TOEPVA: a systematic review and meta-analysis of safety, efficacy and feasibility.

INTRODUCTION We aim to critically evaluate existing literature on transoral endoscopic parathyroidectomy via the vestibular approach (TOEPVA) - a remote-access technique developed to eliminate visible cervical scarring in the management of primary hyperparathyroidism (pHPT) while preserving optimal cure rates. This systematic review evaluates the safety, efficacy and operative outcomes of TOEPVA.

Methods

A total of 1,991 records across PubMed, Cochrane, Embase and Scopus were identified following PRISMA 2020 guidelines. Eligible designs included case series and nonrandomised comparative cohort studies reporting TOEPVA in adults. Primary outcome was biochemical cure; secondary outcomes included operative time, length of stay, complication rates, cosmetic satisfaction and pain scores. Meta-analysis was performed using the Freeman-Tukey double arcsine transformation.

Findings

Nine studies comprising 259 patients were analysed. Biochemical cure was achieved in 98.8% (n = 256). Complication rates were low: transient recurrent laryngeal nerve (RLN) paresis 2.73% (n = 4), permanent RLN injury 0%, mental nerve dysfunction 1.94% (n = 5), transient hypocalcaemia 5.55% (n = 10) and permanent hypoparathyroidism 0%; 4.37% (n = 11) required conversion to open surgery. Mean operative time was 108 minutes; median hospital stay was 3 days.

Conclusions

In a highly selected patient cohort, TOEPVA offers short-term efficacy and low morbidity similar to that of conventional open parathyroidectomy, with the potential for improved cosmetic outcomes. However, current evidence is limited to small single-centre experiences. Prospective multicentre randomised studies with standardised reporting are required to clarify its role among conventional and other remote-access approaches. Further evidence is required to define its role in patients with nonconcordant or negative preoperative imaging.