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• W3080454537 abstract "Increased detection of lung nodules has led to trying to improve technologies for localization and/or tissue acquisition. Previous bronchoscopic techniques have limitations that have led to further advancements in technology. Robotic bronchoscopy has emerged as new technology for the localization, diagnosis, and potential treatment of lung nodules. The robotic bronchoscopic platform was developed to improve peripheral reach of lung nodules, provide direct continuous visualization of the periphery, and offer more precise control of the instrumentation. We review the progression of bronchoscopy, evolution to the robotic platform and its early outcomes, with considerations for future advancements. Increased detection of lung nodules has led to trying to improve technologies for localization and/or tissue acquisition. Previous bronchoscopic techniques have limitations that have led to further advancements in technology. Robotic bronchoscopy has emerged as new technology for the localization, diagnosis, and potential treatment of lung nodules. The robotic bronchoscopic platform was developed to improve peripheral reach of lung nodules, provide direct continuous visualization of the periphery, and offer more precise control of the instrumentation. We review the progression of bronchoscopy, evolution to the robotic platform and its early outcomes, with considerations for future advancements. Central MessageRobotic bronchoscopy has emerged as new technology that has the potential to improve localization of peripheral lesions in a safe manner. Robotic bronchoscopy has emerged as new technology that has the potential to improve localization of peripheral lesions in a safe manner. Lung cancer remains the leading cause of cancer-related mortalities in the United States, with the number of lung cancer deaths exceeding the combined deaths from breast, prostate, and colon cancer.1United States cancer statistics: data visualizations. Center for Disease Control and Prevention. Available at: https://gis.cdc.gov/cancer/USCS/DataViz.htmlGoogle Scholar This difference in mortality is partially related to delay in diagnosis for lung cancer,2Ellis PM Vandermeer R. Delays in the diagnosis of lung cancer.J Thorac Dis. 2001; 3: 183-188Google Scholar as opposed to breast, prostate, and colon cancer, which have well-established screening guidelines. In order to address this, the National Lung Screening Trial was performed, which demonstrated that the use of low dose computed tomography (CT) screening in patients with a high-risk profile improves early detection and long-term survival in lung cancer.3DR Aberle Adams AM Beg CD et al.National Lung Screening Trial Research TeamNational Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening.N Engl J Med. 2011; 365: 395-409Crossref PubMed Scopus (6433) Google Scholar Lung cancer screening programs have since emerged, with an estimated 1.6 million new pulmonary nodules detected by chest CT scans annually in the United States.4Gould MK Tang T Liu IL Lee J Zheng C Danforth KN et al.Recent trends in the identification of incidental pulmonary nodules.Am J Respir Crit Care Med. 2015; 192 ([PubMed: 26214244]): 1208-1214Crossref PubMed Scopus (262) Google Scholar While many nodules can be followed with serial imaging, enlarging or suspicious nodules require a tissue diagnosis. The correlating number of diagnostic procedures needed to characterize these lung lesions is increasing. With this growth, there is a need for safe and accurate techniques that can biopsy a wide array of pulmonary nodules, including ground-glass opacities and small peripheral lesions. The two common modalities for the localization or diagnosis of lung lesions are transthoracic image guidance and endoscopic bronchoscopy. Both means provide the ability to localize and biopsy pulmonary nodules for diagnosis. While transthoracic image-guided biopsies are helpful for diagnosis of peripheral pulmonary nodules, they can be associated with increased rates of complications, especially in patients with emphysematous lung changes.5Lendeckel D Kromrey ML Ittermann T Schäfer S Mensel B Kühn JP Pulmonary emphysema is a predictor of pneumothorax after CT-guided transthoracic pulmonary biopsies of pulmonary nodules.PLoS One. 2017; 12 (Published 2017 Jun 2)e0178078Crossref PubMed Scopus (12) Google Scholar Additionally, if the lesion is malignant, further staging of mediastinal lymph nodes with endobronchial ultrasound is often still needed to determine the appropriate clinical course.6Silvestri GA Gonzalez AV Jantz MA et al.Methods for staging non–small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.Chest. 2013; 143: e211S-e250SAbstract Full Text Full Text PDF PubMed Scopus (951) Google Scholar Despite these drawbacks, image-guided biopsies still have a higher diagnostic yield than bronchoscopic samples,7Bhatt KM Tandom YK Graham R et al.Electromagnetic navigational bronchoscopy versus CT-guided percutaneous sampling of peripheral indeterminate pulmonary nodules: a cohort study.Radiology. 2018; 286: 1052-1061https://doi.org/10.1148/radiol.2017170893Crossref PubMed Scopus (22) Google Scholar and remain the best option for small peripheral lesions. Conventional endoscopic biopsies are advantageous in the ability for a concurrent procedure for mediastinal staging and accuracy at evaluating the airways for endobronchial invasion if a sleeve resection is indicated. However, it is still limited in the scope of pulmonary nodules that are accessible. For all lesions that cannot be or are inadequately sampled via image-guidance or bronchoscopy, a surgical biopsy is the next step. While conventional flexible bronchoscopy for biopsy has historically been limited to central or large lesions, emerging technologies have increased the range of pulmonary lesions that can be accessed by bronchoscopy. The need for improvement in bronchoscopy is both to obtain accurate sampling through the least invasive approach, while avoiding the need for surgical excisional biopsy. The most recent development in this field is robotic bronchoscopy. In this paper, we will focus on the evolution of robotic bronchoscopy, the current available platforms and early experience, as well as potential future developments. Flexible bronchoscopy was first introduced by Dr. Shigeto Ikeda in 1965 with the use of forceps for transbronchial biopsy discovered soon afterwards.8Panchabhai TS Mehta AC Historical perspectives of bronchoscopy. Connecting the dots.Ann Am Thorac Soc. 2015; 12: 631-641Crossref PubMed Scopus (66) Google Scholar The technique to obtain biopsies was then expanded to include transbronchial needle aspiration for cytologic analysis of specimens.9Koerner SK Sakowitz AJ Appelman RI Becker NH Schoenbaum SW Transbronchial lung biopsy for the diagnosis of sarcoidosis.N Engl J Med. 1975; 293: 268-270Crossref PubMed Scopus (139) Google Scholar While all of these advances helped facilitate growth, early bronchoscopic biopsies were still restricted to central or endoluminal lesions.10Mehta AC Kavuru MS Meeker DP Gephardt GN Nunez C Transbronchial needle aspiration for histology specimens.Chest. 1989; 96: 1228-1232Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar In the 1990s, Hurter and Hanrath developed the use of radial probe ultrasound (rEBUS), which utilized ultrasound catheters through the operating channel of fiberoptic bronchoscopes to assess lung parenchyma and abnormal lesions.11Hürter T Hanrath P Endobronchial sonography: feasibility and preliminary results.Thorax. 1992; 47: 565-567Crossref PubMed Scopus (205) Google Scholar rEBUS has been instrumental in expanding bronchoscopes use to diagnose peripheral pulmonary lesions. However, rEBUS is still limited, as ultrasound is used to localize the lesion, but the radial probe is then removed and the biopsy performed in a blind fashion. Convex probe endobronchial ultrasound (cEBUS), which is a linear ultrasound probe, was developed during the same time-period, which can be used for the diagnosis of central and hilar lesions. It has additionally been shown to have a high diagnostic yield in sampling mediastinal lesions,12Yasufuku K Chiyo M Sekine Y et al.Real-time endobronchial ultrasound–guided transbronchial needle aspiration of mediastinal and hilar lymph nodes.Chest. 2004; 126: 122-128Abstract Full Text Full Text PDF PubMed Scopus (580) Google Scholar and is now the standard diagnostic tool for mediastinal staging in lung cancer.6Silvestri GA Gonzalez AV Jantz MA et al.Methods for staging non–small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.Chest. 2013; 143: e211S-e250SAbstract Full Text Full Text PDF PubMed Scopus (951) Google Scholar Still with both linear and radial probe endobronchial ultrasound, the ability to access peripheral lung lesions remained a challenge. Electromagnetic navigation bronchoscopy (ENB) was the next step in expanding the reach of diagnostic bronchoscopy. ENB is based on virtual bronchoscopy combined with real-time reconstruction of three-dimensional CT images. This technology uses multi-planar CT planning to allow for the appropriate identification of the airway, electromagnetic navigation based on CT data to create virtual lungs and track the movement of the probe, and a steerable probe with an extendable working channel to allow the physician to guide biopsy instruments to the target.13Gildea TR Mazzone PJ Karnak D Meziane M Mehta AC Electromagnetic navigation diagnostic bronchoscopy: a prospective study.Am J Respir Crit Care Med. 2006; 174: 982-989https://doi.org/10.1164/rccm.200603-344OCCrossref PubMed Scopus (363) Google Scholar The result is a dynamic, spatially and temporally tracked virtual representation of the device within the preplanned, patient-specific anatomic map.14Burks AC Akulian J Bronchoscopic Diagnostic Procedures Available to the Pulmonologist.Clinics in Chest Medicine. 2020; 41: 129-144Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar This technique has shown to be safe in navigating to and sampling peripheral lung lesions located beyond the optic limits of the standard flexible bronchoscope.15Schwarz Y Greif J Becker HD Ernst A Mehta A Real-time electromagnetic navigation bronchoscopy to peripheral lung lesions using overlaid CT images: the first human study.Chest. 2006; 129: 988-994Abstract Full Text Full Text PDF PubMed Scopus (262) Google Scholar However, the accuracy and effectiveness of ENB for diagnosis of peripheral pulmonary nodules ranges drastically,16Ost DE Ernst A Lei X et al.Diagnostic Yield and Complications of Bronchoscopy for Peripheral Lung Lesions. Results of the AQuIRE Registry.Am J Respir Crit Care Med. 2016; 193: 68-77Crossref PubMed Scopus (251) Google Scholar with one prospective randomized controlled trial finding similar results for ENB and rEBUS.17Eberhardt Ralf Anantham Devanand Ernst Armin Feller-Kopman David Herth Felix Multimodality Bronchoscopic Diagnosis of Peripheral Lung Lesions.American journal of respiratory and critical care medicine. 2007; 176: 36-41https://doi.org/10.1164/rccm.200612-1866OCCrossref PubMed Scopus (420) Google Scholar Several factors have been identified that may increase ENB yield, such as lung nodule location in the upper or middle lobe,18Gex G Pralong JA Combescure C Seijo L Rochat T Soccal PM Diagnostic Yield and Safety of Electromagnetic Navigation Bronchoscopy for Lung Nodules: A Systematic Review and Meta-Analysis.Respiration. 2014; 87: 165-176https://doi.org/10.1159/000355710Crossref PubMed Scopus (172) Google Scholar combined use with rEBUS, and larger size of peripheral pulmonary nodules (≥2 cm).19Memoli Jessica S Wang Nietert Paul J Silvestri Gerard A Meta-analysis of Guided Bronchoscopy for the Evaluation of the Pulmonary Nodule.CHEST. 2012; 142: 385-393Abstract Full Text Full Text PDF PubMed Scopus (400) Google Scholar The presence of a bronchus sign, where a bronchus leads directly to the target lesion on CT imaging, is also associated with improved localization. ENB remains limited by the difficulty of navigating small-angulated airways without full visibility, the risk of catheter slippage when a certain amount of torque is necessary, and the need to keep the catheter stationary while samples are taken.19Memoli Jessica S Wang Nietert Paul J Silvestri Gerard A Meta-analysis of Guided Bronchoscopy for the Evaluation of the Pulmonary Nodule.CHEST. 2012; 142: 385-393Abstract Full Text Full Text PDF PubMed Scopus (400) Google Scholar In addition, ENB platforms rely on preoperative CT for planning and navigation, resulting in CT body divergence (the difference between the location of the nodule on the pre-procedure CT and the actual location of the nodule during the procedure on a dynamic breathing lung). This divergence is believed to be attributable to the change in lung seen on the static pre-procedural CT vs. intra-procedural; and can be due to change in patient positioning, muscle movement, atelectasis, or due to physiologic effects from general anesthesia. CT body divergence may account for some of the disappointing yields previously seen using the standard ENB system.20Aboudara M Roller L Rickman O et al.Improved diagnostic yield for lung nodules with digital tomosynthesis-corrected navigational bronchoscopy: Initial experience with a novel adjunct.Respirology. 2020; 25: 206-213https://doi.org/10.1111/resp.13609Crossref PubMed Scopus (27) Google Scholar In order to correct for the CT-to-body divergence, this new FDA approved platform by Medtronic™ provides real time imaging using fluoroscopic navigation to enhance the visibility of the nodule and correct for the discrepancy. The new platform uses digital tomosynthesis technology with fluoroscopy to visualize and localize the nodule with real time imaging. In the initial experience using fluoroscopic ENB software, a 25% increase in diagnostic yield was observed when compared to standard ENB, without appreciable difference in complication rate. This improved diagnostic yield may approach that of image guided transthoracic biopsy, and allows for more accurate localization and sampling of small lung nodules.20Aboudara M Roller L Rickman O et al.Improved diagnostic yield for lung nodules with digital tomosynthesis-corrected navigational bronchoscopy: Initial experience with a novel adjunct.Respirology. 2020; 25: 206-213https://doi.org/10.1111/resp.13609Crossref PubMed Scopus (27) Google Scholar Robotic bronchoscopy is the most recent development localization techniques of peripheral pulmonary nodules. Since the diagnostic yield of ultrasonography and ENB remains suboptimal, the robotic bronchoscopic platform was developed to meet these shortcomings. Robotic bronchoscopy may allow more precisely maneuverability into the periphery of the lungs with greater stability and accuracy; this is done by advancing the scope further into the lung periphery based on bronchial generation counts and insertion depth when compared to conventional bronchoscopy.21Yarmus L Akulian J Wahidi M et al.A prospective randomized comparative study of three guided bronchoscopic approaches for investigating pulmonary nodules: the precision-1 study.Chest. 2019; Abstract Full Text Full Text PDF Google Scholar Similar to ENB, a high-resolution chest CT is needed pre-procedurally to create a virtual map for robotic bronchoscopy and guidance of the bronchoscope/instruments is achieved through electromagnetic navigation. Also like ENB, rEBUS can be added to the platform to help with nodule localization, though real-time fluoroscopy can also be integrated into both existing robotic platforms.14Burks AC Akulian J Bronchoscopic Diagnostic Procedures Available to the Pulmonologist.Clinics in Chest Medicine. 2020; 41: 129-144Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Early analysis of robotic bronchoscopic systems showed greater reach in all segmental bronchi within human cadaveric lungs compared to conventional thin bronchoscope with identical outer diameter.22Chen Alexander C Gillespie Colin T Robotic Endoscopic Airway Challenge: REACH Assessment.Annals of Thoracic Surgery. 2018; 106: 293-297Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar Improved access was markedly increased in areas where the endoscope underwent more acute turns, such as upper lobes and superior segments of lower lobes. Enhanced maneuverability is attributed to the ability to control and manipulate the distal end of robotic scope to negotiate subtle turns at distal airway bifurcations. Improved access and ability to control instrumentation may affect diagnostic yield by improving proximity to peripheral lesions.22Chen Alexander C Gillespie Colin T Robotic Endoscopic Airway Challenge: REACH Assessment.Annals of Thoracic Surgery. 2018; 106: 293-297Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar Cadaveric studies using the robotic platform have also demonstrated the ability to successfully biopsy simulated tumor targets 10-30mm in size. Robotic bronchoscopy successfully obtained a diagnosis in 97% of lesions in human cadaveric lungs with implanted tumor targets 10-30 mm in size. This is significant because despite introduction of advanced image guided techniques, no singular approach has demonstrated consistently high diagnostic yields for nodules of this size.23Chen AC Pastis NJ Machuzak MS et al.Accuracy of a Robotic Endoscopic System in Cadaver Models with Simulated Tumor Targets: ACCESS Study.Respiration. 2020; 99: 56-61https://doi.org/10.1159/000504181Crossref PubMed Scopus (19) Google Scholar Two robotic bronchoscopy platforms are currently commercially available: the Monarch™ (MA; Auris Health, Redwood City, CA), FDA approved in March 2018; and the Ion™ Endoluminal Platform (IEP; Intuitive, Sunnyvale, CA) that became FDA approved in February 2019. The Monarch™ system is composed of the bronchoscope, the cart with robotic arms, the tower with monitor for endoscopic and electromagnetic navigation display, and the controller (Figure 1). The bronchoscope has an inner scope and an outer sheath, both of which are controlled by the robot with four way steering. There are two independently articulating scopes housed within one another, which can be controlled simultaneously or independently with the remote control. The remote control is modeled after popular console video gaming systems, allowing for familiarity with a joy stick to control driving and articulating the scope, and buttons to control irrigation, aspiration, and other such functions. The cart is positioned near the patient's head and locked in place to provide stability, with a touchscreen on the cart handle to provide easy feedback for system set up. There are two robotic arms on the cart that control the scopes.24Fielding, D. Robotic Bronchoscopy: Driveless IP?Journal of Thoracic Oncology, Volume 14, Issue 10, S187Google Scholar The tower allows the clinician to control the system through the procedure. It provides real time video captured from the bronchoscope and integrates with the information from the pieces of the system.25Murgu SD Robotic assisted-bronchoscopy: technical tips and lessons learned from the initial experience with sampling peripheral lung lesions.BMC Pulm Med. 2019; 19: 89https://doi.org/10.1186/s12890-019-0857-zCrossref PubMed Scopus (27) Google Scholar Once the scope is navigated to selected target, bronchoalveolar lavage, brushings, forceps biopsies, and needle aspirations can all be performed through the working channel of the scope.14Burks AC Akulian J Bronchoscopic Diagnostic Procedures Available to the Pulmonologist.Clinics in Chest Medicine. 2020; 41: 129-144Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The Ion™ Endoluminal Platform uses a single bronchoscope controlled by a single robotic arm. The trackball controller for navigation is used by the physician to direct the scope into the pre-planned airways under direct vision (Figure 2). The scope has a single catheter with which a removable optic, facilitating the placement of biopsy instruments for deployment. The catheter can articulate 180 degrees in any direction and pass around tight angles to reach distal segments. The vision probe allows for real time vision of the airway while navigating to the target, and the fiber optic shape sensor provides real time precise location and shape information throughout the navigation and biopsy process. Ion has a Flexision Needle, designed to pass through the catheter even around tight angles, and can then be deployed at target. The needle is available in 19G through 23G. The system allows for visualization of different biopsy needle trajectories. The Ion also allows for previous technologies, rEBUS and fluoroscopy, to be used with the system.26How Ion Works: a comprehensive look at Intuitive's robotic-assisted minimally invasive biopsy platform. Available at: https://www.intuitive.com/en-us/products-and-services/ion/how-ion-worksGoogle Scholar Early studies have shown that robotic bronchoscopy may improve the ability to localize peripheral lesions in a safe and effective manner (Table 1). A single institution study demonstrated target was reached in 93% of patients (14/15) undergoing bronchoscopy for a suspected lesion with a bronchus sign confirmed on CT, using the Monarch™ robotic endoscopic platform (RES) platform. Malignant diagnosis was confirmed in nine of the fifteen patients (60%), and five of six cases demonstrated benign pathology. The median time of the procedure initially was 45 minutes in the first five cases, and was reduced to 20 minutes in the last nine cases. There were no reports of serious adverse events related to the use of the RES.27Rojas-solano JR Ugalde-gamboa L Machuzak M Robotic bronchoscopy for diagnosis of suspected lung cancer: a feasibility study.J Bronchology Interv Pulmonol. 2018; 25: 168-175Crossref PubMed Scopus (57) Google Scholar A multicenter prospective study, evaluated 46 patients that were enrolled across five sites using the Monarch™ RES for targeting and biopsy of lesions. Lesions were localized and confirmed using rEBUS in 43/45 cases (95.6%). The procedure was complicated by pneumothorax in two of the cases (4.3%), one of which required tube thoracostomy. This study demonstrated feasibility and safety comparable to the conventional transbronchial biopsy.28Chen A Pastis N Mahajan A et al.Multicenter, prospective pilot and feasibility study of robotic-assisted bronchoscopy for peripheral pulmonary lesions.CHEST. 2019; 156: A2260-A2261https://doi.org/10.1016/j.chest.2019.08.313Abstract Full Text Full Text PDF Google Scholar A retrospective review utilizing the Monarch™ platform across multiple institutions demonstrated navigation was successful in 88.6% lesions (148/167), as confirmed by rEBUS. Tissue was obtained in 97.6% patients, and the diagnostic yield ranging from 69-77%. Pre-procedure bronchus sign was observed in 63.5% lesions, and yield was higher for these lesions, 78% vs 54%. Pneumothorax was reported in 3.6% of patients, with overall 2.4% of patients requiring tube thoracostomy.29Chaddha U Kovacs SP Manley C et al.Robot-assisted bronchoscopy for pulmonary lesion diagnosis: results from the initial multicenter experience.BMC Pulm Med. 2019; 19: 243Crossref PubMed Scopus (50) Google Scholar Airway bleeding was reported in 2.4% of cases.29Chaddha U Kovacs SP Manley C et al.Robot-assisted bronchoscopy for pulmonary lesion diagnosis: results from the initial multicenter experience.BMC Pulm Med. 2019; 19: 243Crossref PubMed Scopus (50) Google ScholarTable 1Early studies/trials demonstrating the localization, diagnostic yield, and complications of the robotic platforms.Robotic PlatformTrial# pts enrolledAbility to reach target/LocalizePathologic Diagnostic YieldAdverse Events/ComplicationsMonarch™Rojas-Solano et al, 20181593.3%93.3%none reportedChen et al, 20194695.6%-4.3% pneumothorax; 2.1% tube thoracostomyChaddha et al, 201916597.6%69-77%3.6% pneumothorax, 2.4% tube thoracostomy, 2.4% airway bleedingIon™Fielding et al, 20192996.6%79.3%0% Open table in a new tab The Intuitive Ion™ robotic bronchoscopy early outcomes have shown that the system is able to navigate through small peripheral airways and show a comparable safety profile. In a single center study, 30 consecutive cases with mean lesions size of 12mm (overall range: 10-30mm), demonstrated that in 96.6% of cases the target was reached (confirmed by rEBUS) and tissue was obtained. Overall diagnostic yield was 79.3%, of which 88% were malignant. Bronchus sign was present in 58.6% of all biopsied lesions. Mean procedure times were 95 minutes in the first five cases, and 61 minutes in the last five cases. There were no peri-procedural pneumothorax, significant bleeding, or airway injury.30Fielding DIK Bashirzadeh F Son JH Todman M Chin A Tan L Steinke K Windsor MN Sung AW First Human Use of a New Robotic-Assisted Fiber Optic Sensing Navigation System for Small Peripheral Pulmonary Nodules.Respiration. 2019; 98: 142-150https://doi.org/10.1159/000498951Crossref PubMed Scopus (55) Google Scholar A current prospective clinical trial is being conducted to evaluate the clinical utility and performance of the FDA Ion™ Endoluminal System for approaching and facilitating the sampling of pulmonary nodules across multiple institutions.31PRECIsE: A Prospective Evaluation of the Clinical Utility for the Ion Endoluminal System (Clinicaltrials.gov Identifier NCT03893530). Retrieved from: https://clinicaltrials.gov/ct2/show/NCT03893539Google Scholar Current data regarding the efficacy of robotic bronchoscopy for diagnosis of peripheral pulmonary nodules is still early. Though conflicting reports exist, robotic bronchoscopy potentially offers a technical advantage over existing bronchoscopic platforms. It builds on base provided by ENB by using CT-guided planning and probe localization via electromagnetic localization, but offers increased maneuverability of the instrument tip, as well as stability of the probe. Additionally, the camera at the end of the robotic bronchoscope allows for real-time concurrent visualization of the airway, similar to conventional fiberoptic bronchoscopy. Both robotic platforms also can accommodate rEBUS probes, similar to ENB to potentially further increase the diagnostic yield of biopsies. On top of access to peripheral pulmonary nodules for biopsies, robotic bronchoscopy is another platform to inject dyes (ie: indocyanine green) or place fiducial markers for preoperative marking of difficult to localize nodules for surgical resection. Currently trans-thoracic image-guidance or peri-operative ENB is used for these tasks. As technology improves and physician familiarity increases, robotic bronchoscopy offers the potential advantage of being less invasive than CT-guided procedures and occurring in the operating room as a single procedure, while improving on ENB by offering increased maneuverability and possible accuracy. These robotic systems may also allow for endoluminal therapies.32Fielding D Oki M Technologies for targeting the peripheral pulmonary nodule including robotics.Respirology. 2020; https://doi.org/10.1111/resp.13791Crossref Scopus (19) Google Scholar For patients that are not candidates for surgical resection or where surgery is not appropriate, transthoracic image guided biopsy is performed with rapid onsite evaluation (ROSE), followed by image guided therapies (ie: cryoablation, microwave ablation, etc). Further evaluation is needed to assess whether these therapies could be performed utilizing the robotic bronchoscope.33Harris K Puchalski J Sterman D Recent advances in bronchoscopic treatment of peripheral lung cancers.Chest. 2017; 151: 674-685Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar A bronchoscopic approach, which allows for one procedure with ROSE to perform mediastinal staging with cEBUS and bronchoscopic navigation to localize/biopsy a target lesion, could also incorporate endoluminal therapy, obviating the need for a separate procedure. Though still in its early phases of use and development, the potential of robotic bronchoscopy, as highlighted above, remains promising. Many drawbacks still exist, such as likely increased cost, need for specialized training and equipment, and potentially increased procedure time without an obvious improvement in diagnostic accuracy over ENB. Further studies would need to be completed to evaluate the robotic bronchoscopy versus ENB. However, this current phase in robotic bronchoscopy is similar to the early stages of robotic surgery, where the same arguments regarding cost, training, and no obvious benefits were present.34Nasir Basil S Bryant Ayesha S Minnich Douglas J Wei Ben Cerfolio Robert J Performing Robotic Lobectomy and Segmentectomy: Cost, Profitability, and Outcomes.Annals of Thoracic Surgery. 2014; 98: 203-209Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar As the technology progressed, techniques became refined, and available of equipment expanded, these previous arguments in relation to robotic surgery have become obsolete.35Ramadan OI Cerfolio RJ Wei B Tips and tricks to decrease the duration of operation in robotic surgery for lung cancer.J Vis Surg. 2017; 3: 11Crossref PubMed Google Scholar Hopefully, the future of robotic bronchoscopy fulfills its current potential of becoming a widespread, minimally invasive, and accurate means to biopsy, target, and/or treat peripheral pulmonary nodules." @default.
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