Search Results (26)

Background/Objectives: Robotic-assisted bronchoscopy has emerged as an advanced technique for the evaluation of peripheral pulmonary lesions, offering improved navigation and targeting accuracy. While several studies investigating other diagnostic modalities have identified factors associated with higher diagnostic yield, such determinants remain poorly defined for shape-sensing robotic-assisted bronchoscopy (ssRAB). This study therefore aimed to identify predictors of diagnostic yield in robotic bronchoscopy. Methods: This retrospective single-center study included all consecutive patients who underwent ssRAB (ION^TM system, Intuitive Surgical, Sunnyvale, CA, USA) between August 2024 and March 2026. Lung nodules undergoing marker placement only or procedures performed without cone-beam CT (CBCT) guidance were excluded. Collected variables included demographic characteristics, lesion size, lesion density (solid, part-solid, ground-glass), biopsy modality, and number of biopsy samples obtained. Diagnostic yield was defined as a definitive pathological diagnosis of the target lesion. Predictors of diagnostic success were assessed using univariable logistic regression. Results: In total, 111 pulmonary nodules were included in the analysis. The overall diagnostic yield was 88.3% (98/111). The mean patient age was 64.94 ± 7.9 years, with a predominance of female patients (58.4%). No significant associations were observed between diagnostic yield and lesion size (odds ratio [OR] 1.014 per mm; p = 0.764), lesion density (p = 0.892), or biopsy instrument (p = 0.835). However, an increased number of biopsy samples showed a positive association with diagnostic yield, showing a statistical trend (OR 1.22 per additional sample; p = 0.084). Conclusions: Robotic-assisted bronchoscopy provides a high diagnostic yield for peripheral pulmonary lesions. The number of biopsy samples appears to be the most relevant modifiable factor influencing diagnostic success, underscoring the importance of adequate tissue acquisition. In contrast, lesion characteristics and biopsy modality did not significantly affect outcomes in this cohort. Full article

As thoracic surgeons more frequently address smaller lung lesions and perform lung-sparing resections, their objective is to resect an adequate specimen and margin without removing excess healthy lung tissue. Although perioperative lung nodule localization has been in practice for decades, the existing and emerging techniques used for the identification of targeted and occult lesions are more widely utilized today than they were in the past. In this review, we detail the logic behind this increase in use, classify the techniques into preoperative and intraoperative categories, and define the specific modalities available. Where applicable, we review the published data comparing techniques, detailing efficacy and safety. In the preoperative space, we describe standard computed tomography (CT)-guided localization, virtual-assisted lung mapping, electromagnetic navigation bronchoscopy, robotic-assisted bronchoscopy, and novel fiducial markers. In the intraoperative space, we describe classical localization techniques, novel applications of intraoperative cone-beam CT, and fluorescence-guided surgery and intraoperative molecular imaging (IMI). Lastly, we review emerging approaches for intraoperative molecular imaging including a report on agents in early-stage clinical trials and a brief survey of promising preclinical models. With each approach mentioned, we analyze the potential benefits and hazards, and appraise the evidence for (or against) the use of any specific modality. Full article

The adoption of neoadjuvant immune checkpoint inhibitor (ICI)-based chemoimmunotherapy has fundamentally transformed the operative landscape of resectable non-small cell lung cancer (NSCLC). Surgeons are now routinely confronted with ICI-altered tissue planes characterized by hilar fibrosis, vascular friability, and disrupted lymph node architecture. Simultaneously, robotic-assisted thoracic surgery (RATS) has consolidated its position as the dominant minimally invasive platform for pulmonary resection, accounting for the majority of lobectomies and segmentectomies performed at high-volume centers in 2023. Whether RATS confers specific technical advantages in this increasingly complex operative context remains incompletely characterized. We conducted a structured narrative review of published evidence, synthesizing data from randomized controlled trials, prospective cohorts, national registry analyses, and emerging technology reports addressing RATS in the setting of neoadjuvant ICI-based therapy for NSCLC. A systematic literature search was conducted across PubMed and EMBASE using predefined search terms. Available evidence, though largely retrospective and limited by small sample sizes, consistently demonstrates that RATS after neoadjuvant chemoimmunotherapy is technically feasible and oncologically sound, with R0 resection achievable in virtually all cases. The enhanced three-dimensional visualization, tremor filtration, and instrument degrees of freedom afforded by robotic platforms appear particularly advantageous in the setting of dense hilar adhesions and fragile pulmonary vasculature. Lymph node yield, a recognized robotic advantage, is preserved or enhanced despite post-ICI fibrosis. Pooled conversion rates to thoracotomy, derived from post hoc surgical analyses of ICI trial populations rather than trials designed to measure conversion, are higher than for upfront resection; available retrospective single-center data, including one direct RATS-versus-VATS comparison, suggest lower conversion rates with RATS in experienced hands, though this conclusion requires prospective validation. Emerging platform integrations, including combined robotic bronchoscopy and thoracoscopic surgery, single-port systems, and artificial intelligence-assisted anatomical navigation, are poised to further extend the reach of minimally invasive surgery in this challenging clinical scenario. In experienced centers, RATS appears to offer a technically favorable minimally invasive platform for pulmonary resection after neoadjuvant ICI-based therapy, with potential advantages over VATS in managing immunotherapy-altered anatomy; however, this conclusion is derived from retrospective series and should be interpreted cautiously pending prospective comparative data. Prospective multicenter trials with standardized surgical endpoints are urgently needed. Full article

Background: Robotic-assisted bronchoscopy enables precise navigation to peripheral pulmonary lesions and expands minimally invasive diagnostic options in thoracic surgery. At our institution, the ION™ Endoluminal System (Intuitive Surgical, Sunnyvale, CA, USA) was introduced to improve diagnostic accuracy in challenging peripheral targets. It is widely recognized that a defined number of procedures is required to achieve procedural proficiency and optimal clinical outcomes when adopting a novel platform. Therefore, this retrospective single-center study aimed to evaluate the learning curve associated with the implementation of this technology in a thoracic surgery center. Methods: In this retrospective study, all consecutive patients who underwent robotic-assisted bronchoscopies performed using the ION™ Endoluminal System (Intuitive Surgical, Sunnyvale, CA, USA) for the diagnosis of peripheral pulmonary lesions between August 2024 and March 2026 were analyzed. A total of 128 lesions in 89 patients were initially identified. Cases involving marker placement without diagnostic biopsy, as well as procedures not performed by the primary operator, were excluded. After applying exclusion criteria, 109 procedures in 76 patients were included. The mean patient age was 65.4 ± 9.1 years, and 44 patients were female (57.9%). To assess the learning curve, procedures were chronologically divided into three groups: early (cases 1–36), intermediate (37–73), and late (74–109). Outcome measures included procedure time, number of biopsies per lesion, tumor size, and diagnostic yield. Group comparisons were performed using non-parametric and chi-square tests. Procedural learning was assessed by cumulative sum (CUSUM) analysis of procedure time. Results: The overall diagnostic yield was 85.3% (93/109). The diagnostic yield increased over time from 73.0% in the early phase to 83.3% in the intermediate phase and 94.6% in the late phase. The overall comparison was statistically insignificant (χ² p = 0.117); however, there was a significant linear trend across phases, indicating progressive improvement with exposure to the application of this technology. Procedure time decreased significantly from a median of 49.0 min in the early phase to 31.0 min in the intermediate phase and 30.0 min in the late phase (p < 0.001). At the same time, the number of biopsies per lesion increased significantly (p < 0.001). Tumor size did not differ significantly between groups (p = 0.170). Conclusions: Robotic-assisted bronchoscopy demonstrates a clear learning curve, characterized by increasing diagnostic yield and significantly reduced procedure time during the implementation phase. The technique can be effectively integrated into the thoracic surgical diagnostic workflow and represents a valuable addition to minimally invasive diagnostics for peripheral pulmonary lesions. Full article

Thin-slice high-resolution computed tomography (CT) has improved the detection of small pulmonary nodules, increasing the demand for minimally invasive diagnostic and therapeutic resection. While lobectomy with lymph node dissection remains the standard surgical approach for many patients with resectable non-small cell lung cancer, accumulating evidence supports sublobar resection for selected small, peripheral, and ground-glass-dominant lesions when sufficient margins are achievable. In thoracoscopic and robotic surgery, localization of nodules ≤10 mm or lesions located >5 mm from the pleural surface can be challenging, and failure to identify the target may lead to conversion, larger resection than intended, or prolonged operative time. Several localization strategies have been developed, including CT-guided percutaneous wire/coil/dye marking, bronchoscopic dye mapping, and virtual-assisted lung mapping (VAL-MAP), robotic-assisted bronchoscopic dye or fiducial localization, radiofrequency identification microtag systems (Surgical Real-Time FInger Navigation and Detection) that provide real-time depth information, and single-stage intraoperative CT-guided marking and resection in hybrid operating rooms. This review synthesizes representative evidence and published outcome ranges, and compares workflows, marker-to-lesion precision metrics, complication profiles, operational burden, and cost structures. We emphasize the practical contrast between two-stage and single-stage workflows, the access-route differences between transthoracic and transbronchial techniques, and the need to report localization-to-incision “time at risk”. We also present an expert-consensus decision algorithm aimed at facilitating tailored selection of localization strategies for modern minimally invasive thoracic surgery. Full article

Lung cancer remains the leading cause of cancer-related mortality worldwide despite advances in screening, navigational bronchoscopy, and systemic therapies. Diagnostic and therapeutic limitations persist, including uncertainty regarding intraprocedural tissue adequacy during biopsy sampling and constraints of existing ablative modalities for tumors located near critical thoracic structures. This review examines two emerging technologies: Full-Field Optical Coherence Tomography-based Dynamic Cell Imaging (DCI) and monopolar biphasic Pulsed Electric Field (PEF) ablation as complementary emerging technologies that may address these gaps. The Van Gogh™ Microscopy System (CellTivity Scientific, Inc.) utilizes DCI to enable real-time visualization of cellular metabolic activity without tissue destruction, providing functional information regarding tissue viability and microstructural morphology. The Aliya^® PEF ablation system (Galvanize Therapeutics, Inc.) delivers biphasic high-voltage electrical pulses that induce non-thermal tumor cell death while preserving extracellular matrix architecture, potentially allowing treatment near sensitive thoracic structures such as airways, vasculature, and pleura. Early preclinical studies and initial clinical experience suggest that DCI can facilitate rapid intraprocedural assessment of biopsy adequacy, while PEF ablation may provide reproducible focal tumor destruction with a favorable safety profile near critical structures. Although the current evidence base remains limited to early-phase studies and feasibility trials, the convergence of real-time biologic tissue assessment with structurally preserving ablation technologies introduces the possibility of integrating diagnostic confirmation and local therapy within a single procedural workflow. This review summarizes the mechanistic rationale, emerging evidence, and potential clinical applications of these technologies and proposes a conceptual “See and Strike” framework within these two emerging technologies. The methodological limitations, workflow considerations, and future research directions required to validate this approach are also discussed. Prospective multicenter trials and long-term oncologic outcomes will be necessary before widespread clinical adoption. Full article

Background. Robotic-assisted bronchoscopy with the ION™ Endoluminal System facilitates precise access to peripheral pulmonary lesions. However, procedural duration and diagnostic performance remain influenced by patient and lesion-specific factors. To investigate the impact of lesion diameter, radiological appearance, and presence of bronchial signs on procedural duration and diagnostic yield using conventional regression and gradient boosting machine learning models. Methods. In this single-center retrospective cohort study, 189 ION™ Endoluminal System procedures (November 2024–June 2025) were analyzed. Procedural duration and diagnostic yield served as primary outcomes. Predictive modeling included multivariable regression and gradient boosting. Feature importance metrics were extracted. Results. The median lesion diameter was 12.3 mm, with a “strict” diagnostic yield of 87.3%. Gradient boosting regression identified lesion diameter as the primary predictor of procedural time (89.2% importance; test MSE = 865.6). Diagnostic classification achieved an ROC-AUC of 0.68, with lesion diameter (85.8%) and bronchial sign (14.2%) as key predictors. Conclusions. Lesion diameter emerged as the most consistent predictor of procedural efficiency and was associated with diagnostic performance, albeit within the limitations of the dataset. Broader datasets are needed for external validation and generalizability. Full article

Background: Artificial intelligence (AI) is increasingly applied in pulmonary endoscopy, including diagnostic bronchoscopy, interventional pulmonology and endobronchial imaging. Advances in computer vision, machine learning and robotic systems have expanded the potential for automated lesion detection, navigation to peripheral pulmonary lesions, and real-time procedural support. However, the current evidence base remains heterogeneous, and translational challenges persist. Methods: This review summarizes current applications and developments of AI across white-light bronchoscopy (WLB), image-enhanced bronchoscopy (e.g., narrow-band imaging and autofluorescence imaging), endobronchial ultrasound (EBUS), virtual and robotic bronchoscopies, and workflow optimization and training. The authors also examine the methodological limitations, regulatory considerations, and implementation barriers that affect translation into routine practice. Results: Reported developments include deep learning-based models for mucosal abnormality detection, lymph-node characterization during EBUS-guided transbronchial needle aspiration (EBUS-TBNA), improved lesion localization, and reduction in operator-dependent variability. Additionally, AI-assisted simulation platforms and decision-support tools are reshaping training paradigms. Nevertheless, most studies remain retrospective or single-center, with limited external validation, dataset heterogeneity, unclear model explainability, and incomplete integration into clinical workflows. Conclusions: AI has the potential to support lesion detection, navigation, and training in pulmonary endoscopy. However, robust prospective validation, standardized datasets, transparent model reporting, robust data governance, multidisciplinary collaboration, and careful integration into clinical practice are required before widespread adoption. Full article

Robotic-assisted bronchoscopy (RAB) represents a significant technological advance, providing superior precision, enhanced visualization, and increased maneuverability relative to conventional bronchoscopic methods. This review provides an overview of current research evaluating RAB’s diagnostic performance and exploring future prospects. Recent literature demonstrates advantages in navigating difficult-to-reach lung lesions with improved safety profiles compared to transthoracic approaches. Incorporating advanced imaging technologies has enhanced real-time decision-making during procedures, and artificial intelligence applications are emerging. RAB has been rapidly adopted at many high-volume centers based on favorable navigational success and safety data. As the field matures, ongoing prospective studies will further define its role in improving patient outcomes, cost-effectiveness, and optimal integration with lung cancer screening programs. RAB faces ongoing challenges including substantial capital costs, training requirements, and need for standardized protocols. Therapeutic applications show promise and are under active investigation. Full article

Introduction: Lung cancer is a leading cause of cancer-related deaths globally, with approximately 1.5 million new peripheral pulmonary lesions (PPLs) detected annually in the United States. Robotic-assisted bronchoscopy (RAB) has emerged as a promising technology, with two platforms initially approved, the Monarch platform (Auris Health Inc, Redwood City, CA, USA) and the Ion Endoluminal System (Intuitive Surgical, Sunnyvale, CA, USA), offering improved stability and distal airway visualization. As RAB adoption increases, there is a critical need for comparative effectiveness data of these systems to guide clinical decision-making and institutional investments. This study aims to compare the diagnostic yield and safety profiles of the Ion and Monarch RAB platforms after introduction at a single institution. Methods: We conducted a retrospective chart review of patients undergoing RAB in the first six months following the introduction of each platform. Demographic and radiographic data were collected. Diagnostic yield was defined as obtaining a malignant or specific benign diagnosis from bronchoscopy. Results: The study included 56 Ion and 36 Monarch procedures. Diagnostic yield was similar between Ion (75%) and Monarch (72%) groups (p = 0.8), with an adjusted odds ratio 0.89 (95% CI 0.30–2.72). Complications were low, with one pneumothorax occurring in each group. Conclusions: Early adoption and use of both RAB platforms suggests comparable diagnostic yields and safety profiles in our limited sample size. Larger studies including standardized anesthesia protocol and systematic use of real-time imaging are needed for further evaluation and comparative analysis. Full article

Background: Robotic-assisted navigational bronchoscopy (RNB) using the ION system (Intuitive Surgical, Sunnyvale, CA, USA) combined with cone-beam computed tomography (CBCT) (Cios Spin, Siemens Healthineers, Erlangen, Germany) and tool-in-lesion verification enables precise diagnosis of peripheral pulmonary nodules. Integrating RNB with intraoperative frozen section analysis may allow same-day resection, avoiding delays between diagnosis and treatment. Standard airway management with a single-lumen tube (SLT) limits immediate transition to lung resection, whereas initial double-lumen tube (DLT) placement could streamline workflow and improve safety. This study evaluated the diagnostic performance, procedural efficiency, and feasibility of an integrated ION-guided RNB workflow using either SLT or DLT. Methods: In this single-center retrospective study, 36 consecutive patients undergoing ION-guided RNB for pulmonary nodules between August 2024 and June 2025 were analyzed. Airway management (SLT vs. DLT) was selected based on surgical planning. Lesions were targeted using CBCT or C-arm fluoroscopy, and biopsies were performed via forceps or cryoprobes. Frozen section results guided immediate surgical resection when malignancy was confirmed. Results: Thirty-six patients (mean age 64.9 ± 7.9 years; female/male ratio 16/20) with 42 nodules (mean diameter 1.22 ± 0.76 cm) were included; 76.2% were peripheral. Mean RNB time was 58.3 ± 21.3 min. Overall diagnostic yield was 73.0%, significantly higher with DLT versus SLT (84.2% vs. 50.0%, p = 0.035), with more biopsies per patient (7.9 ± 2.2 vs. 3.2 ± 3.1, p = 0.035). No major complications occurred. Conclusions: ION-guided RNB with CBCT and intraoperative frozen section enables accurate, single-session diagnosis and treatment of pulmonary nodules. Upfront DLT placement facilitates procedural efficiency within a streamlined “one-stop-shop” workflow without compromising diagnostic yield. Full article

Background: Bronchoscopic thermal ablation has emerged as a minimally invasive therapeutic option for managing pulmonary nodules in patients unsuitable for surgery or radiotherapy. Robotic-assisted bronchoscopy (RAB) offers enhanced stability and precise navigation, potentially improving the safety and accuracy of bronchoscopic ablation. However, clinical data on RAB-guided microwave ablation (MWA) remains limited. Therefore, further evidence is needed to evaluate its feasibility, safety, and early therapeutic performance. Methods: We conducted a single-center retrospective feasibility study of shape-sensing RAB-guided MWA (ssRAB-MWA) for pulmonary nodules between October 2024 and September 2025. Eligible lesions (≤3.0 cm) included both primary lung cancers and metastatic nodules. All procedures were performed under general anesthesia using the ssRAB system integrated with cone-beam CT for intra-procedural confirmation. Technical success, safety outcomes, and short-term efficacy were assessed. Results: Nine patients (with 11 lesions: 3 primary, 8 metastatic) underwent ssRAB-MWA with 100% technical success. The median ablation time per nodule was 10 min (range, 1–26). One patient developed post-ablation pneumonia requiring hospitalization; no pneumothorax, major bleeding, or airway injury occurred. All lesions exhibited a transient increase in size immediately following MWA, followed by gradual reduction or stabilization over time. PET-CT evaluation demonstrated metabolic remission in primary lesions, with one patient achieving pathologic complete response after surgery. Conclusions: ssRAB-MWA appears to be a feasible and safe navigation-guided technique for small pulmonary lesions, offering encouraging early local control in both primary and metastatic lung cancers. This platform may expand the therapeutic spectrum of interventional pulmonology, bridging diagnosis and local therapy. Larger multicenter studies are warranted to validate long-term outcomes. Full article

Background: Airway stenting is an alternative therapy for patients with complicated esophagectomy. Case presentation: A 60-year-old man with clinical stage IIIA esophageal cancer underwent neoadjuvant chemotherapy followed by robot-assisted subtotal esophagectomy with cervical esophagogastrostomy and jejunostomy. During surgery, both bronchial arteries were ligated to facilitate esophageal mobilization. Bronchoscopy on the first postoperative day showed no abnormalities; however, by the second postoperative day, the patient developed pneumonia and septic shock, requiring mechanical ventilation. On the fifth postoperative day, bronchoscopy revealed extensive epithelial injury extending from the trachea to both main bronchi, indicating ischemic airway damage. He was diagnosed with airway necrosis and referred to our respiratory department. Serial bronchoscopic examinations and suctioning of the sloughed epithelium were performed, and a tracheostomy enabled weaning from mechanical ventilation. By the twenty-fourth postoperative day, bronchoscopy revealed the accumulation of large, hardened secretions within the trachea, carina, and both main bronchi, resulting in airway narrowing and a high risk of asphyxiation. A silicone Y-shaped airway stent was inserted to maintain patency. Following stent placement, airway secretions progressively decreased, and the patient was discharged on the sixty-third postoperative day. The stent was removed six months later, with no recurrence of airway or respiratory complications. Conclusion: This case illustrates a rare but severe complication of extensive airway necrosis, likely caused by intraoperative bronchial artery ligation and dissection of the tracheal membranous portion. Although preservation of the bronchial arteries and meticulous surgical technique are essential preventive strategies, such complications may be unavoidable. In cases of extensive airway necrosis, airway stenting can serve as an effective therapeutic option to prevent obstruction and support recovery. Full article

Background: The diagnostic work-up of small peripheral pulmonary nodules (PPNs) is becoming increasingly important, especially in light of the upcoming lung cancer screening programs and recommendations in practice. The systematic clinical introduction of the ION robotic-assisted navigational bronchoscopy (RNB) system represents a significant innovation in Germany, whereas clinical experience in the United States has already yielded promising results. The objective of this study is to present the outcomes of the first 50 patients examined with the ION system at our institutions. Materials and Methods: This is a retrospective, single-center analysis. We included the first 50 consecutive patients who underwent diagnostic evaluation of pulmonary nodules using the ION-RNB system, either in the Department of Thoracic Surgery or the Department of Pulmonology. Results: A total of 50 patients were evaluated, including 24 from the Department of Thoracic Surgery and 26 from the Department of Pulmonology. The pulmonary nodules were found in the peripheral third of the lung in 74% of cases, in the middle third in 18% of cases, and in the central third in 8% of cases. The mean lesion size was 1.64 cm (±0.91 cm). In all, 84% of the nodules were solid, 4% were subsolid, and 12% presented as ground-glass opacities (GGOs). Cone beam computed tomography (CBCT) was used to confirm tool-in-lesion position in 68% of cases compared to C-arm fluoroscopy in 32%. Additionally, radial endobronchial ultrasound (rEBUS) was applied in 30% of procedures. The overall diagnostic yield, independent of imaging modality or histological processing method, was 78%. When CBCT and formalin-fixed paraffin-embedded (FFPE) histological analysis were utilized, the diagnostic yield exceeded 90%. Conclusions: Initial clinical experience with the ION-RNB system in Germany shows encouraging results. The high diagnostic accuracy underlines the system’s potential for evaluating peripheral pulmonary lesions precisely. The use of advanced imaging techniques, particularly CBCT, and the choice of histopathological processing methods are critical variables in optimizing patient-centered diagnostic pathways. Further prospective studies are warranted to assess the long-term clinical utility of robotic-assisted bronchoscopy in diverse clinical settings. Full article

Background/Objectives: Robot-assisted bronchoscopy (RAB) is a novel platform for sampling peripheral pulmonary nodules (PPNs). To further clarify the role robot-assisted platforms have in diagnosing PPNs, we performed a review of the recent literature. Methods: A systematic review was performed in Medline from 2019 to 2024 using the search terms “robotic bronchoscopy”, “diagnostic yield”, “sensitivity”, and “positive predictive value”, alone and in combination. Studies that focused on earlier electromagnetic bronchoscopies were excluded. The patient demographic information, nodule characteristics, intra-procedure imaging modality, biopsy methods, diagnostic yield, sensitivity for malignancy, and adverse outcomes were analyzed. A total of 22 studies were available for the analyses. Results: The diagnostic yield was variable and ranged from 69 to 93%, with a median of 86%. The sensitivity ranged from 69% to 91.7%, with a median of 85%. The effect of the nodule size on the diagnostic yield was variable across the literature. Obtaining an eccentric or concentric view on a radial endobronchial ultrasound (rEBUS) was associated with a higher diagnostic yield than obtaining no view. A nodule appearance on CT imaging and the location were not definitively associated with a higher diagnostic yield. Fine needle aspiration usage ranged from 93.5 to 100%, with a median of 96.95%, while the use of biopsy forceps ranged from 2.7 to 96%, with a median of 69.9%. The most common complication was a pneumothorax, which occurred in 1–5.7% of cases, with a median of 1.6%. Conclusions: Robot-assisted transbronchial biopsies produce diagnostic yields that approach those of transthoracic needle aspirations. The nodule location and appearance may not affect the diagnostic yield. Obtaining a concentric or eccentric view on rEBUS is likely associated with an increased diagnostic yield. Additional prospective studies would better inform practitioners as this technology becomes more widespread. Full article