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The past two decades have witnessed a revolutionary era for peripheral bronchoscopy. Though the initial description of radial endobronchial ultrasound can be traced back to 1992, it was not until the mid-2000s that its utilization became commonplace, primarily due to the introduction of electromagnetic navigation (EMN) bronchoscopy. While the diagnostic yield of EMN-assisted sampling has shown substantial improvement over historical fluoroscopy-assisted bronchoscopic biopsy, its diagnostic yield plateaued at around 70%. Factors contributing to this relatively low diagnostic yield include discrepancies in computed tomography to body divergence, which led to unsuccessful lesion localization and resultant unsuccessful sampling of the lesion. Furthermore, much of peripheral bronchoscopy utilized a plastic extended working channel whose tips were difficult to finely aim at potential targets. However, the recent introduction of robotic-assisted bronchoscopy, and its associated stability within the peripheral lung, has ignited optimism for its potential to significantly enhance the diagnostic performance for peripheral lesions. Moreover, some envision this technology eventually playing a pivotal role in the therapeutic delivery to lung tumors. This review aims to describe the currently available robotic-assisted bronchoscopy technologies and to discuss the existing scientific evidence supporting these.

Robotic‐assisted bronchoscopy (RAB) is a newly developed bronchoscopic technique for the diagnosis of peripheral pulmonary lesions (PPLs). The objective of this meta‐analysis was to analyze the diagnostic yield and safety of RAB in patients with PPLs. Five databases (PubMed, Embase, Web of Science, CENTRAL, and ClinicalTrials.gov) were searched from inception to April 2023. Two independent investigators screened retrieved articles, extracted data, and assessed the study quality. The pooled diagnostic yield and complication rate were estimated. Subgroup analysis was used to explore potential sources of heterogeneity. Publication bias was assessed using funnel plots and the Egger test. Sensitivity analysis was also conducted to assess the robustness of the synthesized results. A total of 725 lesions from 10 studies were included in this meta‐analysis. No publication bias was found. Overall, RAB had a pooled diagnostic yield of 80.4% (95% CI: 75.7%–85.1%). Lesion size of >30 mm, presence of a bronchus sign, and a concentric radial endobronchial ultrasound view were associated with a statistically significantly higher diagnostic yield. Heterogeneity exploration showed that studies using cryoprobes reported better yields than those without cryoprobes (90.0%, 95% CI: 83.2%–94.7% vs. 79.0%, 95% CI: 75.8%–82.2%, p < 0.01). The pooled complication rate was 3.0% (95% CI: 1.6%–4.4%). In conclusion, RAB is an effective and safe technique for PPLs diagnosis. Further high‐quality prospective studies still need to be conducted. We performed a meta‐analysis to analyze the diagnostic yield and safety of robotic‐assisted bronchoscopy in patients with peripheral pulmonary lesions. A total of 725 lesions from 10 studies were included. The pooled diagnostic yield was 80.4% (95% CI: 75.7%–85.1%), and the pooled complication rate was 3.0% (95% CI: 1.6%–4.4%). Lesion size of >30 mm, presence of a bronchus sign, and a concentric radial endobronchial ultrasound view were associated with a statistically significantly higher diagnostic yield.

Background Shape‐sensing robotic‐assisted bronchoscopy (ssRAB) is a navigation platform for biopsy of indeterminate pulmonary lesions. Large‐scale, real‐world evidence confirming the safety profile of ssRAB compared to transthoracic needle biopsy (TTNB) is needed. Study Design and Methods A retrospective cohort study was performed using the PINC AI healthcare database among patients who underwent ssRAB or TTNB lung lesion biopsy at participating hospitals between April 2019 and March 2023. Outcomes were rates of pneumothorax and pneumothorax requiring chest‐tube intervention within 3 days, and rates of in‐hospital bleeding or all‐cause death. Quasi‐binomial logistic regression analysis was performed after one‐to‐five propensity score matching (PSM) accounting for patient‐ and hospital‐related characteristics. Results A total of 119 424 patients (5121 ssRAB, 114 303 TTNB) were identified with 4554 ssRAB and 14 319 TTNB patients after PSM. Relative to ssRAB, TTNB had significantly higher risk of pneumothorax (18.4% vs. 2.6%, OR = 7.10, p < 0.001) and pneumothorax requiring chest‐tube (10.8% vs. 1.4%, OR = 7.62, p < 0.001). TTNB was associated with a higher risk for bleeding (1.5% vs. 0.6%, OR = 2.20, p < 0.001) and all‐cause death (0.48% vs. 0.15%, OR = 2.47, p = 0.023); however, rates for both outcomes were relatively low. Interpretation In this large‐scale, real‐world database analysis with diverse patient populations, physician experience, and health care settings, ssRAB demonstrated a better safety profile compared to TTNB. Superior safety combined with a potentially comparable performance profile and known advantages of bronchoscopy, including concurrent staging, support ssRAB as an optimal choice for non‐surgical biopsies for suspicious pulmonary lesions. In this large‐scale database analysis, ssRAB demonstrated a better safety profile compared to TTNB. Superior safety combined with a potentially comparable performance and known advantages of bronchoscopy including concurrent staging support ssRAB as an optimal choice of biopsy for suspicious pulmonary lesions.

Background: We tested a new, investigational robotic-assisted bronchoscope system with a remotely controlled catheter to access small peripheral bronchi with real-time driving under live visualization and distal tip articulation of the catheter. The unique catheter remains stationary once located at the biopsy position. Objectives: The primary objectives of this study were to evaluate the safety and feasibility of a new shape-sensing robotic bronchoscope system to bronchoscopically approach and facilitate the sampling of small peripheral pulmonary nodules of 1–3 cm. Secondary objectives included evaluating procedural characteristics and early performance trends associated with the use of the new robotic bronchoscope system. Methods: Subjects were enrolled according to study eligibility criteria at a single center. Navigation pathways were semi-automatically created using pre-procedure CT scans. Simultaneous (real-time) viewing of actual and virtual bronchi was used real time during navigation to the displayed target. An endobronchial ultrasound mini-probe was used to confirm lesion location. Flexible 19- to 23-G needles specifically designed to accommodate tight bend radii in transbronchial needle aspiration were used along with conventional biopsy tools. Enrolled subjects completed follow-up visits up to 6 months after the procedure. Results: The study included 29 subjects with a mean lesion size of 12.2 ± 4.2, 12.3 ± 3.3, and 11.7 ± 4.1 mm in the axial, coronal, and sagittal planes, respectively. The CT bronchus sign was absent in 41.4% of cases. In 96.6% of cases, the target was reached, and samples were obtained. No device-related adverse events and no instances of pneumothorax or excessive bleeding were observed during the procedure. Early performance trends demonstrated an overall diagnostic yield of 79.3% and a diagnostic yield for malignancy of 88%. Conclusion: This new robotic-assisted bronchoscope system safely navigated to very small peripheral airways under continuous visualization, and through maintenance of a static position, it provides a unique sampling capability for the biopsy of small solitary pulmonary nodules.

Purpose Tissue acquisition in lung cancer is vital for multiple reasons. Primary reasons reported for molecular testing failure in lung cancer biopsy specimens include insufficient amount of tumor cells provided and inadequate tissue quality. Robotic bronchoscopy is a new tool enabling peripheral pulmonary lesion sampling; however, diagnostic yield remains imperfect possibly due to the location of nodules adjacent to or outside of the airway. The 1.1-mm cryoprobe is a novel diagnostic tool and accesses tissue in a 360-degree manner, thus potentially sampling eccentric/adjacent lesions. This study examines the diagnostic yield of the cryoprobe compared to standard needle aspiration and forceps biopsy. It additionally evaluates yield for molecular markers in cases of lung cancer. Methods This is a retrospective analysis of 112 patients with 120 peripheral pulmonary lesions biopsied via robotic bronchoscopy using needle aspirate, forceps, and cryobiopsy. Results The overall diagnostic yield was 90%. Nearly 18% of diagnoses were made exclusively from the cryobiopsy sample. Molecular analysis was adequate on all cryobiopsy samples sent. Digital imaging software confirmed an increase in quantity and quality of samples taken via cryobiopsy compared to needle aspirate and traditional forceps biopsy. Conclusion Using the 1.1-mm cryoprobe to biopsy PPN combined with the Ion robotic bronchoscopy system is safe, feasible, and provides more diagnostic tissue than needle aspirates or traditional forceps biopsies. The combination of cryobiopsy with robotic-assisted bronchoscopy increased diagnostic yield, likely due to its 360-degree tissue acquisition which is beneficial when targeting extraluminal lesions adjacent to the airway.

Background The Robotic Endoscopic System (Auris Health, Inc., Redwood City, CA) has the potential to overcome several limitations of contemporary guided-bronchoscopic technologies for the diagnosis of lung lesions. Our objective is to report on the initial post-marketing feasibility, safety and diagnostic yield of this technology. Methods We retrospectively reviewed data on consecutive cases in which robot-assisted bronchoscopy was used to sample lung lesions at four centers in the US (academic and community) from June 15th, 2018 to December 15th, 2018. Results One hundred and sixty-seven lesions in 165 patients were included in the analysis, with an average follow-up of 185 ± 55 days. The average size of target lesions was 25.0 ± 15.0 mm. Seventy-one percent were located in the peripheral third of the lung. Pneumothorax and airway bleeding occurred in 3.6 and 2.4% cases, respectively. Navigation was successful in 88.6% of cases. Tissue samples were successfully obtained in 98.8%. The diagnostic yield estimates ranged from 69.1 to 77% assuming the cases of biopsy-proven inflammation without any follow-up information ( N  = 13) were non-diagnostic and diagnostic, respectively. The yield was 81.5, 71.7 and 26.9% for concentric, eccentric and absent r-EBUS views, respectively. Diagnostic yield was not affected by lesion size, density, lobar location or centrality. Conclusions RAB implementation in community and academic centers is safe and feasible, with an initial diagnostic yield of 69.1–77% in patients with lung lesions that require diagnostic bronchoscopy. Comparative trials with the existing bronchoscopic technologies are needed to determine cost-effectiveness of this technology.

Robotic‐assisted bronchoscopy (RAB) has improved lung nodule evaluation, but its feasibility to biopsy aortopulmonary lymph nodes remains underexplored. This study explored the safety and effectiveness of RAB for sampling aortopulmonary lymph nodes suspected of malignancy. We conducted a literature review on RAB for aortopulmonary lymph node biopsy and present a case of a patient with a history of malignancy. Using the Ion Endoluminal System, we navigated to the anterior segment of the left upper lobe to access a subaortic lymph node in a patient with a history of mantle cell lymphoma. Biopsy confirmed disease recurrence. Our literature review identified seven patients who underwent RAB to assess aortopulmonary lymph nodes, with most findings showing small‐cell lung cancer. Our study reports an 88% diagnostic yield, and no complications associated with the procedure. RAB is a safe and effective approach for biopsying aortopulmonary lymph nodes. We present a case of a patient with a suspicious subaortic lymph node who underwent robotic‐assisted bronchoscopy sampling for hilar and mediastinal staging. A literature review is also presented.

Introduction The sensitivity of suspicious lung nodules biopsied by currently available techniques is suboptimal. Robotic-assisted navigation bronchoscopy (RANB) is a novel method for biopsying lung nodules. Our study objective was to determine the sensitivity for malignancy and overall diagnostic accuracy for RANB when combined with cone beam CT (CBCT) for secondary confirmation. Methods 52 consecutive patients were prospectively enrolled. Demographic data, nodule characteristics, procedural information, and follow-up results were obtained. Results Mean patient age was 66, with the majority Caucasian (73%) females (65%) with a similar number of never (46%) and former (46%) smokers. 15 patients had a history of cancer and 3 had a prior thoracic surgery. 59 total nodules were included as 7 patients had two nodules biopsied. Mean nodule diameter was < 2 cm in all dimension with the majority solid (41, 70%) and located in the upper lobes (left: 22, 37%; right: 17, 29%). Bronchus sign was absent (32, 54%) or present (27, 46%) in a similar number. All nodules were successfully reached with nine (15%) requiring minor directional changes after initial cone beam CT. A tissue diagnosis was obtained in 83% (49/59) of biopsied nodules, with malignancy (31, 65%) most common. Including all biopsy results and follow-up imaging, we obtained an 84% (31/37) procedural sensitivity for malignancy and an overall 86% (51/59) diagnostic yield. Conclusion RANB with CBCT increases sensitivity for malignancy and diagnostic accuracy of lung nodule biopsies. Combining these modalities has the potential to shift the diagnostic approach to pulmonary nodules.

Purpose Lung nodules are a common radiographic finding. Non-surgical biopsy is recommended in patients with moderate or high pretest probability for malignancy. Shape-sensing robotic-assisted bronchoscopy (ssRAB) combined with radial endobronchial ultrasound (r-EBUS) and cone beam computed tomography (CBCT) is a new approach to sample pulmonary lesions. Limited data are available regarding the diagnostic accuracy of combined ssRAB with r-EBUS and CBCT. Methods We conducted a retrospective analysis of the first 200 biopsy procedures of 209 lung lesions using ssRAB, r-EBUS, and CBCT at UT Southwestern Medical Center in Dallas, Texas. Outcomes were based on pathology interpretations of samples taken during ssRAB, clinical and radiographic follow-up, and/or additional sampling. Results The mean largest lesion dimension was 22.6 ± 13.3 mm with a median of 19 mm (range 7 to 73 mm). The prevalence of malignancy in our data was 64.1%. The diagnostic accuracy of ssRAB combined with advanced imaging was 91.4% (CI 86.7–94.8%). Sensitivity was 87.3% (CI 80.5–92.4%) with a specificity of 98.7% (CI 92.8–100%). The negative and positive predictive values were 81.3% and 99.2%. The rate of non-diagnostic sampling was 11% (23/209 samples). The only complication was pneumothorax in 1% (2/200 procedures), with 0.5% requiring a chest tube. Conclusion Our results of the combined use of ssRAB with r-EBUS and CBCT to sample pulmonary lesions suggest a high diagnostic accuracy for malignant lesions with reasonably high sensitivity and negative predictive values. The procedure is safe with a low rate of complications.

Lung biopsy in patients with pulmonary arterial hypertension (PH) poses a diagnostic challenge due to potential increased procedure‐related risks. This case series describes a single institution's experience using shape‐sensing robotic‐assisted bronchoscopy (ssRAB) with multi‐modality imaging to biopsy eight pulmonary lesions in eight patients with haemodynamically confirmed PH receiving pulmonary vasodilator therapy. A specific diagnosis was obtained for seven pulmonary lesions. No complications, including pneumothorax, bleeding, respiratory failure or escalation of care, were observed, and all patients were safely discharged on the day of the procedure. This study highlights that ssRAB, when conducted with advanced imaging techniques and supported by a multidisciplinary team, appears to be a safe and effective diagnostic approach for PH patients on pulmonary vasodilator therapy when evaluating suspicious lung lesions. Patient selection should be individualized, and procedures should be performed at specialized centres equipped with expertise in the peri‐procedural management of PH as well as complex bronchoscopy. Lung biopsy in patients with pulmonary arterial hypertension (PH) poses a diagnostic challenge due to potential increased procedure‐related risks. This case series describes a single institution's experience using shape‐sensing robotic‐assisted bronchoscopy (ssRAB) with multi‐modality imaging to biopsy eight pulmonary lesions in eight patients with haemodynamically confirmed PH receiving pulmonary vasodilator therapy.