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Pang et al. Mini-invasive Surg 2024;8:27 https://dx.doi.org/10.20517/2574-1225.2023.124 Page 7 of 11

Robot-assisted resection
The evolution of head and neck surgery has been markedly influenced by robot-assisted resection, especially
with the integration of transoral robotic surgery (TORS) for salvage nasopharyngectomies in recurrent NPC
cases. Robot-assisted nasopharyngectomy is mainly applicable to patients with small recurrent NPC (rT1-
rT2) that is localized and has minimal invasion into surrounding structures. Ozer et al. blazed the trail in
[46]
2008 by pioneering transoral robotic nasopharyngectomy as a therapeutic avenue for NPC . This was soon
followed by the proposition and validation of combined transnasal and transoral robotic
nasopharyngectomy through cadaveric anatomical evaluations [47-49] . Tsang et al. reported that robotic-
assisted nasopharyngectomy for recurrent NPC achieved a five-year local control rate of 85.1%, an overall
[50]
survival rate of 55.7%, and a disease-free survival rate of 69.1% .
The distinguishing features of TORS nasopharyngectomy include exceptional tumor visualization provided
by a 3D camera and the enhanced dexterity of the robotic wrist design, which is especially valuable for
navigating the tight spaces of the nasopharynx. When the tumor’s extent mandates a sphenoid bone
resection, a synergistic approach combining transnasal endoscopy and transoral robot assistance proves
effective [45,51] . Nonetheless, TORS nasopharyngectomy has its limitations, particularly the lack of the tactile
feedback intrinsic to open surgeries. While TORS can be utilized for retropharyngeal lymph node
recurrence, its current application remains circumscribed to diminutive recurrent tumors manifesting local
parapharyngeal invasion.

Endoscopic microwave coagulation therapy
In addition to traditional endoscopic approaches, novel techniques such as endoscopic microwave
coagulation therapy have been explored for managing early recurrent T1 NPC. Mai et al. demonstrated that
this technique offers a promising alternative for local tumor control with reduced complications and
[52]
improved patient outcomes .

Indications for different surgical methods
Endoscopic nasopharyngectomy
This approach is particularly suitable for early-stage (T1-T2) or recurrent (rT1-rT2) NPC confined to the
nasopharynx or parapharyngeal space, with no involvement of critical structures such as the skull base or
internal carotid artery. It is ideal for patients who cannot undergo radiotherapy or who experience
significant side effects from prior radiation.

Robot-assisted nasopharyngectomy
Recommended for small, localized tumors requiring precise dissection, this method provides enhanced
visualization and dexterity, making it suitable for early-stage NPC where detailed excision is necessary.

Maxillary swing approach
Indicated for cases where early-stage NPC extends into the parapharyngeal space or when greater access is
required to ensure complete resection. This approach is beneficial when endoscopic methods may not
achieve clear surgical margins.

SURVIVAL AND PROGNOSIS
Surgical treatment of locally recurrent NPC has shown promising outcomes, with 5-year survival rates
generally ranging from 63% to 77.1%. For nasopharyngeal adenocarcinoma, the 5-year survival rate is
around 57.1% [16,32,53-56] . Notably, about 30% of patients who receive salvage nasopharyngectomy for recurrent
NPC eventually succumb to the disease, with distant metastasis being the predominant cause of