Introduction
The parapharyngeal space (PPS) is an anatomically complex region situated in the suprahyoid, intracranial fascial compartment of the neck. It is bounded by several critical anatomical structures, including the pharynx, parotid space, upper cervical lymphatic levels, prevertebral musculature, masticatory muscles and the submandibular space. Tumours arising within the PPS are rare, accounting for approximately 0.5 per cent of all head and neck neoplasms.Reference Fermi, Botti, Chiari, Abeshi, Presutti and Miglio1
The majority of PPS tumours are benign, typically originating from salivary glands (e.g., pleomorphic adenomas), neurogenic tissues (e.g., schwannomas) or adipose tissue (e.g., lipomas).Reference Riffat, Dwivedi, Palme, Fish and Jani2 However, up to 20 per cent of PPS tumours are malignant. These include primary PPS malignancies, such as mucoepidermoid carcinoma (MEC), adenoid cystic carcinoma (ACC) and lymphomas, as well as secondary tumours invading the PPS from adjacent anatomical regions (e.g., nasopharynx, oropharynx) and nodal metastases, such as those from papillary thyroid carcinoma (PTC), medullary thyroid carcinoma (MTC) or squamous cell carcinoma.Reference Fermi, Botti, Chiari, Abeshi, Presutti and Miglio1, Reference Chiari, Filippini, Serafini, Fermi, Presutti and Maniaci3
A wide spectrum of surgical approaches has been developed for PPS tumour resection, with selection tailored to tumour characteristics and patient-specific anatomical considerations.Reference Ferrari, Schreiber, Mattavelli, Lombardi, Rampinelli and Doglietto4 These approaches are generally classified into anterior routes, including the transnasal, transantral and transoral-trans pharyngeal approaches, and lateral routes, such as the transcervical (TCA), trans parotid (TPA), combined TCA–TPA, trans mandibular and infratemporal type C and D procedures.Reference Ferrari, Schreiber, Mattavelli, Lombardi, Rampinelli and Doglietto4 Recent advances in surgical technology, including endoscope-assisted dissection, intra-operative neuromonitoring and debrider-assisted cavitation, have been introduced to optimise resection efficacy while minimising operative morbidity.Reference Paderno, Piazza and Nicolai5, Reference Nicolai, Paderno, Farina and Piazza6
Transoral robotic surgery (TORS) has become an increasingly reliable option to remove PPS tumours, due to its continuous technological improvements over the years.Reference O’Malley and Weinstein7 Enhanced optical systems, high-definition 3D visualisation and superior magnification capabilities have substantially improved surgical precision and safety.Reference Arshad, Durmus and Ozer8 TORS has been associated with reduced peri-operative morbidity, a lower complication profile compared to open techniques and a diminished need for prophylactic tracheostomy. The approach allows for the preservation of critical neurovascular structures, expedited post-operative recovery, shortened hospital stays and the avoidance of external incisions and scarring.Reference Chiari, Guarino, Di Martino, Caporale, Presutti and Molteni9 As a result, TORS has proven particularly advantageous for the excision of small, well-localised lesions, as well as for diagnostic biopsies of unknown PPS tumours. Furthermore, it has been used in combined approaches, such as TORS with TCA, transcervical-endoscopic (TCE) or trans-parotid (TPA) access, for the management of larger or anatomically complex tumours at risk of fragmentation and capsular rupture, with curative intent.Reference Chu, De Berardinis, Tagliabue, Zorzi, Bandi and Ansarin10
Despite several case reports and small case series documenting clinical and surgical outcomes of PPS malignancies treated via robotic-assisted approaches, a comprehensive synthesis of the literature still remains lacking. Accordingly, the present study aims to provide the first systematic review focusing specifically on the oncologic and functional outcomes associated with various robotic techniques in the treatment of PPS malignancies.
Material and Methods
Search strategy and information sources
Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 checklist for review and meta-analysis, a systematic review of the current literature and the PICOS search approach was performed.Reference Page, McKenzie, Bossuyt, Boutron, Hoffmann and Mulrow11, Reference Schardt, Adams, Owens, Keitz and Fontello12 A computerised search was performed using the Embase/Pubmed, Scopus and Cochrane databases, for articles published from 2007 to 2025. The search string for each database is reported in Table 1.
Search string for each database
Study selection and data extraction
After running the above search string, abstracts and titles obtained were screened independently by two authors (F.C. and P.G.), who subsequently met and discussed disagreements on citation inclusion. The PICOS approach was adopted to assess eligibility. The following items were considered, such as:
- Participants (patients affected by PPS malignancies);
- Intervention (robotic approach);
- Controls (not applicable);
- Outcomes (functional and oncological outcomes, intra-operative and post-operative complications);
- Study type (observational study).
Inclusion criteria for abstract selection were the use of the English language and subjects having undergone a robotic approach to treat PPS malignancies. Studies without abstract, non-English language and those not describing any information about PPS malignancies were excluded. The same authors screened the full texts and thus identified, met and discussed disagreements on article inclusion. A further manual check of the references included in the articles was performed. Information from each study was extracted using a standardised data extraction form. Details on the study selection process are reported in a PRISMA flow chart (Figure 1).
Identification of studies via databases and registers.
Quality assessment
The same two authors (F.C. and P.G.) independently assessed the quality of the included studies using an assessment tool for case series and case reports,Reference Murad, Sultan, Haffar and Bazerbachi13 which considers four domains (selection, ascertainment, causality and reporting) and provides eight questions to aid quality score. Studies were rated as having low, moderate or high risk of bias according to the description (Table 2). The articles with a high risk of bias were excluded. Moreover, AMSTAR 2 criteria were used to confirm the eligibility of studies with a low and intermediate risk of bias.Reference Shea, Reeves, Wells, Thuku, Hamel and Moran14
Quality assessment of included case reports and case series, based on four domains (selection, ascertainment, causality and reporting)
Note: Studies were classified as low, intermediate or high risk of bias.
Data analysis
A patient-level analysis was performed. Patients’ data from published papers were extracted. The statistical analysis was performed with IBM SPSS for statistics v.27. Quantitative variables were summarised as median and interquartile range (IQR) or mean and standard deviation (SD) as appropriate. The normality of distribution for continuous variables was assessed with the Shapiro–Wilk test. For discrete variables, the chi-squared test or Fischer’s exact test was used to compare categorical variables. Association between variables was considered significant for p less than 0.05, with the confidence interval set at 95 per cent.
Results
A total of 99, 22 and 6 manuscripts were initially identified through the application of the search strategies described in Table 1, using the Embase/PubMed, Scopus and Cochrane databases, respectively. Following the removal of duplicates, 108 records were retained for further evaluation. Subsequent abstract screening led to the selection of 75 articles deemed potentially relevant for full-text review. The remaining 33 articles were excluded for the following reasons: absence of an abstract (n = 10), publication in a language other than English (n = 8) or focus on a topic unrelated to PPS malignancies (n = 15). Of the 75 full-text articles assessed for eligibility, 12 studies met the preliminary inclusion criteria for risk of bias assessment. A total of 63 articles were excluded at this stage due to: lack of individual patient data (n = 52), unavailability of full-text (n = 4) or content unrelated to malignant PPS tumours (n = 7). Following the bias risk assessment, one additional study was excluded due to a high risk of bias, as detailed in Table 2. Ultimately, 11 studies were included in the final analysis.
Cohort’s features
A total of 11 studies, comprising 6 case reports and 5 case series, were included in this systematic review.Reference Arshad, Durmus and Ozer8, Reference Chu, De Berardinis, Tagliabue, Zorzi, Bandi and Ansarin10, Reference Kim and Zanation15–Reference Hyvrard, Couineau, Rigal, Louerat, Hans and Baudouin24 The publications spanned from 2012 to 2024. Across all studies, 20 patients were identified and included for analysis. The individual characteristics of each patient are detailed in Table 3. The largest cohort reported within a single study included five patients.Reference Chu, De Berardinis, Tagliabue, Zorzi, Bandi and Ansarin10 Of the total population, 9 patients (45 per cent) were females and 11 (55 per cent) were males. The mean age at diagnosis was 50.85 years (SD ± 13.59), with a range from 25 to 70 years. Table 4 presents a summary of the key clinical and surgical features of the entire patient cohort, as well as two distinct subgroups: patients treated exclusively with a TORS-only approach and patients managed with TORS in combination with an open approach, including TORS+TCA and TORS+TCE.
Patients features
ACC = adenoid cystic carcinoma; AWD 0 alive with disease; BED = biochemical evidence of disease; CHT = chemo radiotherapy; CR = capsular rupture; CRC = clear cell renal carcinoma; CT = computed tomography; d = days; DOD = died for other reasons; FN = facial nerve; FNA = fine needle biopsy; FT = feeding tube; I = iodine; m = month; MEC = mucoepidermoid carcinoma; MRI = magnetic resonance imaging; MTC = medullary thyroid carcinoma; N/A = not available; NED = not evidence of disease; PA = pleomorphic adenoma; PEG = percutaneous endoscopic gastrostomy; PET = positron emission tomography; PTC = papillary thyroid carcinoma; pts = patients; rec = recurrence; SPC = superior pharyngeal constrictor; RT = radiotherapy; T = tracheotomy; TCA = trans-cervical approach; TCE = trans-cervical endoscopic approach TORS = trans oral robotic surgery; VC = vocal cord; y = year.
Comparison of clinical, surgical and functional outcomes between patients treated with TORS alone and those treated with combined TORS–open approaches
Note: Diagnostic TORS cases were excluded from the comparative analysis.
ACC = adenoid cystic carcinoma; CT = computed tomography; FN = facial nerve; FNA = fine needle aspiration; FT = feeding tube; MEC = mucoepidermoid carcinoma; min = minutes; mm = millimetres; ml = millilitre; MRI = magnetic resonance imaging; pts = patients; MTC = medullary thyroid carcinoma; Nr = number; NED = not evidence of disease; PET = positron emission tomography; PTC = papillary thyroid carcinoma; TORS = trans oral robotic surgery; TCA = transcervical approach; TCE = transcervical endoscopic approach; tracheo = tracheostomy
Pre-operative assessment
Radiological features were described in nine studies.Reference Duek, Amit, Sviri and Gil17, Reference Lajud, Aponte-Ortiz, Garraton and Giraldez19, Reference Ross, Malik and Awad21–Reference Cadena-Piñeros, Correa-Marin and Moreno-Torres23 Computed tomography (CT) was performed in five patients (71 per cent), while magnetic resonance imaging (MRI), positron emission tomography (PET) and iodine-131 (I-131) scintigraphy were each performed in four, three and two patients, respectively. In addition, fine needle aspiration (FNA) was conducted in two cases, although it failed to yield a definitive diagnosis. Regarding tumour laterality, lesions were located on the right side in seven patients (66 per cent) and on the left side in four patients (33 per cent). The mean maximum tumour diameter was 31.90 mm (SD ± 13.08), ranging from 16 to 60 mm. From a histopathological examination, the most frequently encountered diagnoses were PTC metastases (six cases; 30 per cent) and ex-pleomorphic adenoma (PA) carcinoma (five cases; 25 per cent). Other histological types included MTC metastases (two cases; 10 per cent), ACCs (two cases, 10 per cent) and MECs (two cases; 10 per cent). Additionally, single cases were reported for adenocarcinoma, plasmacytoma and metastasis from clear cell renal carcinoma.
Intra-operative management
Three distinct robotic surgical techniques were identified across the included studies: TORS alone (10 cases; 50 per cent), TORS+TCA (four cases, 20 per cent), TORS+TCE (four cases; 20 per cent) and diagnostic TORS procedures (two cases; 10 per cent). Only one studyReference Arshad, Durmus and Ozer8 reported the robotic system set-up time, which was 20 minutes. In contrast, robotic operative time was documented in four studies,Reference Arshad, Durmus and Ozer8, Reference Boyce, Curry, Luginbuhl and Cognetti16–Reference Duek, Sviri, Billan and Gil18 with a mean duration of 97 minutes (range: 18–169 minutes). Reported intra-operative blood loss was minimal, with a mean volume of 12.5 ml (range: 2–25 ml) across two studies.Reference Arshad, Durmus and Ozer8, Reference Boyce, Curry, Luginbuhl and Cognetti16 Intra-operative complications were noted in two patients, representing 10 per cent of the cohort. Both cases involved capsular rupture during tumour dissection through TORS-TCA to remove a PTC metastasis and an ex-PA carcinoma.
Post-operative evaluation
The mean length of hospitalisation was 5.36 days (SD ± 6.18), with a range of 1 to 26 days. Data regarding the use of prophylactic tracheostomy and feeding tube (FT) placement were reported in four studies.Reference Arshad, Durmus and Ozer8, Reference Chu, De Berardinis, Tagliabue, Zorzi, Bandi and Ansarin10, Reference Ross, Malik and Awad21, Reference Hyvrard, Couineau, Rigal, Louerat, Hans and Baudouin24 Specifically, four patients (50 per cent) underwent temporary tracheostomy, and five patients (63 per cent) required temporary FT placement. Oral diet was reintroduced after a mean of 2.00 days (SD ± 2.00), ranging from 1 to 5 days. The overall post-operative complication rate was 20 per cent. Notably, two patients developed vocal cord palsy at the end of the procedure, one patient experienced transient weakness of the facial nerve marginal mandibular branch and another one presented with cervical emphysema, which was resolved with conservative medical management. In particular, these post-operative complications were developed to remove PPS tumours through TORS with a combined modality. No recurrences of PPS malignancies were observed in the present cohort during the follow-up period. Adjuvant therapy was administered in selected cases: radiotherapy (RT) in two patients, and I-131 RT in one patient. In addition, primary medical treatment was used for the management of plasmacytoma and recurrent MEC, both initially diagnosed via diagnostic TORS. The mean follow-up duration was 15.90 months (SD ± 12.09; range 1 to 50 months), with the majority of patients (13 patients, 87 per cent) reported to be alive and disease-free.
TORS and combined approaches
A total of 18 patients were included in the comparative analysis between two treatment groups: those who underwent therapeutic or radical TORS-only (10 patients, 50 per cent) and those treated with TORS combined approaches (eight patients; 40 per cent). The latter group included 4 patients treated with TORS-TCA and four patients treated with TORS-TCE. Patients who underwent TORS for diagnostic purposes were excluded from this comparison due to a high risk of selection bias for the absence of therapeutic intent. Table 4 presents the comparative evaluation of clinical, surgical and functional outcomes between the two subgroups.
Discussion
Since its introduction in 2007 by O’Malley et al.Reference O’Malley, Weinstein, Snyder and Hockstein25 for the treatment of oropharyngeal cancer, TORS has steadily gained recognition as a reliable and effective option for treating tumours of the larynx and other anatomical sites, including the thyroid, parotid glands, neck nodes and PPS.Reference Caporale, Chiari, D’Alessio, Barbara and Guarino26, Reference Lira and Kowalski27 Moreover, TORS has been increasingly used in the de-intensification treatment of human papillomavirus-related oropharyngeal cancer providing an opportunity to lower the adverse side effects associated with non-surgical adjuvant treatments, both in the short and long term.Reference Molteni, Bassani, Arsie, Zampieri, Mannelli and Orlandi28 Some clinical trials evaluate de-escalation after TORS, such as the recent E3311 phase II trial evidencing its favourable role in terms of both oncologic and functional outcomes.Reference Burtness, Flamand, Quon, Weinstein, Mehra and Garcia29
Traditionally, several surgical approaches, such as TCA, TPA, combined TCA-TPA approach and various infratemporal fossa techniques, have been utilised for the treatment of PPS tumours. While these approaches have yielded favourable oncological outcomes, they are also often associated with higher intra-operative and post-operative complication rates compared to TORS.Reference Lim, Park, Kang, Kim, Choi and Kim20
Despite the fact that malignant PPS tumours represent up to 20 per cent of all parapharyngeal neoplasms, the very small number of TORS-managed malignancies identified in this review does not reflect their epidemiological incidence but rather the highly selective nature of patient eligibility for a transoral approach. Most malignant PPS tumours present with characteristics that contraindicate TORS, including absence of a capsule, infiltration of surrounding soft tissues, extension towards the skull base or encasement of major neurovascular structures. In routine clinical practice, these features frequently mandate an open transcervical or transmandibular exposure. As a consequence, only a limited subset of malignancies—typically small, well-localised, medially positioned and without extracapsular extension—are deemed suitable for TORS. This explains both the small number of published cases and the predominance of single case reports. Current evidence therefore suggests that the indications for TORS in malignant PPS tumours remain narrow. Based on the available literature,Reference Chiari, Filippini, Serafini, Fermi, Presutti and Maniaci3 favourable criteria include: (1) small tumour size, generally less than 3 cm; (2) clear medial displacement of the tumour; (3) an intact capsule; and (4) absence of radiological invasion of the carotid artery, cranial nerves or skull base. Conversely, contraindications include: (1) extracapsular spread, (2) vascular encasement, (3) superior extension toward the skull base, (4) poor transoral exposure and (5) suspicion of high-grade biology requiring wide en-bloc margins.
Arshad et al.Reference Arshad, Durmus and Ozer8 were the first to propose the TORS approach for the treatment of isolated and small malignant PPS tumours (<2.5 cm). In their study, they successfully treated a patient with ACC, achieving excellent oncological results and functional outcomes, evidenced by a hospitalisation time of 1 day, no need for FT or tracheostomy and a prompt return to an oral diet the day after surgery. PTC metastases were the most frequently observed PPS malignancies in the current review, with six cases successfully treated using the TORS-only approach. PTC is a common head and neck malignancy with a strong predilection for lymph node metastases, often affecting the VI and VII neck levels. However, in some cases, PTC metastases can involve the PPS and retropharyngeal space. Yu et al.Reference Yu, Chen, Xu, Xie, Zhou and Yu30 reported the largest series of patients with PPS lymph node metastases, with incidence rates ranging from 0.43 per cent to 2.5 per cent. The literature describes various surgical techniques used to treat these metastases, including TCA, TPA and the combined TCA-TPA approach, all of which offer satisfactory local control rates but are associated with higher positive margin rates and an elevated risk of nerve injury. Kim and Zanation.Reference Kim and Zanation15 were the first to describe the use of TORS for treating PTC metastasis in the PPS. Several years later, Cadena Piñeros et al.Reference Cadena-Piñeros, Correa-Marin and Moreno-Torres23 presented the largest case series of PTC metastases treated with a TORS-only approach, reporting no intraoperative injuries or post-operative complications. All patients demonstrated favourable oncological outcomes, with no disease recurrence during a mean follow-up of 14 months. This minimally invasive technique offers significant advantages, including the clear identification of critical surgical landmarks, a bloodless surgical field and reduced complication rates, coupled with minimal facial scarring and faster recovery. However, it is important to emphasise that TORS is suitable only for isolated, well-encapsulated tumours, as the limited surgical access precludes its use in cases with extracapsular extension.Reference Cadena-Piñeros, Correa-Marin and Moreno-Torres23 Additionally, other studies have demonstrated the successful application of a TORS-only approach for the removal of small primary tumours in the PPS.Reference Arshad, Durmus and Ozer8, Reference Chu, De Berardinis, Tagliabue, Zorzi, Bandi and Ansarin10, Reference Boyce, Curry, Luginbuhl and Cognetti16 For example, Ross et al.Reference Ross, Malik and Awad21 reported the use of TORS to successfully remove an isolated clear cell renal carcinoma metastasis, without any intra-operative or post-operative complications.
Although the complication rate reported across the available studies appears extremely low, this likely reflects the high degree of surgical selection rather than a true representation of risk. Patients undergoing TORS for malignant PPS tumours are typically chosen because their lesions are small, well-localised and often encapsulated, with favourable medial displacement and no involvement of major neurovascular structures. As a result, peri-operative morbidity is expected to approximate that of benign PPS tumours, and the very small sample size prevents reliable detection of infrequent complications; for instance, a 5 per cent adverse-event rate may not be observable in a cohort of only 20 procedures. Similarly, the reported follow-up period ranged from 1 to 50 months (mean 16 months), which limits the strength of conclusions regarding long-term local control or disease-specific survival. Therefore, while the available results are encouraging, they should be interpreted as preliminary findings derived from highly selected cases rather than definitive evidence of excellent outcomes. The treatment of large tumours often requires more invasive combined open approaches or procedures, such as mandibulotomy, which, although enhancing exposure, also increases patient morbidity. In recent years, however, various authors have explored combined TORS and open-access procedures, with the main aim of reducing patient morbidity. Lajud et al.Reference Lajud, Aponte-Ortiz, Garraton and Giraldez19 was the first one to describe the use of combined TORS-TCA for the removal of an isolated MTC metastasis measuring greater than 4 cm in diameter. Similarly, Hyvrard et al.Reference Hyvrard, Couineau, Rigal, Louerat, Hans and Baudouin24 used the same approach to treat another large metastasis of the same histotype. The robotic approach was used to remove the medial portion of PPS metastasis from the tonsil and the paravertebral fascia through a lateral incision to the anterior tonsillar pillar and the separation of the superior pharyngeal constrictor from the parapharyngeal fat pad. Indeed, the lateral portion of the mass was removed from the external carotid branches and the internal carotid through a TCA. Moreover, Lajud et al.Reference Lajud, Aponte-Ortiz, Garraton and Giraldez19 further proposed the advancement of the superior pharyngeal constrictor muscle flap to cover the resultant neck defect. Both studies demonstrated that combined TORS-TCA resection for PPS lesions extending beyond the dissection limits of each technique resulted in reduced hospitalisation time and post-operative morbidity compared to traditional open surgical approaches, such as mandibulotomy, TCA or TPA.
Duek et al.Reference Duek, Amit, Sviri and Gil17, Reference Duek, Sviri, Billan and Gil18 were the first surgeons to propose a combined TORS-TCE approach for the removal of four cases of ex-PA tumours near the internal carotid artery. These authors advocated the use of this approach for achieving a complete circumferential dissection of tumours located higher and laterally at the skull base or for tumours connected to the deep lobe of the parotid gland, thus minimising the risk of tumour spillage. This combination technique enables the removal of very large tumours with superior PPS extension and allows the resection of low-grade malignant tumours involving the skull base or jugular foramen in a minimally invasive manner.Reference Duek, Sviri, Billan and Gil18 Moreover, the same AuthorReference Duek, Amit, Sviri and Gil17 proposed specific indications for the combined TORS-TCE approach, including small benign PPS tumours, PA as difficult to reach via blunt dissection and lateral dissection by TORS-only approach, large PA of the PPS, encapsulated carcinoma ex PA or adenocarcinomas without extracapsular extension and symptomatic PPS schwannomas.
The comparative analysis between patients treated with the TORS-only approach and those treated with combined TORS revealed several interesting findings. Notably, the tracheostomy rate was significantly higher in the combined TORS group (67per cent vs 0 per cent), as was the FT necessity (67 per cent vs 33 per cent). Furthermore, the intraoperative complication rate was higher in the combined TORS group (12 per cent vs 0 per cent), with a similar trend observed in post-operative complications (37 per cent vs 0 per cent). A plausible explanation for these differences may lie in the more selective surgical indications for the TORS-only approach, which is typically reserved for isolated, small tumours (e.g., <2.5 cm metastases).Reference Arshad, Durmus and Ozer8 In the present analysis, the mean tumour diameter in patients treated with the TORS-only approach was 2.3 cm. The longer hospital stay observed in the TORS-only group (8.2 vs. 4 days) is attributable to a single case: a patient with a clear cell renal carcinoma metastasis who was discharged on the 26th post-operative day due to a particularly severe clinical condition. However, it is important to acknowledge that the small sample size in this study is a significant limitation and likely accounts for the absence of statistical significance in these findings.
In conclusion, TORS has also been utilised for performing diagnostic biopsies with the primary goal of obtaining a histological diagnosis.Reference Chu, De Berardinis, Tagliabue, Zorzi, Bandi and Ansarin10 In the past, various Authors typically used transoral open approaches or mandibulectomy to achieve similar diagnostic results, often with longer hospitalisation times and increased surgical complications. The current systematic review included two patients who underwent diagnostic TORS to establish histological diagnoses of recurrent MEC and a solitary plasmacytoma, both of which were treated with chemotherapy (CHT) and RT, respectively.Reference Chu, De Berardinis, Tagliabue, Zorzi, Bandi and Ansarin10 The MEC was treated exclusively with CHT, given the not resectable nature of the loco-regional recurrence of the salivary gland disease, which is typically associated with a poor prognosis. In contrast, the primary plasmacytoma was managed with exclusive RT, due to its effective response to radiation therapy. In both cases, TORS was uneventful. The 3D magnification provided by the robotic system greatly enhanced the visualisation of the neoplasm and improved the sensitivity of the biopsy, all while minimising side effects.
• Parapharyngeal space (PPS) malignancies are rare and surgically demanding due to their deep location and proximity to critical anatomical structures
• Transoral robotic surgery (TORS) is increasingly used in head and neck oncology, although evidence relating specifically to PPS malignancies remains limited
• This systematic review is the first to focus exclusively on oncological and functional outcomes of TORS for PPS malignancies
• TORS-only appears to provide excellent outcomes for small, well-localised and encapsulated tumours
• Combined TORS–open approaches may broaden surgical indications for larger or anatomically complex PPS malignancies while maintaining acceptable morbidity
Limitations and Future Perspectives
The literature offers limited information regarding the functional and oncological outcomes of robotic treatment for malignant tumours of the PPS. For this reason, the authors aimed to review previous studies in order to analyse the indications, advantages and limitations of various robotic approaches and to describe their surgical outcomes. Notably, this is the first review to focus exclusively on the robotic management of malignant PPS tumours. The efficacy of robotic treatments in terms of both functional and oncological outcomes is a significant finding that warrants further investigation to strengthen the current level of evidence. One limitation of this review is the small sample size, which includes only 20 patients reported across 11 studies, most of which are case reports (six studies). Additionally, the inclusion of a high number of metastatic cases may represent another potential source of bias, as these cases often display an unexpectedly favourable prognosis. Despite these limitations, the preliminary findings provide valuable insights and offer important considerations for future observational studies specifically aimed at defining the functional and oncological impact of different robotic techniques. In conclusion, a promising direction for future research could involve comparing various combined TORS and open approaches—such as TORS-TCA, TORS-TCP or TORS-TCE—to better highlight the advantages and limitations of each technique.
Conclusions
This systematic review highlights the innovative role of the transoral robotic approach in the treatment of PPS malignant tumours. Based on the limited and highly selected evidence available, TORS-only may represent a promising option for small, well-localised PPS malignancies, although definitive conclusions cannot yet be drawn. Combined TORS–open approaches may extend surgical indications to larger or anatomically complex tumours, but current data remain insufficient to determine their comparative oncological safety. Overall, these findings should be interpreted as preliminary observations. Robust prospective studies are required to define clear indications and contraindications for TORS and to establish its long-term oncological and functional outcomes in malignant PPS disease.
Funding disclosures
No funding is reported for the present study.
Competing interests
The authors declare no conflict of interest.
Informed consent
Not need.
