Comparative diagnostic performance and safety of radial endobronchial ultrasound versus its combination with electromagnetic or virtual bronchoscopic navigation for peripheral pulmonary lesions: a retrospective study

Background: Radial endobronchial ultrasound (R-EBUS), virtual bronchoscopic navigation (VBN), and electromagnetic navigation bronchoscopy (ENB) are widely used bronchoscopic techniques for diagnosing peripheral pulmonary lesions (PPLs). However, the applications of their combinations remain unclear. Objectives: This study aimed to investigate the diagnostic performance and safety of R-EBUS versus its combination with ENB or VBN and lesion characteristics. Design: This study is a retrospective, single-center cohort study. Methods: Patients who underwent R-EBUS without and with ENB or VBN (R-EBUS+ENB, R-EBUS+VBN) for peripheral pulmonary. Diagnostic yield, sensitivity, specificity, and complications were compared using inverse probability of treatment weighting (IPTW) for baseline difference adjustment. Results: R-EBUS, R-EBUS+ENB, and R-EBUS+VBN groups had diagnostic yields of 74.6%, 78.2%, and 73.0%, respectively (no significant differences after IPTW adjustment). Multimodal approaches significantly improved diagnostic yield in patients with emphysematous lungs (R-EBUS vs R-EBUS+ENB: odds ratio (OR): 3.51; 95% confidence interval (CI): 1.38–8.95; p = 0.009; R-EBUS vs R-EBUS+VBN: OR: 3.14; 95% CI: 1.05–9.35; p = 0.04). R-EBUS+ENB demonstrated superior diagnostic performance in lesions ⩽20 mm (OR: 3.58; 95% CI: 1.28–9.98; p = 0.015), lesions with positive bronchial signs (OR: 1.98; 95% CI: 1.07–3.67; p = 0.029), and solid lesions with combined positive bronchial signs (OR: 2.67; 95% CI: 1.18–6.07; p = 0.019). Mild bleeding was more frequent in the R-EBUS+ENB group than in the R-EBUS group (OR: 3.21; 95% CI: 1.13–9.13; p = 0.029); severe complications did not significantly differ among groups. Conclusion: Comparable diagnostic performances were observed among R-EBUS, R-EBUS+ENB, and R-EBUS+VBN groups. Multimodal approaches significantly enhanced diagnostic accuracy in subtypes with lesions of small size, positive bronchial signs, or emphysematous lungs. These findings highlight the importance of tailored multimodal strategies to improve diagnostic yield and procedural safety in PPL evaluation.