Transoral Endoscopic and Minimally Invasive Thyroidectomy

Importance: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a scarless surgical technique gaining popularity; however, its safety, cost, and impact on pathological evaluation compared with minimally invasive nonendoscopic thyroidectomy (MINET) remain under evaluation. Objective: To compare surgical outcomes, pathological considerations, and cost profiles following TOETVA vs MINET using a propensity-matched cohort. Design, Setting, and Participants: This cohort study included 720 patients undergoing oncoplastic thyroidectomy between January 2021 and January 2023, with 12-month follow-up, at a tertiary referral center in Taipei, Taiwan. Propensity score matching was used to generate balanced cohorts of 210 patients each. Main Outcomes and Measures: Primary outcomes included operative duration (measured from incision to closure), intraoperative neuromonitoring (IONM) alerts (recorded in real time via standard IONM systems), parathyroid preservation (assessed by identification and in situ preservation), postoperative pain (evaluated using the visual analog scale [VAS] score on postoperative day 1), specimen integrity (as documented in final pathology reports), postoperative complications, and overall cost (derived from itemized hospital billing records). Results: Among 420 matched patients (mean age [SD], 45.6 [12.3] years; 371 [88.3%] female), TOETVA was associated with longer mean (SD) operative time (127.9 [43.8] vs 68.1 [23.3] minutes; mean difference, 59.73 minutes; 95% CI, 53.20-66.26; P < .001), fewer IONM alerts (4/255 [1.6%] vs 13/262 [5.0%]; risk difference, -3.39%; 95% CI, -6.54 to 0.08; P = .04), and fewer inadvertently resected parathyroid glands (24/510 [4.7%] vs 57/524 [10.9%]; risk difference, -6.17%; 95% CI, -9.42 to -2.85; P < .001). Pain scores were slightly higher in TOETVA (mean [SD] VAS score: 0.88 [0.22] vs 0.38 [0.13]; mean difference, 0.50; 95% CI, 0.47-0.54; P < .001). Specimen disruption was more frequent with TOETVA (27/210 [12.9%] vs 8/210 [3.8%]; risk difference, 9.05%; 95% CI, 3.52 to 14.28; P = .008). Total costs were higher in TOETVA (mean [SD], $4680 [328] vs $2734 [296]; mean difference, $1946; 95% CI, 1885.19 to 2006.87; P < .001). Conclusions and Relevance: In this propensity-matched cohort study, TOETVA was associated with favorable cosmetic outcomes and improved nerve and parathyroid preservation but longer operative times, higher costs, and greater risk of specimen disruption. These findings support the need for careful patient selection and further prospective evaluation.