Innovations in Robotic-Assisted Bronchoscopy: Current Trends and Future Prospects
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsOverall, this is an excellent review of robotic navigational bronchoscopy and its current applications. It is an excellent summary of contemporary literature including comparative analyses between different systems and prior standards of care, e.g. traditional bronchoscopy and TTNA. It even highlights some of the controversial aspects of these studies in a succinct and efficient manner. The format is easy to read and makes sense logically to follow.
I have very little constructive feedback as I think the paper is already written well. To strengthen the scope of the discussion, there is room to add some lines regarding other application of robotic navigational bronchoscopy. This is discussed briefly from lines 328 - 333 where single anesthesia events are described. I think there is room to discuss other novel uses of robotic systems like single anesthesia dye marking or fiducial placement at time of biopsy (separate event from resection). Both of these are novel to the robotic platform and, similar to replacing TTNA biopsy, have replaced other IR-based or traditional bronchoscopic techniques.
Author Response
Comment 1: The reviewer suggested expanding the discussion of novel applications of robotic navigational bronchoscopy, specifically single-anesthesia dye marking and fiducial placement at the time of biopsy, noting these are unique to the robotic platform and have replaced IR-based or traditional bronchoscopic techniques.
Response: We appreciate this suggestion and agree that RAB fiducial placement and dye marking represent exciting developments. However, given the limited evidence base currently available for these applications, we chose to focus our review on topics supported by a more robust body of literature. We did not feel the existing data were sufficient to support a thorough discussion of these topics within the scope of this review article, and we have noted this as an area warranting future investigation.
Reviewer 2 Report
Comments and Suggestions for Authors-
Concern Regarding the Quality and Strength of Evidence
While the manuscript emphasizes the advantages of RAB, much of the cited evidence consists of single-center studies, retrospective analyses, or early-phase trials. Direct comparisons between platforms are frequently confounded by differences in sampling techniques, anesthesia protocols, integration of CBCT, and sequential implementation over time. These methodological limitations make it premature to draw firm conclusions regarding superiority. Statements describing “superior diagnostic yield” or “enhanced safety” should therefore be tempered, and the level of supporting evidence should be more explicitly acknowledged.
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Overemphasis on Diagnostic Yield Rather Than Patient-Centered Outcomes
The discussion focuses predominantly on diagnostic yield; however, the clinically meaningful question is whether RAB improves patient-centered outcomes, such as time to treatment, avoidance of unnecessary invasive procedures, or long-term survival. Current data linking improved diagnostic performance to improved oncologic outcomes remain limited. In addition, potential lead-time and length-time biases are not sufficiently addressed. A more balanced discussion incorporating these methodological considerations would strengthen the manuscript.
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Insufficient Consideration of Health Economics and Real-World Implementation
Although the manuscript briefly mentions capital costs and workflow considerations, the broader implications for cost-effectiveness and real-world implementation are underdeveloped. The substantial upfront investment, ongoing maintenance costs, disposable instrument expenses, and requirement for general anesthesia may limit adoption in community hospitals and lower-resource settings. A more detailed and quantitative discussion of economic impact and feasibility across different healthcare environments would provide a more realistic assessment of the technology’s practical integration.
Author Response
Comment 1: The reviewer noted that the evidence base predominantly consists of single-center studies, retrospective analyses, and early-phase trials with significant methodological heterogeneity, and recommended that statements regarding "superior diagnostic yield" or "enhanced safety" be tempered with explicit acknowledgment of these limitations.
Response: We fully agree with this critique. We have revised the manuscript throughout to adopt a more measured tone, explicitly acknowledging the methodological limitations of the existing literature and avoiding overstatement of comparative conclusions where head-to-head data are lacking.
Comment 2: The reviewer emphasized that the clinically meaningful question is whether RAB improves patient-centered outcomes—such as time to treatment, avoidance of unnecessary invasive procedures, and long-term survival—and that lead-time and length-time biases were insufficiently addressed.
Response: We appreciate this important perspective. We have worked to better balance the discussion of diagnostic yield with the broader context of patient-centered outcomes throughout the manuscript. We acknowledge that definitive data linking RAB to improved oncologic outcomes remain limited and have addressed lead-time and length-time bias more explicitly (lines 296–297). We also highlight this as a priority area for future research.
Comment 3: The reviewer noted that the discussion of cost-effectiveness, real-world implementation, and economic feasibility—particularly regarding capital costs, maintenance, disposable expenses, and the requirement for general anesthesia—was underdeveloped, especially in the context of community and lower-resource settings.
Response: We thank the reviewer for highlighting this important gap. The evidence base on this topic remains limited; however, we have expanded our discussion of economic considerations at lines 308–310, specifically addressing upfront investment, ongoing costs, and the anesthesia requirement as practical barriers to broader adoption. We agree that a more comprehensive health economics analysis is needed and have identified this as a focus for future work.
Reviewer 3 Report
Comments and Suggestions for AuthorsI read this article with great interest. This manuscript provides a comprehensive narrative review of RAB. The topic is clinically relevant. The manuscript is well structured, well written, and with good recent literature.
However, i have some concerns that must be addressed:
-The manuscript cites Fernandez-Bussy et al (2024 narrative review) . Please clarify how this review differs: update? focus comparative effectiveness?novelty AI + ecosystem integration?
- Please clarify FDA clearance dates and confirm that all platform regulatory statements are up to date.
- Please ad an eye-catching figure illustrating: RAB workflow integration and diagnostic pathway comparison.
Author Response
Comment 1: The reviewer asked for clarification on how our manuscript differs from the Fernandez-Bussy et al. (2024) narrative review, requesting we specify whether this represents an update, focuses on comparative effectiveness, or addresses AI and ecosystem integration.
Response: We have clarified these distinctions in the revised manuscript. While Fernandez-Bussy et al. provide a valuable high-level overview of the field, our manuscript offers several substantive additions: (1) incorporation of practice-changing prospective data from the RELIANT and VERITAS trials establishing non-inferiority of RAB versus TTNA with superior safety profiles; (2) focused analysis of the evolving "procedural ecosystem," specifically the comparative effectiveness of combining robotic platforms with 1.1 mm cryoprobes and advanced real-time imaging modalities; and (3) a novel assessment of artificial intelligence integration, including emerging shared-control algorithms and conditional autonomy frameworks representing the next frontier in standardized, operator-independent navigation.
Comment 2: The reviewer requested clarification of FDA clearance dates and confirmation that all platform regulatory statements are up to date.
Response: We confirm that all regulatory information is accurate and current. The manuscript already correctly lists the primary FDA 510(k) clearance dates for the three major robotic platforms: Monarch (March 2018), Ion (February 2019), and Galaxy (March 2023). We have now explicitly emphasized in the text that all three platforms received marketing authorization via the FDA 510(k) pathway.
Comment 3: The reviewer suggested adding a figure illustrating RAB workflow integration and diagnostic pathway comparison.
Response: We appreciate this suggestion. After careful consideration, we opted not to add a workflow/pathway figure, as similar illustrations have been presented effectively in recent high-impact publications, including Fernandez-Bussy et al. (2024). We believe our figures are best directed toward the novel technical aspects and emerging clinical data that distinguish our review, and that a duplicative figure would not add meaningful new value.
