Development and deployment of robots in a bronchoscopy suite

Abstract

The field of bronchoscopy has undergone remarkable evolution since its inception, transforming from a means to remove a foreign body, to the first rudimentary flexible diagnostic tool, into its current state as a sophisticated platform for both diagnostic and therapeutic intervention. The advent of robotic-assisted bronchoscopy represents one of the most significant milestones in this progression, offering unprecedented precision and safety in pulmonary procedures. This article reviews the data bolstering robotic-assisted bronchoscopy and the associated tools that can advance diagnostic yield, provides some practical tips for setting up your bronchoscopy suite, and outlines future directions.

Shareable abstract

Robotic-assisted bronchoscopy, particularly when coupled with tool-in-lesion technology, can improve pulmonary nodule diagnostics. However, it requires significant capital, personnel and multidisciplinary investment to optimise outcomes. https://bit.ly/43z77Xf

Introduction

Bronchoscopy was first introduced in the late 19th century as a rigid instrument primarily designed to retrieve foreign bodies from the airway. Its diagnostic potential expanded significantly with the advent of fibreoptic bronchoscopy in the 1960s, which enabled direct visualisation and biopsy of central lesions [1–4]. Despite these advancements, challenges in accessing peripheral pulmonary nodules persisted, often resulting in suboptimal diagnostic yields when employing conventional bronchoscopy [5]. This limitation is increasingly pertinent as we enter an era of targeted therapy where adequate tissue sampling for tumour mutations and early detection is even more critical for improving progression-free survival and overall mortality outcomes [6, 7].

Prior to the development of robotic-assisted bronchoscopy (RaB), diagnostic yield for peripheral lung lesions had stagnated, reflecting the inherent limitations of the prior technology [8]. Conventional bronchoscopy remains significantly constrained by the absence of real-time guidance to peripheral airways, leading to low diagnostic accuracy for nodules located beyond the third-order bronchi. The diagnostic yield for peripheral lesions of 2 cm diameter was subsequently improved to 73% with the development and implementation of radial endobronchial ultrasound (rEBUS) and 71% with electromagnetic navigation bronchoscopy (ENB) [8, 9]. Virtual bronchoscopy, ultrathin bronchoscopy and ENB were subsequently introduced, though meta-analyses showed yields of roughly 70% and a well-designed single-arm study described yields for ENB with a same-day computed tomography (CT) of 59% [10, 11].

Alternative diagnostic methods outside of the bronchoscope, such as surgical excision and CT-guided transthoracic needle biopsy (TTNB), were often employed and serve as the “gold-standard” for securing tissue [9]. Surgical excision, typically performed via video-assisted thoracoscopic surgery (VATS) or open thoracotomy, although increasingly performed with robotic-assistance, provides high diagnostic accuracy but is associated with significant morbidity, extended recovery times and high resource utilisation [9]. CT-guided TTNB offers a less invasive alternative with high diagnostic yields [12]. However, this procedure is not without complications, including a risk of pneumothorax and haemorrhage, particularly in patients with underlying emphysema or those receiving anticoagulation therapy [13, 14]. Moreover, there is a reported increased risk for pleural metastasis [15]. These limitations were consistently noted in clinical reviews and trials, highlighting the need for innovative approaches to overcome the diagnostic plateau [12, 16, 17]. Further, use of TTNB frequently led to fragmented lung cancer staging, with patients requiring a non-bronchoscopic biopsy coupled with a staging linear endobronchial ultrasound (EBUS), leading to delays in throughput and a requirement for more procedural intervention [18].

RaB represents a significant evolution of these techniques, combining the safety of bronchoscopy, a small and stable catheter with robotic-precision, and near real-time imaging confirmation. The improved manoeuvrability of robotic platforms allows for more precise navigation and tissue sampling, addressing limitations often encountered in ENB, such as scope instability and limited articulation in challenging airway anatomy [19, 20]. As of today, three RaB platforms are in clinical use: the Ion Endoluminal System (Intuitive Surgical, Sunnyvale, CA, USA), the Monarch Platform (Johnson & Johnson's Auris Health, Redwood City, CA, USA) and the Galaxy System (Noah Medical, San Carlos, CA, USA). Comparison of these systems is beyond the scope of this review and their performance has not been assessed in a head-to-head fashion.

RaB and diagnostic yield

A growing body of evidence underscores the clinical efficacy and safety of RaB in the evaluation and management of peripheral pulmonary lesions. The RaB platforms have quickly become a standard of care in the USA, offering higher diagnostic yields while maintaining bronchoscopy's superior safety profile. The benefit is particularly seen in lesions that are <20 mm or located in the outer third of the lung.

There have been myriad single centre prospective and retrospective cohort studies showing varying diagnostic yields from the low 70s to the high 80s [21–23]. A systemic review and meta-analysis showed a pooled diagnostic yield of 84% [24]. These yields should be evaluated critically, as many of the studies in the meta-analysis were completed prior to the consensus statement laying out a strategy for standardising reporting of procedural outcomes [25]. In addition, the prevalence of malignancy was not reported in many of these studies, so users should assess their individual cohorts in their communities and institutions to determine expected diagnostic yields, as prevalence of malignancy can play a large role [26]. Historical factors associated with higher diagnostic yield included the presence of a bronchus sign, lesion size >20 mm, upper lobe location, shorter procedure time (<60 min), and sampling multiple lesions [27]. Notably, RaB has refined these parameters further, achieving comparable or superior results with improved procedural precision [27].

One comparative study provided additional insight into the advantages of RaB. The Precision-1 study [2], performed in a cadaver model, evaluated ultrathin bronchoscopy combined with rEBUS, ENB and RAB (with fluoroscopy and rEBUS) for peripheral nodule localisation. Robotic platforms demonstrated a 100% success rate in localising targeted nodules compared to 65% with rEBUS and 85% with ENB. Remarkably, 80% of these nodules were located in the outer third of the lung, underscoring the extended reach and precision of robotic systems [5]. In human studies, the Shape-Sensing Robotic-Assisted Bronchoscopy study reported a diagnostic yield of 81.7%, with successful navigation in 98.7% of cases. Diagnostic yield was stratified by lesion size, achieving 66.6% for lesions <10 mm and 70.4% for those measuring 10–20 mm [22]. These outcomes are particularly significant given the historical diagnostic challenges associated with smaller lesions [28].

The BENEFIT study assessed the Monarch platform in 55 patients across five study sites, with a median lesion size of 23 mm. The study demonstrated lesion localisation in 96.2% of cases and a diagnostic yield of 74.1% [29]. These results are comparable to CT-guided biopsies, which traditionally achieve diagnostic yields of 84–96%. However, RaB offers a markedly improved safety profile, with a pooled pneumothorax rate of 2.3% and a post-procedural bleeding risk of 0.6%, as reported in a meta-analysis by Ali et al. [24]. This meta-analysis also highlighted that nodules >20 mm were 2.4 times more likely to yield diagnostic results compared to smaller lesions. In contrast, non-guided transbronchial biopsies achieve diagnostic yields of only 30% for nodules <20 mm and 60% for nodules >20 mm.

Despite the technological advances associated with RaB, there is a discrepancy between “navigation success” and obtaining a true diagnosis. This is probably the result of multiple factors, but perhaps most pertinent is that the platforms still lack a built-in real- or near-time confirmation of tool-in-lesion. With the notable exception of the Galaxy System, which does use an augmented fluoroscopy technology that is part of its platform, although current data are sparse on its performance. To address this, RaB is often paired with cone-beam CT (CBCT) for real-time guidance, and integration of the CBCT into the robotic platform is currently possible and commercially available. CBCT does enhance the precision of peripheral bronchoscopy by providing intra-procedural imaging, enabling dynamic adjustments during navigation and biopsy [22, 30]. Even in cases without RaB it has elevated diagnostic yields into the 80% range, suggesting that synergising RaB with CBCT will further optimise our interventions [31, 32].

Most recently, Lentz et al. [33] completed a landmark randomised clinical trial comparing ENB versus CT-guided biopsy performed by interventional radiology. The study was powered for non-inferiority and patients were enrolled based on a central adjudication board determination that a nodule was in the middle or outer third of the lung and biopsy obtainable via either modality. The results confirmed non-inferiority of ENB with a favourable safety profile. This paves the way for bronchoscopy to be the initial modality of choice for diagnosis of pulmonary nodules, and while RaB was not used for this study, the evidence suggests that diagnostic yield will be further improved with utilisation of this platform. We anxiously await the results of the RELIANT and RELIANT-2 studies, randomised clinical trials comparing ENB and RaB that will hopefully answer some of the platform-specific questions [34]. As robotic platforms become more widely available and integrated into clinical practice, their diagnostic accuracy and therapeutic potential are expected to improve further, shaping the future of pulmonary medicine. However, given the substantial capital investment (discussed later) associated with RaB, it is critical to highlight the other uses of this platform to offset the cost and generate more revenue for your department.

Outside the diagnosis: what else can I do with a RaB platform?

Combine with staging EBUS to promote full staging in a single anaesthesia event

Linear EBUS has largely become the standard of care for mediastinal staging given the safety and efficacy profile of this minimally invasive technique [16]. Prior peripheral navigation had been combined with linear EBUS to stage, although limitations in diagnostic yield often led to patients needing to undergo two separate procedures. With implementation of RaB, a single centre study has shown a decrease in number of procedures required to obtain guideline appropriate staging [18].

Localisation for definitive therapy

Beyond nodule sampling, robotic platforms have proven effective for fiducial marker placement, which can be a useful adjunct for guiding stereotactic body radiation therapy (SBRT). Recent studies demonstrate that 99.2% of fiducial markers placed using robotic systems were accurately positioned, with 94.1% remaining in place on follow-up imaging [35]. Furthermore, procedures involving only fiducial placement reported no instances of pneumothorax, further highlighting the safety advantages of robotic platforms [27].

In patients where robotic-assisted surgical resection is planned, use of RaB to locate and dye mark can be useful to aid localisation of the primary nodule. As surgical techniques strive for less invasion and removal of smaller lesions, there is a loss of tactile feedback in the lung and “tattooing” or dye marking can be a helpful guide. Typical practice involves navigating to the lesion and using a combination of fluoroscopy, rEBUS and even CBCT to confirm proximity to the nodule. Once proximity is confirmed, the nodule is injected with a dye (usually methylene blue or a fluorescent dye such as indocyanine green) [36]. Our institutional practice is to use a combination of the two dyes. The patient then undergoes surgical resection under the same anaesthetic event. This helps to reduce the length of the procedure and ideally reduce the amount of healthy tissue needed for clean margins [37].

There are some institutions that will perform RaB for a previously undiagnosed lesion and use rapid on-site evaluation to obtain a diagnosis. If malignancy (or atypical cells) are confirmed, then the patient proceeds to dye marking and surgical resection all under then same anaesthesia event [38, 39]. These cases require prior multidisciplinary discussion and confirmation of stage 1 lung cancer to ensure appropriate patient selection. Intraprocedural decision-making often hinges on the accuracy of the frozen section or cytopathology, underscoring the importance of having experienced cytopathologists and a coordinated team. As immunotherapy continues to be studied in earlier-stage lung cancers, PD-L1 (programmed death-ligand 1) testing and other molecular markers may soon become relevant even at the time of initial diagnosis, which could further influence the procedural approach and timing of therapy. This high level of coordination across multiple subspecialties ultimately allows for a streamlined, patient-centred and potentially cost-effective care pathway. Further studies in this arena should evaluate patient outcomes and financial considerations [40].

Peripheral ablation of malignant tumours

The stability of the RaB catheter and the ability to combine with tool-in-lesion confirmation modalities like CBCT scan make it the ideal delivery tool for peripheral ablation of tumours. There is pilot data in porcine models as well as humans, although rigorous randomised trials proving efficacy and the ideal patient population are lacking [41, 42].

The diagnostic and potentially therapeutic applications of RaB do appear to offer a significant improvement from traditional technologies. However, this does come with a substantial price tag.

Financial considerations in implementing RaB

The implementation of RaB introduces a complex interplay of cost considerations, encompassing both initial investments and long-term financial implications. One of the most significant barriers to adoption is the high start-up cost, as institutions must allocate substantial capital for acquiring a RaB platform. Drawing from our own institutional experience, purchasing the platform and CBCT machines required an initial capital investment of approximately USD 1.025 million. Additionally, per-procedure costs, primarily from disposables such as catheters, add roughly USD 850 per case, depending on the platform and tools used. Beyond the direct costs of equipment and disposables, integrating adjunctive technologies such as CBCT, augmented fluoroscopy and rEBUS, as well as the necessary staff to operate these tools, further escalates the financial burden.

In addition to equipment expenses, institutions must also consider the cost of outfitting a bronchoscopy suite to accommodate this technology. A dedicated bronchoscopy suite must be large enough to house the robotic platform, CBCT and additional staff, potentially necessitating renovations or repurposing existing procedural spaces. Some institutions opt to adopt operating room time for these procedures, but this further increases costs due to anaesthesia, operating room staffing and scheduling demands. These costs are only minimally offset by procedural reimbursement, as bronchoscopy-related relative value units remain relatively low, the multiple endoscopy rule applies, and the Current Procedural Terminology code for RaB (31627) is only an add-on [43]. While reimbursement modalities differ throughout the world, the return on investment when only considering the bronchoscopy procedure itself is a hard “sell”.

It is important to acknowledge that the financial dynamics discussed here are particularly relevant in healthcare systems where procedures generate revenue, such as in the USA. In many nationalised systems, such as those found in parts of Europe, the incentive structures and cost-recovery mechanisms differ substantially. While we have attempted to address cost implications broadly, we recognise that the economic rationale for adopting RaB may not directly translate to systems in which procedural volume does not generate income. Therefore, further examination of the cost–benefit profile of RaB within various healthcare delivery models is warranted.

So, how do bronchoscopists convince institutions to fund such a loss-leader? The crux of the matter is defining the value of a precision diagnostic tool to afford patients a safe and efficient method of entry into your healthcare system. Bronchoscopists must appeal to stakeholders involved in these decisions, including hospital administrators, medical and radiation oncologists, infectious disease physicians, pulmonologists, thoracic surgeons and financial analysts, all of whom must weigh the upfront costs against potential downstream benefits in terms of patient outcomes and satisfaction. While clinical precision is the main motivation, one of the secondary drivers for justifying these investments is the anticipated revenue generated from diagnostic and therapeutic procedures [44]. RaB enables accurate diagnosis of both malignant and benign conditions, often serving as the gateway and initial entry into a healthcare system for subsequent interventions such as surgical resection, radiation therapy or medical oncology consultations. For example, patients diagnosed with lung cancer through robotic-assisted procedures are more likely to undergo timely surgical resection or SBRT, both of which contribute to institutional revenue streams. [45, 46]. Proceduralists and surgeons can also use RaB as a means to assist localisation for surgical resection. This procedure can be combined with a surgical resection under the same anaesthesia event and has the potential to decrease amount of tissue required and incidence of conversion to lobectomy, and provide another revenue stream to offset cost, although this needs to be further evaluated in the data [47]. A thorough analysis of one's pulmonary nodule population can inform decision makers on the prevalence of malignancy in your particular community. Communities with a high prevalence of malignancy can expect better diagnostic yields and an improved return on investment with the surgical and oncological care that is provided [26, 48].

Furthermore, the integration of advanced imaging modalities, such as CBCT, enhances diagnostic accuracy and reduces the need for repeat procedures, thereby improving cost-effectiveness over time. CBCT or augmented fluoroscopy during RaB significantly increases the likelihood of tool-in-lesion confirmation, which is critical for obtaining high-quality tissue samples [49]. Intraprocedural CBCT-guided adjustments increased the likelihood of obtaining tool-in-lesion confirmation [32]. This improvement minimises the risk of inconclusive results and enhances patient satisfaction by reducing procedure-related anxiety and inconvenience.

The long-term financial sustainability of RaB also hinges on its ability to reduce complication rates compared to alternative diagnostic methods. CT-guided TTNB biopsy, while effective, is associated with higher rates of pneumothorax and haemorrhage, often necessitating additional medical interventions that increase healthcare costs [14]. By contrast, the safety profile of RaB minimises these downstream expenses, making it a more attractive option for both patients and healthcare providers.

While it is disingenuous to characterise patients as a means of revenue generation, it can be helpful to understand the downstream monetary effects from RaB. This extends beyond the initial diagnostic procedure. For instance, the identification of malignancy often triggers a cascade of appointments with other subspecialists, including multidisciplinary tumour board consultations, advanced imaging studies and therapeutic interventions. Even benign diagnoses can lead to long-term surveillance and follow-up procedures, ensuring continued patient engagement within the healthcare system, but only if the system maintains its superior performance [50].

One of the most important features of RaB is that it allows for a single anaesthesia event in which biopsy followed by lung resection can be achieved, mitigating costs. Weiser et al. [38] showed that not only does this lead to a significant reduction in time from diagnosis to treatment but reduces total costs by USD 10 434. Additionally, the combined diagnosis and staging event can also assist patients with low health literacy or a high degree of health-related social needs (e.g. difficulty with transportation) and lead to improvements in care [51].

Despite these advantages, challenges remain in ensuring the cost-effectiveness of RaB. High-volume centres are more likely to achieve a favourable return on investment, as the fixed costs of robotic systems are distributed across a larger number of procedures. Conversely, low-volume centres may struggle to justify the financial outlay without adequate procedural demand. Reimbursement policies also play a critical role, as current reimbursement rates for robotic-assisted procedures may not fully reflect the associated costs of technology acquisition and maintenance. Efforts to standardise reimbursement practices and incentivise the adoption of robotic systems could significantly influence their widespread implementation.

Future economic analyses should focus on comparing the total cost of care, including complications, repeat procedures and downstream revenue, between RaB and alternative modalities. These studies would provide valuable insights into the long-term financial viability of robotic systems and help guide institutional decision-making. Overall, while the upfront costs of RaB are substantial, the potential for improved patient outcomes, procedural efficiency and involvement of multidisciplinary teams underscores its transformative impact on pulmonary care.

Optimising your outcomes

Once a RaB platform has been curated, it is critical to focus on setting the practice up for success and improved efficiency. This starts well before the actual procedure day and involves multiple disciplines and departments within your healthcare system.

Radiology

An appropriate CT protocol that will provide the most accurate airway tree to reduce CT-to-body divergence intraoperatively is imperative and depends on the RaB platform used. Each currently available platform uses a slightly different protocol, so consultation with the clinical team from the manufacturer can be critical to reduce delays in care.

• Monarch (Auris Health Inc.): requires a pre-procedural CT with slice thickness of 1–1.25 mm at intervals of 0.8–1 mm.

• Ion Endoluminal System (Intuitive Surgical) utilises a proprietary PlanPoint planning software that requires a pre-procedural CT scan with slice thickness of 0.5–1 mm at an interval of 0.5–0.8 mm.

• The Galaxy system (Noah Medical) does not necessitate a pre-procedural CT as it incorporates digital tomosynthesis-based augmented fluoroscopy with real-time target position update (TiLT+: Tool-in-lesion Techonology) [52].

Meeting with your radiology department to ensure the exact size of the slices and other parameters are met will provide the best chance for success. One other consideration is that using a same-day CT scan immediately prior to the procedure may also prevent unnecessary interventions [53]. It is our practice to get a CT within a week of the procedure if possible.

Further, if your healthcare system does not have the capital to afford your own CBCT platform, discuss using either a fixed system with your interventional radiology colleagues, or approach other surgical subspecialties (i.e. vascular surgery, orthopaedics or neurosurgery) to inquire if there is a device that can have shared use.

Anaesthesiology

It is imperative to meet with your anaesthesia department to discuss ideal ventilatory strategies. Intraprocedural atelectasis and CT-to-body divergence can be a significant hindrance on the ability to diagnose a small pulmonary nodule [53]. There are multiple trials that have shown a reduction in atelectasis by applying a standardised amount of positive end-expiratory pressure, minimising inspiratory oxygen fraction and preventing delays with intubation [54]. The impact of the order of RaB and staging EBUS (i.e. RaB first or linear EBUS first) is not yet known, but is being investigated in a randomised trial with one of the secondary outcomes being incidence of atelectasis [55]. Patient positioning, including lateral decubitus and even prone, have been performed safely in patients with lesions where intraprocedural atelectasis was deemed likely [56]. This can be considered on a case-by-case basis, although we would not recommend this for novice users and our site currently does not employ these techniques.

Furthermore, we do recommend general anaesthesia, endotracheal intubation with an 8.0 or greater size endotracheal tube, and use of a paralytic, as breath holds are a key tenet of optimising CBCT performance [56]. It is important to emphasise that performing guided bronchoscopy under conscious sedation is suboptimal, largely due to progressive de-recruitment of lung tissue during the procedure, which impairs both navigation and visualisation.

Optimising RaB workflow

Endoscopy staff/equipment

Establishing a core team consisting of nurses, respiratory therapists, anaesthesiologists and radiology technicians is beneficial for standardising the process and improving efficiency. Setting expectations early is crucial, as initial procedures will require significant time, and scheduling should reflect this learning curve. While each case presents its own challenges, high-functioning centres can now perform a RaB and staging EBUS in <90 min, with many achieving procedure times closer to 60 min.

At our institution, we have a dedicated procedural workflow to streamline efficiency. Two nurses typically process the patient pre-operatively, assist with preparation and positioning, and play a vital role intraoperatively by aiding in sample processing. Post-procedure, they turn over the room, ensuring it is cleaned and ready for the next case while documenting all nurse-directed procedural details. They also prepare the RaB system for the next case and send used catheters for processing. Respiratory therapists assist with specimen collection, preparing rEBUS, bronchoscopy with linear EBUS, and other adjuncts such as forceps or cryoprobes. A radiation technologist manages CBCT image acquisition, while the anaesthesia team provides general anaesthesia support throughout the procedure. This structured team approach allows for an efficient case turnover and optimised workflow, ensuring that procedural and operational demands are met effectively.

Beyond the procedural team, training a dedicated group of scope processors and cleaners is equally important. Proper training can prevent catheter malfunctions and reduce costly repairs, minimising downtime between cases. Additionally, rEBUS probes will probably experience increased wear and tear due to repeated passage through the robotic catheter. Having multiple probes available on-site, if your site has the resources to allocate, helps prevent delays and ensures smooth workflow continuity.

Space and equipment considerations

A critical logistical factor is ensuring that the procedure room is large enough to accommodate the robotic platform (figure 1), along with any adjunctive imaging technology such as CBCT. The space should also allow for standard bronchoscopy equipment, anaesthesia setup and appropriate personnel movement. A cramped environment can lead to inefficiencies, procedural difficulties and poor ergonomics [57]. Therefore, planning and selecting a sufficiently spacious procedural area will facilitate a seamless and effective workflow.

FIGURE 1.

a) Our bronchoscopy suite with CBCT (Siemens Cios), robotic-assisted bronchoscopy (Ion Endoluminal System by Intuitive) radial EBUS (Olympus), and our anaesthesia equipment. b) Our nursing team (left) assisting with proper tissue specimen processing while bronchoscopist (middle) is obtaining further biopsies. The radiation technologist (left) using real-time fluoroscopy. c) Another broad, encompassing view of the suite set up, showing radial EBUS (top left screens), robotic-assisted view (right screens), and fluoroscopy view (bottom left screen).

During the procedure

With the peripheral nature of most of the lesions we biopsy, proceduralists will lack vision once an initial biopsy has taken place due to bleeding from the biopsy site. As such, providers should ensure optimal position of the catheter based on the pre-procedural plan, then performing advanced imaging (i.e. CBCT), and then biopsy to prevent haemorrhage or inflammation from disrupting views. The ACCURACY study did show the best predictor of biopsy success without tool-in-lesion confirmation on the Ion Endoluminal System platform specifically was proximity to the target approximation seen on the screen [58]. While this has not been replicated in other platforms, it would stand to reason that this would hold true.

Consider your biopsy tools. Each platform will have its own proprietary needles that will be standardised. However, consider utilisation of forceps versus a 1.1 mm cryoprobe for diagnostics. There is a price increase at the time of writing for cryoprobe use; however, single centre and retrospective data do show improvement in diagnostic yield in favour of the cryoprobe with a similar safety profile [59, 60]. We are anxiously awaiting the results of the Frostbite-II randomised clinical trial to see whether its impact is proven in a randomised, multicentre fashion [61].

Conclusion

RaB is a safe and increasingly efficacious way to diagnose peripheral pulmonary lesions. This technology, particularly when coupled with tool-in-lesion confirmatory imaging, has revolutionised the standard of care in the USA. While upfront capital investment is significant, the downstream improvement in patient outcomes and multidisciplinary care requirements should offset those concerns and make acquiring a system more palatable for a healthcare system. It is likely that this platform will be the standard bearer going forward and may ultimately assist in peripheral therapeutics of malignancies.

Key points

• RaB, which garnered US Food and Drug Administration approval in 2019, has become the bronchoscopic tool of choice in the USA given catheter stability, peripheral reach, and ability to pair with tool-in-lesion technology (i.e. CBCT scan).

• Acquisition of a RaB platform, with possible tool-in-lesion radiographic confirmation tools, requires a significant up-front capital investment although it could lead to more efficient lung cancer diagnostics and patient throughput.

• Diagnostic yield of RaB is improved in comparison to prior iterations of bronchoscopy technology, although it is still prone to data reporting biases.

• Successful implementation of a RaB platform requires multidisciplinary support – including administration, nursing, anaesthesia, radiology, thoracic surgery and pulmonology commitments.

Self-evaluation questions

1. In addition to diagnostic applications, what other methodologies can RaB be used for?

2. What does the recently published consensus statement on diagnostic yield define as the standard for reporting to enhance comparison across centres? What is the data for RaB?

3. Who/what are the key stakeholders in improving your performance of RaB?

Suggested answers

1. There are many answers to this question and some that are still in the early stages of research; however, these are the main two at this time:

1) Therapeutic applications

 a) Ablation therapies: radiofrequency ablation, microwave ablation or laser therapy can potentially be delivered to peripheral pulmonary lesions through robotic platforms. This is still largely investigational but actively being explored in clinical trials.

 b) Localised drug delivery: direct delivery of chemotherapy, immunotherapy or gene therapy into lung tumours via RaB-guided catheters or microinjection systems.

2) Navigational mapping and imaging research: for example, airway mapping for surgical planning. Detailed three-dimensional airway reconstructions can aid thoracic surgeons in segmentectomy or nodule resection planning. As well as allowing insertion of fiducial markers or dye marking to aid discovery of nodes.

2. The recent American Thoracic Society/American College of Chest Physicians consensus statement defines a standardised, strict diagnostic yield methodology to enable meaningful comparisons across centres.

Yield is defined by:

Numerator: number of procedures yielding a specific diagnosis – either malignant or specific benign.

Denominator: all procedures performed, based solely on the index encounter.

Follow‑up data may inform broader diagnostic accuracy assessments, but must not be used to boost the index diagnostic-yield rate. Reporting should also follow STARD guidelines to ensure clarity, and reference standards (histological confirmation or imaging/clinical follow‑up) must be explicitly stated. Diagnostic yield for RaB ranges from ~60–90%, with a meta-analysis quoting 84.3%. This should be interpreted with caution as not all papers report strict definition. We appeal to the audience to use strict definitions when reporting data.

3. There are many key stakeholders and they are summarised in table 1.

TABLE 1.

Key stakeholders for improving performance of robotic-assisted bronchoscopy

Stakeholder	Role	Key leverage point
Interventional pulmonologists	Perform the procedure	Procedural planning, technical skill, training
Programme Leadership	Manage resources and team structure	Multidisciplinary support, investment in tools
Radiologists	Provide imaging before, during and after the procedure	Lesion targeting, imaging confirmation
Pathologists/cytopathologists	Interpret biopsy samples	Rapid on-site evaluation availability, tissue adequacy, timely diagnosis