Diagnostic Performance and Safety Profile of Robotic-assisted Bronchoscopy: A Systematic Review and Meta-Analysis

Rationale: Conventional electromagnetic navigation (ENB) and other guided bronchoscopic modalities have a very desirable safety profile but their diagnostic yield is only 60-70% for pulmonary lesions. Recently, robotic-assisted bronchoscopy (RAB) platforms have been introduced to improve the diagnostic performance of bronchoscopic modalities. Objectives: To determine the diagnostic performance and safety profile of RAB (shape-sensing and electromagnetic navigation-based platforms), by performing a systematic review and meta-analysisMethods: PubMed, Embase, and Google Scholar databases were searched to find studies that had reported on the diagnostic performance and/or the safety profile of one of the RAB systems. The quality of included studies was assessed using the QUADAS-2 tool. Meta-analysis was performed using MedCalc version 20.118. Pooled diagnostic yield was calculated using a Freeman-Tukey transformation. We planned to use random effects model if the I² index was > 40%. Results: 25 studies were included in our study: 20 (diagnostic and safety analyses), 5 (only safety analysis). The pooled diagnostic yield of RAB (20 studies, 1779 lesions) was 84.3% (95% CI 81.1-87.2). I2 index was 65.6%. Based on our subgroup analyses the heterogeneity was likely driven by the differences in the study designs (prospective vs. retrospective) and procedural protocols (such as different RAB systems). Lesion size > 2cm, presence of a CT-bronchus sign, and concentric radial-EBUS view were associated with a statistically significant increase in the odds of diagnosis with RAB. The overall rates of pneumothorax, need for tube thoracostomy and significant hemorrhage were 2.3%, 1.2%, and 0.5%, respectively. Conclusion: RAB systems have significantly increased the diagnostic yield of navigational bronchoscopy as compared to conventional systems such as ENB, however, well-designed prospective studies are needed to better understand the impact of various factors such as the use of 3D imaging modalities, cryobiopsies, and specific ventilatory protocols, on the diagnostic yield of RAB.