Oncologic, Functional, and Economic Outcomes of Transoral Robotic Surgery in HPV-Positive Oropharyngeal Squamous Cell Carcinoma: A Systematic Review and Meta-analysis of Pathology- and Imaging-Guided Treatment Strategies

BackgroundThe incidence of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) has increased substantially, predominantly affecting younger patients with favourable survival outcomes. As long-term survival improves, minimizing treatment-related morbidity has become a key clinical objective. Transoral robotic surgery (TORS) provides precise pathological staging that may facilitate treatment de-escalation; however, integrated evidence on oncologic, functional, and economic outcomes remains limited. ObjectiveTo systematically evaluate oncologic, functional, and economic outcomes of TORS-based treatment strategies in patients with HPV-positive OPSCC through systematic review and meta-analysis. MethodsA systematic review and meta-analysis were conducted in accordance with PRISMA 2020 guidelines. PubMed, Wiley Online Library, MDPI, Cureus, and MedRxiv were searched for English-language studies published between 2019 and 2025. Meta-analyses were performed for 2-, 3-, and 5-year overall survival, postoperative tracheostomy rates, long-term gastrostomy dependence, and postoperative hemorrhage using random-effects models. Study quality was assessed using validated tools, including RoB 2.0, NOS, MINORS, and JBI checklists. ResultsTwenty-two studies (20 clinical and 2 economic analyses), comprising over 7,000 patients, were included. Meta-analysis demonstrated pooled overall survival rates exceeding 95% at 2 years and favourable survival at 3 and 5 years. Pooled rates of long-term gastrostomy dependence and tracheostomy were low (<5%), and postoperative hemorrhage was infrequent. Pathological upstaging following TORS frequently identified adverse features, enabling risk-adapted adjuvant therapy. De-escalation strategies were associated with substantial reductions in severe treatment-related toxicity while preserving swallowing function and quality of life. Economic analyses suggested that higher upfront surgical costs may be offset by reduced adjuvant therapy and long-term morbidity. ConclusionTORS represents an oncologically sound primary treatment for HPV-positive OPSCC that enables accurate pathological risk stratification and supports treatment de-escalation. Meta-analytic evidence indicates excellent survival outcomes with low rates of major functional morbidity, and TORS may offer long-term economic advantages in appropriately selected patients treated at experienced centres.