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Background

The incidence of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) has increased substantially. Transoral robotic surgery (TORS) provides precise pathological staging that may facilitate treatment de-escalation; however, integrated evidence on oncological, functional, and economic outcomes remains limited.

Objective

To systematically evaluate oncological, functional, and economic outcomes of TORS-based treatment strategies in patients with HPV-positive OPSCC through systematic review and meta-analysis.

Methods

A systematic review and meta-analyses were conducted (PRISMA 2020). PubMed, Wiley, MDPI, Cureus, and MedRxiv were searched for studies published between 2019 and 2025. Meta-analyses were performed for 2-, 3-, and 5-year overall survival (OS), tracheostomy rates, long-term gastrostomy dependence, and postoperative bleeding using random-effects models.

Results

Twenty-two studies (20 clinical, 2 economic), comprising patients across 14 studies contributing to the quantitative meta-analysis. The pooled 2-, 3-, and 5-year overall survival (OS) rates were 86%, 96%, and 82%, respectively (with the 5-year OS reaching 92% in the consistent subgroup analysis). Functional preservation was excellent, with a remarkably low long-term gastrostomy dependence rate of 2% and a pooled tracheostomy rate of 9% (increasing to 11% after addressing study outliers). The pooled postoperative hemorrhage rate was 7%. Pathological upstaging following TORS frequently identified adverse features, enabling risk-adapted adjuvant therapy. De-escalation strategies were associated with substantial reductions in severe toxicity (Grade 3–5 toxicity dropping from 60% to 14% in key trials) while preserving quality of life. Economic modeling studies suggested that higher upfront surgical costs associated with TORS may be partially offset by reduced utilization of adjuvant therapy and lower rates of long-term treatment-related morbidity; however, these findings are based on limited available economic data.

Conclusion

TORS is an oncologically sound primary treatment for HPV-positive OPSCC, enabling accurate risk stratification and treatment de-escalation. Meta-analytic findings suggest favorable survival outcomes and low rates of major functional morbidity) 2% feeding tube dependence), supporting the potential value of TORS-based strategies in appropriately selected patient populations.