Ten Years After TOETVA: Why Did We Abandon the Transoral Route?

Background Transoral endoscopic thyroidectomy via the vestibular approach (TOETVA) was introduced in our programme 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 summarises a decade of practice, showing how TOETVA was progressively deemphasised and discontinued, and identifying clinical and technical factors driving case allocation toward percutaneous thermal ablation or minimally invasive video-assisted thyroidectomy (MIVAT). Methods All thyroid procedures performed from 2015 to 2025 were reviewed. Among 2,848 operations, 650 minimally invasive or percutaneous interventions (TOETVA, MIVAT, thermal ablation, open surgery) were analysed. 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 MIVAT over TOETVA. Results TOETVA use declined rapidly, while MIVAT and open surgery remained stable and ablation became the dominant minimally invasive strategy for benign nodules and selected papillary microcarcinomas. Conversion from TOETVA/MIVAT proposals to ablation increased from 19.2% to 54.3%, and later surgical year independently favoured ablation. Benign nodules with negative molecular results showed the strongest association with ablation, whereas molecularly suspicious nodules were preferentially directed to MIVAT. Ablation had the lowest morbidity and best preservation of thyroid function. TOETVA incurred access-specific complications, higher neuromonitoring failure, and the greatest composite complication burden. Conclusion Within a high-volume endocrine surgery programme offering all available approaches, TOETVA was progressively marginalised and effectively discontinued, supplanted by ablation for cytologically/molecularly low-risk nodules and by MIVAT when oncological assurance was required.