title: Transoral Robotic Surgery and the Unknown Primary: A Cost-Effectiveness Analysis.
abstract: To evaluate the cost-effectiveness of transoral robotic surgery (TORS) for the diagnosis and treatment of cervical unknown primary squamous cell carcinoma (CUP).
  
  
  
  Case series with chart review.
  
  
  
  Tertiary academic hospital.
  
  
  
  A retrospective chart review was performed on patients with new occult primary squamous cell carcinoma of the head and neck with nondiagnostic imaging and/or endoscopy who were treated with TORS at a tertiary hospital between 2009 and 2012. Direct costs were obtained from the hospital's billing system, and national data were used for inpatient hospital costs and physician fees. The proportion of tumors found in 3 strategies was used as effectiveness to calculate the incremental cost-effectiveness ratio.
  
  
  
  In total, 206 head and neck robotic cases were performed at our institution between December 2009 and December 2012. Three surgeons performed TORS on 22 patients for occult primary squamous cell carcinoma. The primary tumor was located in 19 of 22 patients (86.4%). The incremental cost-effectiveness ratio for sequential and simultaneous examination under anesthesia with tonsillectomy (EUA) and TORS base of tongue resection was $8619 and $5774 per additional primary identified, respectively.
  
  
  
  Sequential EUA followed by TORS is associated with an incremental cost-effectiveness ratio of $8619 compared with traditional EUA alone. Bilateral base of tongue resection should be considered in the workup of these patients, particularly if the palatine tonsils have already been removed.
authors.affiliation: Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA byrdjk@upmc.edu.
authors.forename: J Kenneth
authors.initials: JK
authors.lastname: Byrd
authors.affiliation: Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Smith
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.
authors.forename: John R
authors.initials: JR
authors.lastname: de Almeida
authors.affiliation: Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: W Greer
authors.initials: WG
authors.lastname: Albergotti
authors.affiliation: Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Kara S
authors.initials: KS
authors.lastname: Davis
authors.affiliation: Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Seungwon W
authors.initials: SW
authors.lastname: Kim
authors.affiliation: Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Jonas T
authors.initials: JT
authors.lastname: Johnson
authors.affiliation: Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Ferris
authors.affiliation: Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA VA Pittsburgh Health System, Pittsburgh, Pennsylvania, USA.
authors.forename: Umamaheswar
authors.initials: U
authors.lastname: Duvvuri
mesh_terms: D000328:Adult; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000556:secondary / Q000601:surgery*; D003362:Cost-Benefit Analysis; D004180:Direct Service Costs; D005260:Female; D006258:Head and Neck Neoplasms / Q000556:secondary / Q000601:surgery*; D017721:Hospital Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D009382:Neoplasms, Unknown Primary / Q000601:surgery*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000191:economics*
keywords: TORS; cost-effectiveness analysis; occult primary; transoral robotic surgery