INTRODUCTION
Robotic surgery was first used in 1985 to perform the biopsy in the field of brain surgery. Afterward, it has become widely used worldwide, especially in prostate cancer cases.1 Robotic thyroid surgery has been extensively used in the Far East in the last 20 years;2 but not in western countries. Since the time of Nobel Prize-winning scientist Theodor Kocher, one of the pioneers of modern surgery, open thyroid surgery has been successfully implemented in many countries worldwide without major changes.
Considering the basic criteria in surgical method selection for cases with surgical indication, such as cost, risk, and advantages,3 robotic thyroidectomy (RT) and open thyroidectomy (OT) were compared in our study. Therefore, this study aimed to increase the awareness of the surgeons when deciding on the surgical method for thyroid cancers. Additionally, ethical and medico-legal problems that may arise in the selection of operations were evaluated.
MATERIALS and METHODS
Our study evaluated the breast, axillar, bilateral axillary breast, and facelift approaches within the scope of RT. Standard classical thyroidectomies that were not performed by remote control were evaluated as OT.
Long-term follow-up and RT and/or OT studies, which consisted of a large number of cases compared the reported results with each other and statistically evaluated and revealed the cost, risk, and advantages. Criteria used to evaluate the advantages and risk factors include operative time, morbidity rates, recurrence rates, and cosmetic results.
Studies conducted by Cabot et al.4, by Broom et al.5, and in Turkey6 compared the RT and OT costs and statistically evaluated results.
Russel et al.7 conducted a study of total thyroidectomy in 216 RT and 419 OT cases, Lee et al.8 in 68 RT and 110 OT cases, Kim et al.9 in 69 RT and 138 OT cases, and Christine et al.10 in 25 RT and 25 OT cases undergoing lobectomy, wherein mean operation times were compared and results were statistically evaluated.
The morbidity rate in 4751 patients who underwent RT in the study of Kim et al.11 in the same institute, 1503 patients who underwent OT by Sciuto et al.12 in the same institute, and 40,025 thyroid cancer cases by Caulley et al.13 were compared and results were statistically evaluated.
Seul and et al.14 conducted a study in 245 RT and 494 OT cases, Kim et al.15 in 41 RT and 102 OT cases, and Billmoriave et al.16 in 10,247 OT cases, wherein results were compared and statistically evaluated.
The study results of Lee et al.17 in 66 OT and 62 RT cases and of Kyung et al.18 in 75 RT and 226 OT cases were compared and statistically evaluated.
Statistical Analysis
Independent t-test between the samples at the a=0.01 level of significance was performed for large samples and the Wilcoxon-Rank-Sum test for samples of <30. Standard deviations and sample sizes were obtained from reference articles and t-statistics, and two-sided p-values were obtained for significance. When standard deviations were not given, range values (R) were used to estimate the standard deviation by using s = (max − min)/4.
Ethics Committee Approval
Ethics committee approval was received for this study from Girne American University Ethics Committee (approval date: 01.13.2020, approval number: 2020-009).
RESULTS
The results that compare the obtained data from the publications in which the costs were determined in RT and OT cases are presented (Table 1).
Table 1 shows the comparison of the costs in cases with RT or OT. A significant difference was determined in the cost between RT and OT (p <0.0001) in all cases; RT cases being significantly more costly compared to OT cases.
The results of the comparison of the mean operation times in the reported publications of RT and OT cases are shown in Table 2.
Table 2 shows the mean operation times compared in the reported publications of RT and OT cases. The RT times are significantly longer than that of OT in all cases.
Morbidity rates in patients with thyroid cancer undergoing RT and OT are shown in Table 3.
Table 3 shows the comparison of morbidity rates in patients with thyroid cancer undergoing RT and OT. The morbidity rates between the two groups were significantly different from each other, and morbidity rates were significantly higher in the RT group compared to the OT group.
Recurrence rates in patients who were followed for >5 years and underwent robotic total thyroidectomy (RTT) and open total thyroidectomy (OTT) (Table 4).
Table 4 shows the recurrence rates in patients with thyroid cancer undergoing RTT and OTT. Results show no statistically significant differences between RTT and OTT in recurrence rates.
The comparison of cosmetic results of RT and OT is shown in Table 5.
Table 5 shows the comparison of cosmetic results in RT and OT cases. A significant difference was seen between the RT and OT cases, wherein RT cases were significantly more satisfied compared to OT cases.
The advantages and disadvantages of RT compared to OT in thyroid cancer cases (Table 6).
DISCUSSION
OT surgeries can be performed together with support staff with basic operating room knowledge and experience in all hospitals that can provide second-degree health services that do not require advanced technological logistic support. The patient can be taken to surgery immediately after surgical indication and complete routine preparations. RT operations require operator and support staff that passed the course with sufficient knowledge and experience.19
RT operations require approximately 3 million USD investments in operating theaters.20
Once these machines are supplied, establishing relations with companies for every logistic need before each operation is necessary. This situation makes the patient’s circulation significantly difficult and cumbersome.21
The comparison of OT and RT surgery costs revealed a significant difference (Table 1). The robotic arm payment that needs to be changed in each operation is approximately ₺ 3,000. This charge is not payable by the National Insurance Institution (SGK).6 SUT prices in OT operations are ₺ 1,200 in Turkey. It can be done with operating room materials in medium-sized hospitals without any extra logistic requirements. Hospitals, where RT surgeries can be performed, have quite high operating costs apart from the need for extra logistics and is approximately ₺ 25,000.22 The evaluation of both surgical methods in “cost, risk, and benefits” revealed that RT was disadvantageous in “cost” compared to the OT.
Operation times under general anesthesia significantly increase morbidity. Myocardial infarction, renal failure, thromboembolic complications, arrhythmia, atelectasis, and other pulmonary complications can occur in the postoperative period. A meta-analysis conducted by Cheng et al.23 revealed that an increased postoperative complication rate by 14% with every half-hour increased operation time. The comparison of operating times in RT and OT in patients with thyroid cancer revealed a significantly higher RT time than OT (Table 2). RT cases undergoing total thyroidectomy have approximately 40 min longer operating times. Few studies have reported a statistically insignificant difference between the cases with RT and OT.24 The number of studies with higher operation times in RT is more.7,8,10,19 According to these study results, longer operation times seem to be a major disadvantage of RT.
Postoperative morbidity rates were considered as an important risk factor in determining the surgical methods for thyroid cancers. Among the studies performed on RT and OT in thyroid cancers, especially those with a high number of cases were included in this study. The comparison of the morbidity rates in RT and OT cases revealed that morbidity rates are higher in RT cases (Table 3). The study conducted by Kim et al., where the largest case series with RT in thyroid cancers have been published so far, revealed the average morbidity rate of 24.1. Cases that were followed up for an average of 52.5 months were divided into 4 periods and revealed that morbidity rates were 25.8 in the first period, 23.2 in the second period, and 29.5 in the third period, which reduced to 14.7% in end-stage patients with 964 cases.11 However, a large series of 40,025 cases with OT thyroid cancer cases published by Caulley et al. revealed an average of 7.74 morbidity rate.13 There are small case series where the difference between the morbidity rates in heterogeneous patient groups performed RT and AT is meaningless.7
One of the most important reasons for higher postoperative complications in thyroid cancer cases with RT may be the longer operation time.22 The high amount of dissection in RT causes more bleeding.21 Comparative studies revealed significantly more bleeding in patients who performed RT than those who had OT.8,21,25 Although not seen in cases with OT, some complications are seen in RT cases such as spinal accessory nerve palsy,11 hypoglossus injury,25 numbness in the brachial plexus distribution (breast skin) on the operation side,10 induration due to dissection under the breast skin and suspicious image in related mammography,21 and Horner syndrome.11 The comparison of morbidity rates revealed that RT is riskier.
Some factors affected the recurrence rates in thyroid cancers, especially papillary thyroid cancers (PTC) are likely to be multicentric (MC) tumor and is approximately 20%.26 Cervical lymph node metastases and tumor recurrence rates are high in MC PTCs.27 Recurrence rates of tumors were higher in PTC cases with BRAFV600E mutation.28 Results of studies in large differential thyroid cancer (DTC) series revealed increased recurrence rates after age 45 years and in males.29 Tumor diameter is an important factor in increasing recurrence rates in differentiated thyroid cancers. Recurrence rates increase after the operation in cases of >1 cm.30
The series of thyroid cancer cases in our study with RT and followed for >5 years are very few. Current studies revealed no statistically significant difference between the recurrence rates in patients with RT of <1 cm in diameter and patients with RT and OT in thyroid cancer cases (Table 4). Many cases that are considered recurrences in thyroid cancers reported no relapse but residual tissue.31 Considering approximately 20% of DTC cases are MC, thyroid cancers should remove all the thyroid tissue.32 Removing the tissue completely by harmonic dissection especially at the level of the Zuckerkandl protrusion in RT is very difficult.21 Recurrence rates were investigated in some non-homogeneous patients with DTC who underwent RT and OT and are followed for <5 years and revealed no significant differences.9,32 Many studies compared RT and OT surgeries and do not recommend RT in risky cases because it increases morbidity and recurrence rates.19,24 When risky patients are separated, the patient group suitable for RT decreases.
Mortality rates could not be compared as a risk factor in both surgical methods since the absence of case series in which 10 years of follow-up was reported in patients undergoing RT.
RT and OT studies that compared the results related to cosmetic satisfaction after the operation revealed a significantly higher patient satisfaction in patients with RT (Table 5). This situation is an advantage in favor of RT. In patients who underwent OT without lateral neck dissection, scarring is avoided if incisions are made with the appropriate surgical technique parallel to the skin lines.33 Thus, if the patient does not want any scar tissue on his neck, the higher risks of RT surgery than OT should be clearly explained to the patient for ethical reasons.21 However, even if the patient prefers RT, it should be kept in mind that medical problems that may arise since RT may cause legal and criminal problems, despite the detailed consent form.
The advantages and disadvantages of RT are collectively shown in Table 6. According to these results, the only advantage of RT seems to be better cosmetic results.
CONCLUSION
According to our study results, RT decisions should be taken under limited conditions in thyroid cancers based on necessary outside logistic support, a significant amount of operating room extra machines and materials, low patient circulation rate, and the medico-legal problems that may arise.
Main Points
• RT is a new surgical method whose long-term follow-up results are unclear.
• RT is several times more expensive than OT and requires specialized personnel who are relatively trained, thus cannot be performed in every hospital.
• Operation time is significantly longer in RT than OT. Therefore, postoperative complication rates are higher than OT.
• RT has no obvious superiority over OT. When an appropriate operation technique is applied, very few scars remain in the neck in OT. Even without a scar on the patient’s neck, numbness can occur on the breast skin, as well as stiffness under the breast skin, which may give false-positive results in future mammograms for tumor risk assessments.
• A patient who does not want any scar on her neck and if she insists on RT surgery, risks of RT should be clearly explained before surgery for medico-legal reasons.
ETHICS
Ethics Committee Approval: Ethics committee approval was received for this study from Girne American University Ethics Committee (approval date: 01.13.2020, approval number: 2020-009).
Informed Consent: It was obtained.
Peer-review: Externally peer-reviewed.
Author Contributions
Concept: H.A.; Design: H.A.; Supervision H.A.; Resources: H.A.; Data Collection and/or Processing: H.A.; Analysis and/or Interpretation: A.Ü.; Literature Search: H.A.; Writing: H.A.; Critical Review: H.A.
DISCLOSURES
Conflict of Interest: The authors declare no conflicts of interest.
Financial Disclosure: The authors declared no financial support for this study.