GS, et al. Long‑Term Follow‑Up of E3311, an ECOG‑ACRIN Cancer Research Group Phase II Trial of Transoral Surgery and Risk‑Based Adjuvant Treatment in Human Papillomavirus‑Initiated Oropharynx Cancer. J Clin Oncol. 2024. doi:10.1200/JCO‑24‑02550.