Ten years after transoral endoscopic thyroidectomy vestibular approach (TOETVA): Why did we abandon the transoral route?

Abstract

Background: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) was introduced in our program as a remote-access, "scarless" alternative to open thyroidectomy to meet cosmetic demand. With increasing experience and the availability of outpatient technologies, its role shifted. This study summarizes a decade of practice, showing how the transoral endoscopic thyroidectomy vestibular approach was progressively de-emphasized and discontinued, and identifying clinical and technical factors driving case allocation toward percutaneous thermal ablation or minimally invasive video-assisted thyroidectomy.

Methods: All thyroid procedures performed from 2015 to 2025 were reviewed. Among 2,848 operations, 650 minimally invasive or percutaneous interventions (transoral endoscopic thyroidectomy vestibular approach, minimally invasive video-assisted thyroidectomy, thermal ablation, and open surgery) were analyzed. Primary outcomes were temporal trends in modality use, migration from an initial endoscopic plan to ablation, and approach-specific complications. Secondary endpoints included neuromonitoring performance, long-term levothyroxine requirement, and predictors of selecting ablation or minimally invasive video-assisted thyroidectomy over the transoral endoscopic thyroidectomy vestibular approach.

Results: Transoral endoscopic thyroidectomy vestibular approach use declined rapidly, whereas minimally invasive video-assisted thyroidectomy and open surgery remained stable, and ablation became the dominant minimally invasive strategy for benign nodules and selected papillary microcarcinomas. Conversion from transoral endoscopic thyroidectomy vestibular approach/minimally invasive video-assisted thyroidectomy proposals to ablation increased from 19.2% to 54.3%, and the later surgical year independently favored ablation. Benign nodules with negative molecular results showed the strongest association with ablation, whereas molecularly suspicious nodules were preferentially directed to minimally invasive video-assisted thyroidectomy. Ablation had the lowest morbidity and best preservation of thyroid function. The transoral endoscopic thyroidectomy vestibular approach incurred access-specific complications, higher neuromonitoring failures, and the greatest composite complication burden.

Conclusion: Within a high-volume endocrine surgery program offering all available approaches, the transoral endoscopic thyroidectomy vestibular approach was progressively marginalized and effectively discontinued, supplanted by ablation for cytologically/molecularly low-risk nodules and by minimally invasive video-assisted thyroidectomy when oncologic assurance was required.