ABSTRACT
Objective(s)
Direct comparisons of functional outcomes between transoral videolaryngoscopic surgery (TOVS) and transoral robotic surgery (TORS) for oropharyngeal cancer remain limited.
Methods
This retrospective single‐center study included 35 patients who underwent TOVS and 13 who underwent TORS. The European Organisation for Research and Treatment of Cancer (EORTC) QLQ‐C30, EORTC QLQ‐H&N35, and Hyodo scores were assessed preoperatively and at 1, 3, 6, and 12 months. A linear mixed‐effects model (LMM) included time, treatment, the group‐by‐time interaction, T stage (Tis/T1/T2 vs. T3), anatomic subsite (Tonsil vs. not Tonsil), prior cancer‐directed treatment, concurrent neck dissection, sex, and age.
Results
Both groups showed transient postoperative deterioration followed by recovery. In the prespecified primary longitudinal LMM, treatment had no statistically significant main effect on pain, opening mouth, swallowing, or total Hyodo score.
Conclusion
In this cohort, no statistically significant differences in postoperative quality of life or swallowing recovery were detected between TOVS and TORS. This design does not establish functional equivalence; however, TOVS may be a practical transoral option when robotic systems are unavailable.
Level of Evidence
3.
Keywords: oropharyngeal cancer, quality of life, swallowing, transoral robotic surgery, transoral videolaryngoscopic surgery
1. Introduction
Transoral surgery is an established treatment strategy for selected patients with oropharyngeal cancer because it can achieve oncologic control while preserving speech and swallowing function. More recently, transoral robotic surgery (TORS) has gained international acceptance as a minimally invasive approach for oropharyngeal malignancies, with favorable oncologic outcomes reported in appropriately selected patients [1, 2].
Nevertheless, the clinical adoption of TORS remains dependent on access to robotic platforms, institutional resources, and technical expertise. Consequently, TORS remains difficult to implement in many clinical settings. By contrast, transoral videolaryngoscopic surgery (TOVS), developed in Japan as a nonrobotic transoral technique, offers a practical, less resource‐intensive approach for minimally invasive resection of pharyngeal and laryngeal tumors [3]. Previous studies have reported acceptable oncologic outcomes and encouraging functional preservation after TOVS, suggesting that TOVS may represent an appropriate alternative transoral approach in routine clinical practice [4, 5, 6]. We previously developed methods to enhance the safety and effectiveness of TOVS [7]. We also assessed postoperative swallowing function and quality of life (QOL) in patients with head and neck tumors treated with TOVS [8].
Beyond oncologic control, postoperative function is central to the selection of a transoral surgical procedure for oropharyngeal cancer. Postoperative swallowing ability and health‐related QOL are clinically important outcomes because they directly influence nutritional status, social functioning, and long‐term patient well‐being. Several studies have examined postoperative QOL after TORS. Dysphagia and pain are common during the first few months to 1 year after TORS [9, 10], and older patients have a higher risk of dysphagia [11]. Furthermore, the primary treatment site and neck dissection have been reported to contribute to reduced postoperative QOL after TORS [12]. We previously evaluated QOL after TOVS and TORS for head and neck cancer and reported no statistically significant difference between the two surgical procedures [13]. Although several studies have evaluated postoperative swallowing function after TORS and TOVS, studies evaluating postoperative QOL after both procedures remain limited [14, 15]. Direct comparative evidence on postoperative functional outcomes after TORS and TOVS also remains scarce.
Accordingly, directly comparing longitudinal patient‐reported outcomes and flexible endoscopic evaluation of swallowing (FEES)‐based swallowing outcomes after TOVS versus TORS is clinically important, especially in healthcare environments where robotic access is constrained. We compared postoperative QOL and swallowing outcomes after TOVS and TORS in patients with oropharyngeal cancer at a single institution. The present cohort includes 35 of the 37 TOVS patients and 13 of the 14 TORS patients with oropharyngeal cancer reported in the previous study, extending that analysis by restricting the cohort to oropharyngeal cancer, adding FEES‐based Hyodo score assessment, and using a prespecified longitudinal linear mixed‐effects framework. By integrating the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires with serial Hyodo score assessments, we aimed to clarify whether the recovery patterns after TOVS differed from those after TORS, thereby clarifying whether the more accessible TOVS approach may offer comparable functional outcomes without implying equivalence.
2. Materials and Methods
2.1. Ethical Considerations
This retrospective single‐center study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board (IRB) of Tokai University School of Medicine (approval no. 25R067; August 19, 2025). The IRB waived the requirement for written informed consent for this retrospective study, and approved patient enrollment through an opt‐out procedure. Patients who declined to participate were excluded from the study.
2.2. Participants
The primary objective was to compare postoperative swallowing function and quality‐of‐life trajectories between the TOVS and TORS groups. Exploratory secondary analyses were performed to identify symptom domains that changed over time after each procedure.
We retrospectively analyzed data from 48 patients who underwent TOVS or TORS for oropharyngeal cancer in our department between July 2016 and December 2024. All included patients met the inclusion criteria, did not meet any exclusion criteria, and had not declined participation through the opt‐out process. The inclusion criteria were as follows: (1) malignant tumors with primary lesions in the oropharynx for which TOVS or TORS was performed; (2) clinical Tis/T1/T2/T3 lesions; (3) no lymph node metastasis or resectable cervical lymph node metastasis; (4) lesions involving no more than half of the circumference; and (5) no distant metastases. The exclusion criteria were (1) age < 18 years; (2) Eastern Cooperative Oncology Group performance status ≥ 2; (3) contraindications to transoral resection, such as trismus; (4) simultaneous surgery at two or more subsites; (5) tracheostomy performed during the evaluation period; (6) postoperative radiation therapy; and (7) physician‐determined ineligibility, including obvious aspiration pneumonia or incapacity to provide consent. The present cohort overlaps substantially with our previous study and includes 35 of the 37 TOVS patients and 13 of the 14 TORS patients with oropharyngeal cancer described in that report [13]; the remaining patients did not meet the prespecified eligibility criteria for the present analysis. Patients were censored at the time of recurrence, development of new esophageal or head and neck lesions, additional treatment, or conditions affecting postoperative swallowing function or QOL. The eighth edition of the Union for International Cancer Control guidelines was used for TNM staging.
The EORTC Quality of Life Questionnaire Core 30 (QLQ‐C30) and Quality of Life Questionnaire Head and Neck 35 (QLQ‐H&N35) were administered preoperatively and at 1, 3, 6, and 12 months postoperatively [16, 17].
2.3. Surgical Procedure
The surgical approach followed the TOVS method described by Tomifuji et al. [4, 18] Surgical exposure was achieved using an FK‐WO retractor (Olympus Medical Systems, Tokyo, Japan) or a Weerda distending laryngoscope (Karl Storz, Tuttlingen, Germany). The surgical field was visualized using a video endoscope with a movable tip, including OLYMPUS LTF‐S190–5 or ENDOEYE FLEX 3D (Olympus Medical Systems, Tokyo, Japan). Electrocautery was performed using either a Colorado microdissection needle (Stryker Japan KK, Tokyo, Japan) or a malleable electrocautery needle (KD 600, Olympus Medical Systems). The grasping forceps used were STEINER grasping forceps, LARYNGOFORCER II grasping forceps (Karl Storz, Tuttlingen, Germany), and a MicroFrance Heart‐Shaped grasper (Integra MicroFrance, Saint Aubin le Monial, France). Lesions were confirmed using narrow‐band imaging and iodine staining.
TORS was performed using the da Vinci Xi (Intuitive Surgical Inc., Sunnyvale, CA, USA) beginning in June 2022. Tumors were resected en bloc with a 5–10 mm safety margin. Fibrin glue and polyglycolic acid sheets were applied to cover the mucosal defects [19]. Neck dissection was performed in patients with cervical lymph node metastasis, and tracheostomy was not routinely performed.
2.4. Swallowing Assessment
Swallowing function was evaluated with FEES and scored using the Hyodo score. This endoscopic scoring system assesses four domains: salivary pooling in the vallecula and piriform sinuses; the glottal closure reflex; initiation of the swallowing reflex, assessed by white‐out timing; and pharyngeal clearance after swallowing. Each item is scored on a four‐point scale from 0 to 3, and the total score ranges from 0 to 12; higher scores indicate more severe dysphagia. The Hyodo score has been reported to be useful in estimating aspiration risk and the feasibility of oral intake [20, 21, 22].
2.5. Statistical Analysis
All analyses were performed using JMP (version 19 Student Edition, RRID: SCR_014242). Because each functional outcome was assessed repeatedly at up to five time points per patient (preoperatively and at 1, 3, 6, and 12 months postoperatively) with unbalanced follow‐up, the prespecified primary framework for longitudinal analysis was a linear mixed‐effects model (LMM) that accounted for within‐patient correlation. Prior cancer‐directed treatment was defined as a history of head and neck cancer, esophageal cancer, or radiotherapy and was modeled as a composite covariate because each component has been associated with postoperative swallowing function and QOL. The primary LMM evaluated four prespecified functional outcomes: pain (EORTC QLQ‐C30), swallowing (EORTC QLQ‐ H&N35), opening mouth (EORTC QLQ‐H&N35), and total Hyodo score.
Each LMM included a patient‐level random intercept and a first‐order autoregressive residual covariance structure. Fixed effects were time, treatment, the time × treatment interaction, T stage, anatomic subsite, prior cancer‐directed treatment, concurrent neck dissection, sex, and age. Pairwise group comparisons at each visit were based on least‐squares means with Tukey–Kramer adjustment for multiple comparisons.
Kruskal–Wallis and Dunn's tests were used only to describe within‐group changes over time, whereas the Mann–Whitney U test provided exploratory cross‐sectional comparisons between groups at individual time points. Missing data were not imputed; the LMM retained all available observations under a missing‐at‐random assumption. All tests were two‐sided, with p < 0.05 considered statistically significant [23, 24, 25, 26].
3. Results
Forty‐eight patients were included in this study; 35 and 13 underwent TOVS and TORS, respectively. Sex distribution was comparable between groups (TOVS, 31 male patients and four female patients; TORS, 11 male patients and two female patients), and the median age was 70 years (range, 43–83 years) in the TOVS group and 68 years (range, 36–79 years) in the TORS group. T2 disease was the most common T stage in both groups, representing 51.4% and 84.6% of TOVS and TORS cases, respectively. A history of esophageal cancer treatment was more common in the TOVS group than in the TORS group (34.3% vs. 7.7%), whereas neck dissection was performed more often in the TORS group than in the TOVS group (76.9% vs. 31.4%). For primary tumor site, tonsillar tumors were most frequent in the TORS group, whereas the TOVS group had a wider distribution of tonsillar, base‐of‐tongue, posterior‐wall, and soft‐palate lesions (Table 1).
TABLE 1.
Baseline characteristics of patients treated with TOVS and TORS.
| Characteristic | TOVS (n = 35) | TORS (n = 13) |
|---|---|---|
| No. of patients | 35 | 13 |
| Sex (male: female) | 31:4 | 11:2 |
| Median age, years (range) | 70 [43–83] | 68 [36–79] |
| T stage | ||
| Tis | 3 (8.6) | 0 |
| T1 | 12 (34.3) | 1 (7.7) |
| T2 | 18 (51.4) | 11 (84.6) |
| T3 | 2 (5.7) | 1 (7.7) |
| History of esophageal cancer treatment | 12 (34.3) | 1 (7.7) |
| History of head and neck cancer treatment | 13 (37.1) | 2 (15.4) |
| In same area | 3 (8.6) | 0 |
| In other area | 6 (17.1) | 2 (15.4) |
| In same and other area | 4 (11.4) | 0 |
| History of radiotherapy | 8 (22.9) | 1 (7.7) |
| With neck dissection | 11 (31.4) | 10 (76.9) |
| Primary site | ||
| Oropharyngeal [p16+] | 35 [23] | 13 [8] |
| Tonsil | 14 [5] (40.0) | 9 [7] (69.2) |
| Tongue base | 4 [2] (11.4) | 2 [1] (15.4) |
| Posterior wall | 7 [6] (20.0) | 2 [0] (15.4) |
| Soft palate | 10 [10] (28.6) | 0 |
Note: Values are shown as n (%) unless otherwise specified. Percentages were calculated by column. Baseline characteristics are reported descriptively because treatment allocation was nonrandomized. The number in brackets [] indicates the number of p16‐positive patients in each group.
Abbreviations: ND, neck dissection; TORS, transoral robotic surgery; TOVS, transoral videolaryngoscopic surgery.
The EORTC QLQ‐C30 and QLQ‐H&N35 questionnaires were administered preoperatively and 1, 3, 6, and 12 months postoperatively. Patients were censored from subsequent assessments after recurrence or other events that could affect swallowing function or QOL. In addition to form‐level missingness, some questionnaires had item‐level missing responses because patients could omit individual items. Questionnaire availability declined over time in both groups. In the TOVS group, available forms/total enrolled patients were 30/35 (85.7%) preoperatively, 26/35 (74.3%) at 1 month, 21/35 (60.0%) at 3 months, 20/35 (57.1%) at 6 months, and 16/35 (45.7%) at 12 months. Corresponding values in the TORS group were 13/13 (100%), 10/13 (76.9%), 7/13 (53.8%), 7/13 (53.8%), and 6/13 (46.2%). Event‐adjusted eligible denominators were 35, 34, 30, 29, and 22 in the TOVS group and 13, 12, 11, 11, and 9 in the TORS group, respectively.
Missing questionnaire data were classified at the form level according to the primary reason for non‐availability. Clinical event‐related missingness included recurrence, new lesions, other malignancies, events affecting swallowing function or QOL, and loss to follow‐up. Administrative/operational missingness mainly reflected questionnaire distribution failures and study‐system‐related factors. The numbers of missing questionnaire forms by reason and time point are summarized in Table S1.
Descriptive analyses characterized the overall postoperative trajectories of the questionnaire‐based and FEES‐based outcomes. Several measures showed transient postoperative deterioration followed by recovery in one or both groups. Kruskal–Wallis and Dunn's tests were used to describe these within‐group temporal patterns, which are presented in Table 2. Because these tests do not account for within‐patient correlation, they were treated as descriptive rather than as the primary longitudinal analysis.
TABLE 2.
EORTC QLQ‐C30 and QLQ‐H&N35 scores by group and time‐point.
| Preoperative | 1 M | 3 M | 6 M | 12 M | Kruskal–Wallis | Dunn's test | |
|---|---|---|---|---|---|---|---|
| Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | p value | M and p value | |
| TOVS QLQ‐C30 | |||||||
| Physical | 89.33 ± 14.71 | 89.17 ± 11.15 | 90.56 ± 11.15 | 88.00 ± 10.05 | 89.38 ± 14.57 | 0.8151 | |
| Role | 87.22 ± 22.61 | 84.62 ± 22.07 | 90.48 ± 16.31 | 92.50 ± 12.65 | 91.67 ± 19.25 | 0.5656 | |
| Emotional | 83.33 ± 15.32 | 84.29 ± 18.15 | 91.27 ± 11.33 | 91.67 ± 10.81 | 94.27 ± 12.44 | 0.0292 | 12 M, 0.0414 |
| Cognitive | 86.67 ± 14.12 | 85.90 ± 16.12 | 86.51 ± 11.33 | 85.83 ± 11.18 | 87.50 ± 11.39 | 0.9905 | |
| Social | 89.44 ± 15.46 | 91.03 ± 12.68 | 94.44 ± 12.17 | 95.83 ± 10.64 | 95.83 ± 9.62 | 0.2489 | |
| Global health status | 67.22 ± 26.89 | 67.31 ± 27.68 | 69.44 ± 21.14 | 73.75 ± 17.99 | 77.60 ± 17.41 | 0.7433 | |
| Fatigue | 19.63 ± 21.58 | 24.57 ± 21.78 | 19.58 ± 15.68 | 20.56 ± 14.54 | 21.53 ± 18.36 | 0.8761 | |
| Nausea and vomiting | 4.44 ± 10.66 | 1.28 ± 6.54 | 3.17 ± 6.71 | 0.83 ± 3.73 | 2.08 ± 5.69 | 0.3861 | |
| Pain | 6.11 ± 10.25 | 21.15 ± 23.36 | 10.32 ± 16.22 | 9.17 ± 12.65 | 4.17 ± 9.62 | 0.0059 | 1 M, 0.0144 |
| Dyspnea | 8.89 ± 14.99 | 12.82 ± 16.54 | 12.70 ± 16.59 | 11.67 ± 16.31 | 8.33 ± 19.25 | 0.6995 | |
| Insomnia | 13.33 ± 28.50 | 11.54 ± 22.98 | 9.52 ± 15.43 | 13.33 ± 16.75 | 10.42 ± 15.96 | 0.8903 | |
| Appetite loss | 15.56 ± 22.71 | 10.26 ± 18.30 | 9.52 ± 18.69 | 8.33 ± 14.81 | 16.67 ± 27.22 | 0.7157 | |
| Constipation | 13.33 ± 18.77 | 12.82 ± 19.04 | 4.76 ± 11.95 | 8.33 ± 14.81 | 8.33 ± 19.25 | 0.359 | |
| Diarrhea | 11.11 ± 18.22 | 5.13 ± 12.26 | 11.11 ± 16.10 | 11.67 ± 19.57 | 12.50 ± 16.67 | 0.5429 | |
| Financial difficulties | 15.56 ± 25.87 | 8.33 ± 17.72 | 6.35 ± 13.41 | 8.33 ± 18.34 | 6.25 ± 18.13 | 0.5068 | |
| TORS QLQ‐C30 | |||||||
| Physical | 93.33 ± 9.81 | 90.67 ± 10.04 | 95.24 ± 9.97 | 97.14 ± 5.25 | 90.67 ± 17.38 | 0.6469 | |
| Role | 92.31 ± 12.94 | 88.33 ± 20.86 | 100.00 ± 0.00 | 100.00 ± 0.00 | 100.00 ± 0.00 | 0.0869 | |
| Emotional | 87.82 ± 13.01 | 93.33 ± 7.66 | 96.43 ± 4.45 | 97.22 ± 6.80 | 98.33 ± 3.73 | 0.1808 | |
| Cognitive | 94.87 ± 8.01 | 91.67 ± 11.79 | 92.86 ± 13.11 | 88.89 ± 13.61 | 90.00 ± 14.91 | 0.8863 | |
| Social | 94.87 ± 10.51 | 93.33 ± 11.65 | 100.00 ± 0.00 | 100.00 ± 0.00 | 100.00 ± 0.00 | 0.2356 | |
| Global health status | 68.59 ± 22.09 | 66.67 ± 20.03 | 79.76 ± 15.11 | 91.67 ± 9.13 | 90.00 ± 6.97 | 0.0263 | NS |
| Fatigue | 20.51 ± 13.49 | 22.22 ± 14.81 | 19.05 ± 12.36 | 7.41 ± 9.07 | 8.89 ± 12.17 | 0.1224 | |
| Nausea and vomiting | 2.56 ± 9.25 | 1.67 ± 5.27 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.7842 | |
| Pain | 6.41 ± 12.80 | 20.00 ± 17.21 | 4.76 ± 8.13 | 2.78 ± 6.80 | 3.33 ± 7.45 | 0.063 | |
| Dyspnea | 10.26 ± 16.01 | 3.33 ± 10.54 | 9.52 ± 16.27 | 9.52 ± 16.27 | 13.33 ± 18.26 | 0.7389 | |
| Insomnia | 12.82 ± 16.88 | 16.67 ± 28.33 | 4.76 ± 12.60 | 9.52 ± 16.27 | 13.33 ± 18.26 | 0.8517 | |
| Appetite loss | 10.26 ± 21.01 | 13.33 ± 17.21 | 4.76 ± 12.60 | 4.76 ± 12.60 | 6.67 ± 14.91 | 0.732 | |
| Constipation | 7.69 ± 19.97 | 6.67 ± 14.05 | 9.52 ± 16.27 | 4.76 ± 12.60 | 13.33 ± 18.26 | 0.8302 | |
| Diarrhea | 12.82 ± 21.68 | 0.00 ± 0.00 | 0.00 ± 0.00 | 5.56 ± 13.61 | 0.00 ± 0.00 | 0.1247 | |
| Financial difficulties | 7.69 ± 14.62 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.1468 | |
| TOVS QLQ‐H&N35 | |||||||
| Pain | 11.11 ± 14.90 | 21.79 ± 23.58 | 7.94 ± 10.03 | 5.00 ± 9.13 | 5.00 ± 7.59 | 0.0037 | NS |
| Swallowing | 11.39 ± 12.85 | 18.91 ± 18.49 | 15.87 ± 18.05 | 16.67 ± 19.12 | 10.00 ± 11.00 | 0.5891 | |
| Teeth | 4.44 ± 12.33 | 7.05 ± 12.63 | 5.56 ± 13.26 | 5.83 ± 11.18 | 5.56 ± 12.06 | 0.7423 | |
| Opening mouth | 9.63 ± 13.91 | 16.24 ± 16.70 | 12.70 ± 16.21 | 12.22 ± 13.92 | 8.33 ± 15.45 | 0.0001 | 1 M, 0.0002 |
| Dry mouth | 16.67 ± 21.44 | 18.91 ± 17.25 | 17.20 ± 17.38 | 14.86 ± 13.31 | 13.54 ± 14.55 | 0.7875 | |
| Sticky saliva | 2.74 ± 5.68 | 5.60 ± 9.94 | 5.21 ± 8.82 | 4.22 ± 7.13 | 3.26 ± 7.21 | 0.7531 | |
| Senses problems | 12.35 ± 19.39 | 11.81 ± 19.34 | 15.00 ± 24.72 | 14.91 ± 22.15 | 19.23 ± 33.92 | 0.8248 | |
| Coughing | 14.44 ± 25.80 | 12.82 ± 19.04 | 8.33 ± 14.81 | 7.02 ± 13.96 | 6.67 ± 13.80 | 0.3619 | |
| Speech problems | 4.44 ± 14.47 | 21.79 ± 20.96 | 9.52 ± 18.69 | 3.33 ± 10.26 | 2.22 ± 8.61 | 0.2763 | |
| Felt ill | 25.56 ± 25.80 | 29.49 ± 33.10 | 19.05 ± 24.88 | 25.00 ± 33.98 | 20.00 ± 24.56 | 0.6671 | |
| Trouble with social contact | 14.44 ± 20.87 | 24.36 ± 30.63 | 15.87 ± 27.12 | 16.67 ± 22.94 | 15.56 ± 21.33 | 0.7704 | |
| Trouble with social eating | 10.34 ± 18.05 | 15.38 ± 19.39 | 12.70 ± 24.67 | 21.67 ± 24.84 | 11.11 ± 20.57 | 0.8411 | |
| Less sexuality | 14.94 ± 21.06 | 16.67 ± 23.57 | 7.94 ± 14.55 | 11.67 ± 16.31 | 8.89 ± 15.26 | 0.99 | |
| Painkiller use | 17.24 ± 38.44 | 57.69 ± 50.38 | 14.29 ± 35.86 | 15.00 ± 36.63 | 12.50 ± 34.16 | 0.0007 | 1 M 0.0031 |
| Nutritional supplements | 23.33 ± 43.02 | 19.23 ± 40.19 | 14.29 ± 35.86 | 10.00 ± 30.78 | 18.75 ± 40.31 | 0.7953 | |
| Feeding tube | 6.67 ± 25.37 | 3.85 ± 19.61 | 4.76 ± 21.82 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.6883 | |
| Weight loss | 20.00 ± 40.68 | 38.46 ± 49.61 | 9.52 ± 30.08 | 5.00 ± 22.36 | 6.25 ± 25.00 | 0.0152 | NS |
| Weight gain | 23.33 ± 43.02 | 23.08 ± 42.97 | 19.05 ± 40.24 | 20.00 ± 41.04 | 31.25 ± 47.87 | 0.9252 | |
| TORS QLQ‐H&N35 | |||||||
| Pain | 7.64 ± 6.61 | 28.33 ± 25.22 | 8.33 ± 10.76 | 8.33 ± 11.79 | 4.17 ± 8.33 | 0.1976 | |
| Swallowing | 11.11 ± 15.21 | 21.67 ± 18.92 | 5.95 ± 6.30 | 7.14 ± 10.12 | 8.33 ± 10.21 | 0.2814 | |
| Teeth | 0.00 ± 0.00 | 16.67 ± 23.57 | 0.00 ± 0.00 | 9.52 ± 16.27 | 6.67 ± 14.91 | 0.0838 | |
| Opening mouth | 0.00 ± 0.00 | 43.33 ± 35.31 | 14.29 ± 17.82 | 9.52 ± 16.27 | 0.00 ± 0.00 | 0.002 | 1 M, 0.0006 |
| Dry mouth | 16.67 ± 17.41 | 20.00 ± 23.31 | 19.05 ± 17.82 | 9.52 ± 16.27 | 13.33 ± 18.26 | 0.8303 | |
| Sticky saliva | 8.33 ± 15.08 | 23.33 ± 27.44 | 23.81 ± 16.27 | 14.29 ± 17.82 | 6.67 ± 14.91 | 0.2704 | |
| Senses problems | 1.39 ± 4.81 | 8.33 ± 14.16 | 2.38 ± 6.30 | 5.56 ± 8.61 | 0.00 ± 0.00 | 0.3988 | |
| Coughing | 11.11 ± 16.41 | 23.33 ± 27.44 | 9.52 ± 16.27 | 14.29 ± 17.82 | 6.67 ± 14.91 | 0.6575 | |
| Speech problems | 5.56 ± 10.05 | 16.67 ± 19.77 | 12.96 ± 16.36 | 4.76 ± 8.74 | 2.78 ± 5.56 | 0.5037 | |
| Felt ill | 16.67 ± 33.33 | 16.67 ± 32.39 | 4.76 ± 12.60 | 9.52 ± 16.27 | 0.00 ± 0.00 | 0.6872 | |
| Trouble with social contact | 2.05 ± 5.70 | 5.00 ± 5.91 | 1.11 ± 2.72 | 0.95 ± 2.52 | 0.00 ± 0.00 | 0.2295 | |
| Trouble with social eating | 16.67 ± 9.00 | 23.15 ± 16.55 | 8.33 ± 10.54 | 11.90 ± 11.64 | 6.25 ± 7.98 | 0.1245 | |
| Less sexuality | 17.95 ± 30.02 | 3.70 ± 11.11 | 16.67 ± 27.89 | 0.00 ± 0.00 | 25.00 ± 50.00 | 0.4693 | |
| Painkiller use | 23.08 ± 43.85 | 50.00 ± 52.70 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.0382 | NS |
| Nutritional supplements | 7.69 ± 27.74 | 0.00 ± 0.00 | 14.29 ± 37.80 | 0.00 ± 0.00 | 25.00 ± 50.00 | 0.4628 | |
| Feeding tube | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 1 | |
| Weight loss | 23.08 ± 43.85 | 50.00 ± 52.70 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.0382 | NS |
| Weight gain | 7.69 ± 27.74 | 0.00 ± 0.00 | 28.57 ± 48.80 | 71.43 ± 48.80 | 25.00 ± 50.00 | 0.0067 | 6 M, 0.0052 |
Note: Kruskal–Wallis tests were used to assess overall time effects; when results were significant, Dunn's multiple‐comparison tests were performed with the preoperative value used as the reference. Higher symptom scores indicate more severe symptoms, whereas higher functional and global health status scores indicate better status. Time‐specific sample sizes varied because of clinical event‐related censoring and administrative missingness; see Table S1. Statistical significance (p < 0.05) is indicated by underlining.
Abbreviations: EORTC, European Organisation for Research and Treatment of Cancer; M, month; NS, not significant; QLQ‐C30, Quality of Life Questionnaire Core 30; QLQ‐H&N35, Quality of Life Questionnaire Head and Neck 35; SD, standard deviation; TORS, transoral robotic surgery; TOVS, transoral videolaryngoscopic surgery.
Exploratory cross‐sectional Mann–Whitney U comparisons at 1 and 12 months identified no statistically significant between‐group differences across the evaluated EORTC QLQ‐C30 and QLQ‐H&N35 domains (Table S2). These unadjusted, time‐specific comparisons are descriptive and do not establish equivalence between TOVS and TORS.
FEES‐based Hyodo assessments showed no clear evidence of different postoperative patterns between the groups. At individual assessment time points, no statistically significant between‐group differences were observed in salivary pooling, the glottal closure reflex, initiation of the swallowing reflex, pharyngeal clearance, or total Hyodo score (Table 3). These time‐specific findings are descriptive; primary longitudinal inference for total Hyodo score was based on the LMM.
TABLE 3.
FEES‐based swallowing function assessed using the Hyodo score in the TOVS and TORS groups (mean ± SD).
| Group | Preoperative (Mean ± SD) | 1 M (Mean ± SD) | 3 M (Mean ± SD) | 6 M (Mean ± SD) | 12 M (Mean ± SD) | KW p‐value | |
|---|---|---|---|---|---|---|---|
|
Outcome Salivary pooling in the vallecula and piriform sinuses |
TOVS | 0.33 ± 0.48 | 0.42 ± 0.50 | 0.38 ± 0.50 | 0.25 ± 0.44 | 0.33 ± 0.49 | 0.8051 |
| TORS | 0.23 ± 0.44 | 0.20 ± 0.42 | 0.14 ± 0.38 | 0.14 ± 0.38 | 0.00 ± 0.00 | 0.7891 | |
| MWU p‐value | 0.5169 | 0.2265 | 0.2651 | 0.5909 | 0.1264 | ||
|
Outcome Glottal closure reflex induced by touching the epiglottis or arytenoid with an endoscope |
TOVS | 0.50 ± 0.73 | 0.46 ± 0.58 | 0.38 ± 0.59 | 0.30 ± 0.47 | 0.20 ± 0.41 | 0.6074 |
| TORS | 0.38 ± 0.65 | 0.10 ± 0.32 | 0.14 ± 0.38 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.2575 | |
| MWU p‐value | 0.6718 | 0.0711 | 0.3458 | 0.1155 | 0.2755 | ||
|
Outcome Bolus location at swallowing‐reflex initiation assessed by white‐out timing |
TOVS | 0.53 ± 0.51 | 0.69 ± 0.55 | 0.52 ± 0.51 | 0.30 ± 0.47 | 0.33 ± 0.49 | 0.0966 |
| TORS | 0.38 ± 0.65 | 0.60 ± 0.52 | 0.29 ± 0.49 | 0.43 ± 0.53 | 0.40 ± 0.55 | 0.6997 | |
| MWU p‐value | 0.2819 | 0.6936 | 0.2967 | 0.5649 | 1 | ||
|
Outcome Pharyngeal clearance after swallowing blue‐dyed water |
TOVS | 0.40 ± 0.62 | 0.54 ± 0.58 | 0.71 ± 0.78 | 0.45 ± 0.69 | 0.47 ± 0.64 | 0.5547 |
| TORS | 0.23 ± 0.60 | 0.50 ± 0.53 | 0.29 ± 0.49 | 0.43 ± 0.53 | 0.40 ± 0.55 | 0.5179 | |
| MWU p‐value | 0.2886 | 0.9359 | 0.2161 | 0.8966 | 0.8233 | ||
|
Outcome Total Hyodo score |
TOVS | 1.77 ± 1.70 | 2.12 ± 1.53 | 2.00 ± 1.67 | 1.30 ± 1.30 | 1.33 ± 1.50 | 0.7962 |
| TORS | 1.23 ± 1.59 | 1.40 ± 1.07 | 0.86 ± 0.69 | 1.00 ± 1.00 | 0.80 ± 1.10 | 0.3079 | |
| MWU p‐value | 0.4146 | 0.1987 | 0.1209 | 0.6864 | 0.5948 |
Note: The Hyodo total score ranges from 0 to 12, and each component ranges from 0 to 3; higher scores indicate greater swallowing impairment. The Mann–Whitney U test and Kruskal–Wallis test were used for statistical comparisons (p < 0.05).
Abbreviations: FEES, flexible endoscopic evaluation of swallowing; KW, Kruskal–Wallis test; M, month; MWU, Mann–Whitney U test; SD, standard deviation; TORS, transoral robotic surgery; TOVS, transoral videolaryngoscopic surgery.
The primary longitudinal analysis used LMMs for four prespecified functional outcomes: QLQ‐C30 pain, QLQ‐C30 swallowing, QLQ‐H&N35 opening mouth, and total Hyodo score. Treatment had no statistically significant main effect on pain (F = 0.27, p = 0.605), swallowing (F = 3.54, p = 0.065), opening mouth (F = 0.14, p = 0.706), or total Hyodo score (F = 2.74, p = 0.106) (Table 4a).
TABLE 4.
Linear mixed‐effects model for the four functional outcomes.
| Pain | Opening mouth | Swallowing | Total Hyodo score | |||||
|---|---|---|---|---|---|---|---|---|
| F | p‐Value | F | p‐Value | F | p‐Value | F | p‐Value | |
| (a) Fixed‐effect tests | ||||||||
| Time | 1.5745729 | 0.1901 | 1.8146335 | 0.1331 | 4.4840514 | 0.0023 | 1.4252147 | 0.2329 |
| Treatment | 0.2720537 | 0.6048 | 0.1449966 | 0.7055 | 3.5434873 | 0.0654 | 2.7417581 | 0.1056 |
| Time × Treatment | 0.6166116 | 0.6521 | 1.1849522 | 0.3231 | 2.8812893 | 0.0265 | 0.967234 | 0.4301 |
| Tis/T1/T2 vs. T3 | 0.0539002 | 0.8176 | 0.0679252 | 0.796 | 2.9046445 | 0.0957 | 2.0498163 | 0.1609 |
| Tonsil vs. not Tonsil | 0.0019294 | 0.9652 | 0.585656 | 0.4509 | 0.1762108 | 0.6773 | 0.1565718 | 0.6952 |
| Any prior treatment | 0.1465718 | 0.7041 | 0.0020226 | 0.9644 | 0.0269912 | 0.8704 | 1.4602318 | 0.2357 |
| Concurrent neck dissection | 0.146298 | 0.7043 | 0.000681 | 0.9794 | 1.5095527 | 0.2267 | 0.2605208 | 0.6133 |
| Sex female | 0.4056788 | 0.5283 | 1.4823948 | 0.2337 | 0.3843287 | 0.5393 | 0.1488481 | 0.7024 |
| Age | 6.3513284 | 0.0163 | 0.4316423 | 0.5161 | 0.0029481 | 0.957 | 1.9634483 | 0.1702 |
| Pain | Opening mouth | Swallowing | Total Hyodo score | |||||
|---|---|---|---|---|---|---|---|---|
| TORS‐TOVS difference (95% CI) | Adj p‐value | TORS‐TOVS difference (95% CI) | Adj p‐value | TORS‐TOVS difference (95% CI) | Adj p‐value | TORS‐TOVS difference (95% CI) | Adj p‐value | |
| (b) Tukey–Kramer‐adjusted LSMean pairwise contrasts at each time‐point | ||||||||
| Preoperative | 2.45 (−43.07 to 48.04) | 1 | −0.01 (−0.44 to 0.42) | 1 | −0.07 (−0.41 to 0.27) | 0.997 | −0.07 (−1.94 to 1.51) | 0.997 |
| 1 M | 5.58 (−41.06 to 52.21) | 1 | 0.08 (−0.42 to 0.51) | 1 | 0.10 (−0.29 to 0.49) | 0.997 | −0.68 (−2.61 to 1.25) | 0.979 |
| 3 M | 8.76 (−42.27 to 59.80) | 0.99 | −0.1 (−0.63 to 0.44) | 0.999 | −0.25 (−0.69 to 0.19) | 0.717 | −1.39 (−3.54 to 0.74) | 0.53 |
| 6 M | 19.6 (−34.43 to 73.73) | 0.97 | 0.12 (−0.84 to 0.31) | 0.999 | −0.26 (−0.71 to 0.19) | 0.702 | −0.48 (−2.65 to 1.69) | 0.999 |
| 12 M | −1.82 (−60.70 to 57.05) | 1 | −0.27 (−0.42 to 0.51) | 0.885 | −0.31 (−0.82 to 0.20) | 0.622 | −1.06 (−3.35 to 1.24) | 0.889 |
Note: Each model included a patient‐level random intercept and a first‐order autoregressive residual covariance structure and was estimated by restricted maximum likelihood with Kenward‐Roger denominator degrees of freedom. All available observations were retained under a missing‐at‐random assumption. Fixed effects included time, treatment, the time × treatment interaction, T stage (Tis/T1/T2 vs. T3), anatomic subsite (Tonsil vs. not Tonsil), prior cancer‐directed treatment (head and neck cancer, esophageal cancer, or radiotherapy), concurrent neck dissection (binary), sex (female, binary), and age (continuous, centered at the cohort mean). All p‐values are two‐sided; p < 0.05 indicates statistical significance, shown by underlining. TORS‐TOVS difference, TORS‐TOVS difference indicates the difference in least‐squares means (LSMeans) estimated from the linear mixed‐effects model (TORS minus TOVS) at each time‐point. A positive value indicates a higher LSMean for TORS than for TOVS. The direction of interpretation depends on the scale of each outcome (higher scores indicate more severe symptoms or poorer swallowing function for all four outcomes).
Abbreviations: 95% CI, 95% confidence interval for the LSMean difference; adj p‐value, adjusted p‐value; F, fixed‐effect F statistic; LSMean, least‐squares mean; M, month; TORS, transoral robotic surgery; TOVS, transoral videolaryngoscopic surgery.
A statistically significant time × treatment interaction was observed for swallowing (F = 2.88, p = 0.027), suggesting that the longitudinal pattern of swallowing symptoms may have differed between groups. However, Tukey–Kramer‐adjusted pairwise LSMean comparisons at individual postoperative time points were all nonsignificant (adjusted p ≥ 0.62), and every corresponding 95% confidence interval included zero. LSMean estimates numerically favored TORS from 3 months onward, but this pattern represents a numerical tendency rather than a confirmed between‐group difference (Table 4b).
4. Discussion
TORS has been widely adopted internationally and is supported by a growing evidence base demonstrating favorable oncologic and functional outcomes in selected patients with oropharyngeal squamous cell carcinoma. In contrast, TOVS was developed in Japan as a transoral approach that can be performed with conventional endoscopic equipment and standard surgical instruments. This difference in dissemination is clinically relevant because access to TORS remains restricted by platform availability, institutional resources, and reimbursement systems, whereas TOVS may be more readily introduced in a broader range of clinical settings [27, 28].
In this cohort, we found no clear evidence that the postoperative trajectories of quality of life and swallowing recovery differed between TOVS and TORS, although the study was not designed to establish equivalence. Cross‐sectional comparisons at 1 and 12 months identified no statistically significant between‐group differences. In the adjusted longitudinal models, age was the only covariate significantly associated with any outcome, specifically pain, and no functional outcome showed a statistically significant main effect of surgical approach (TORS vs. TOVS). Patient‐reported swallowing showed a significant time × treatment interaction (p = 0.027), suggesting that the longitudinal pattern may have differed by procedure. LSMean differences numerically favored TORS from 3 months onward, but the absolute differences were small (≤ 0.31 score units), the Tukey–Kramer‐adjusted pairwise contrasts at 3, 6, and 12 months were nonsignificant, and all 95% confidence intervals included zero. Accordingly, these data do not demonstrate clinically meaningful superiority of either approach or functional equivalence.
The temporal patterns observed in this study are consistent with prior reports describing early postoperative deterioration followed by gradual recovery after transoral surgery [29, 30]. In the TOVS group, emotional functioning improved significantly over time. Conversely, pain, opening mouth, and painkiller use changed significantly after surgery, with pain and opening mouth most affected during the early postoperative phase. In the TORS group, global health status, opening mouth, painkiller use, weight loss, and weight gain showed significant temporal changes. These findings are consistent with previous TORS studies showing that the early postoperative period is characterized by transient deterioration in eating‐ and swallowing‐related domains, with progressive recovery over time, particularly when adjuvant treatment can be minimized [31].
Nonetheless, this between‐group analysis suggests that these temporal changes do not translate into a measurable long‐term functional disadvantage after TOVS compared with TORS. This finding is clinically relevant because TORS is often viewed as the more technically advanced platform. However, technical sophistication does not necessarily lead to better postoperative patient‐reported or endoscopically assessed function. Therefore, our results support a more balanced interpretation: the choice between TOVS and TORS should not be based solely on technology availability but should also consider patient selection, tumor location and extent, expected adjuvant treatment, surgeon expertise, and local implementation constraints.
A further strength of this analysis was the incorporation of objective swallowing findings. The Hyodo score is a FEES‐based composite ranging from 0 to 12, with higher scores indicating more severe dysphagia, and assesses salivary pooling, laryngeal reflex, timing of swallow initiation, and pharyngeal clearance [32]. Although the Hyodo system is more familiar in Japan than in some international settings, it captures clinically relevant components of pharyngeal swallowing that are not fully represented by symptom questionnaires alone. No statistically significant between‐group interaction was observed for the total Hyodo score, and the corresponding confidence intervals at each time‐point were wide and spanned zero. These findings indicate that a between‐group difference was not detected, but they do not by themselves establish similarity of postoperative swallowing recovery. In a recent TOVS study, postoperative FEES abnormalities were observed in a subset of patients despite generally preserved oral intake and overall QOL, highlighting the value of combining objective and subjective measures [33]. Similarly, previous studies of transoral surgery emphasized that postoperative dysphagia may be influenced by patient performance status, previous irradiation, and treatment intensity, reflecting the multifactorial nature of swallowing recovery [14, 34]. Therefore, this study contributes to the literature by showing that, when patient‐reported QOL and endoscopic swallowing findings are integrated, there was no clear evidence that recovery profiles differed between TOVS and TORS in patients with oropharyngeal cancer.
The current findings should also be interpreted within the context of the established influence of treatment intensification on functional outcomes. Previous TORS studies have shown that adjuvant radiotherapy, particularly chemoradiotherapy, is associated with poorer long‐term swallowing‐related outcomes, greater weight loss, and worse eating‐related QOL [29, 30, 31]. This consideration is directly relevant to comparisons of transoral approaches, because the postoperative functional course may be shaped as strongly by adjuvant treatment as by the primary surgical technique. Although this study was not designed to isolate the independent effects of adjuvant treatment in multivariable analysis, restricting the cohort to oropharyngeal lesions reduced some anatomical heterogeneity that has complicated earlier comparisons across mixed head and neck subsites.
From a practical perspective, these data support the clinical role of TOVS as an organ‐preserving, functionally acceptable transoral procedure for patients with oropharyngeal cancer. This finding is particularly relevant in regions where access to robotic systems is limited and non‐robotic transoral procedures remain the predominant surgical option. In these settings, evidence that TOVS can achieve postoperative QOL and swallowing outcomes that did not differ significantly from those after TORS may inform individual treatment selection, broader technique adoption, and healthcare resource allocation.
Some limitations warrant emphasis. First, the TORS cohort was small, and questionnaire availability declined over time, particularly at 12 months, limiting statistical power and estimate precision. Second, treatment allocation was nonrandomized, and clinically relevant between‐group imbalances may not have been fully addressed by covariate adjustment. Because the present cohort substantially overlaps with the oropharyngeal cancer subset of our previous report [13], these findings should be interpreted as an extension of that analysis rather than as an independent replication. Third, informative missingness cannot be excluded: by 12 months, 53.8% of TORS and 54.3% of TOVS patients had missing PRO data, of which 57.1% and 68.4%, respectively, were attributed to patient‐related events. Missingness was predominantly administrative early and patient‐related later, a pattern that may reflect post‐oncologic recovery; however, differential selection bias between approaches cannot be excluded. The absence of statistically significant differences in the four functional outcomes should therefore not be interpreted as evidence of equivalence; this study was not designed as an equivalence or noninferiority trial. Fourth, the dataset lacked detailed quantitative measures of surgical invasiveness (resected volume, depth of muscular‐layer invasion, defect surface area, reconstruction, or intraoperative tracheostomy); resection extent could therefore only be approximated using categorical proxies (anatomic subsite, T stage, and neck dissection). The higher proportion of functionally high‐risk subsite resections in the TOVS group (60.0% vs. 30.8%) suggests that residual confounding by resection extent may remain despite multivariable adjustment. Fifth, the Kruskal–Wallis and Mann–Whitney analyses in Tables 2 and 3 are descriptive only; the prespecified LMM is the primary analytic framework for the four longitudinal outcomes. Sixth, TORS was introduced later (June 2022) than TOVS, so the groups were accrued during different calendar periods. Although both procedures were performed by the same surgical team under a shared perioperative management protocol, temporal changes in patient selection, surgical experience, and perioperative management may have influenced the observed outcomes. Finally, although the Hyodo score provides objective FEES‐based information, it is less familiar internationally than more widely used swallowing instruments.
5. Conclusion
In this retrospective single‐center cohort, no statistically significant between‐group differences in patient‐reported quality of life or FEES‐based swallowing outcomes were detected between TOVS and TORS. The design does not permit inference of functional equivalence, but the findings support TOVS as a practical, function‐preserving transoral option for selected patients with oropharyngeal cancer. Larger, prospectively collected comparative datasets with more complete follow‐up and stronger control of confounding are needed.
Funding
The authors have nothing to report.
Ethics Statement
This retrospective single‐center study was approved by the Institutional Review Board of Tokai University School of Medicine (approval no. 25R067; date of approval: August 19, 2025). The study was conducted in accordance with the Declaration of Helsinki and its later amendments.
Consent
This retrospective analysis was conducted using an opt‐out process. Patients who declined participation were excluded from the study.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Table S1: Reasons for missing questionnaire forms at each assessment time point.
Table S2: Between‐group comparisons of EORTC QLQ‐C30 and QLQ‐H&N35 scores at 1 and 12 months.
Acknowledgments
The authors used Genspark, a generative artificial intelligence (AI) tool, to assist with initial draft preparation and language refinement. All AI‐generated suggestions were critically reviewed and revised by the authors, who take full responsibility for the final manuscript, including its accuracy, references, and conclusions.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1: Reasons for missing questionnaire forms at each assessment time point.
Table S2: Between‐group comparisons of EORTC QLQ‐C30 and QLQ‐H&N35 scores at 1 and 12 months.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.