Robotic-Assisted Bronchoscopy for Peripheral Pulmonary Lesions: Current Evidence, Clinical Applications, and Future Directions

The evaluation of peripheral pulmonary lesions (PPLs) represents a persistent clinical challenge, particularly in the context of rapidly expanding lung cancer screening programs generating unprecedented volumes of screen-detected nodules requiring tissue evaluation. Conventional bronchoscopic techniques and earlier navigation platforms, including electromagnetic navigation bronchoscopy (ENB), improved access to peripheral airways but demonstrated variable and generally suboptimal diagnostic performance—historically plateauing at 60–70%—attributable principally to CT-to-body divergence and the diagnostic drop-off phenomenon. Robotic-assisted bronchoscopy (RAB) has emerged as a significant advancement integrating robotic catheter control, shape-sensing or electromagnetic navigation, and adjunctive intraprocedural imaging—principally cone-beam computed tomography (CBCT)—to improve lesion localization and procedural stability. Available evidence suggests that RAB achieves improved diagnostic yields compared with conventional bronchoscopic techniques, particularly when combined with real-time CBCT-guided tool-in-lesion confirmation and multimodal biopsy strategies including transbronchial cryobiopsy. Reported diagnostic yields generally range from 70% to 87% across pooled meta-analytic datasets, with higher yields described in centers employing CBCT and cryobiopsy. A favorable safety profile—with pooled pneumothorax rates of approximately 2%, substantially below the 20–25% associated with CT-guided transthoracic needle biopsy—represents a clinically important differentiator, particularly in patients with emphysema, coagulopathy, or contralateral lung compromise [1,3]. RAB additionally enables procedural capabilities beyond peripheral lesion biopsy, including simultaneous mediastinal lymph node staging, bilateral same-session lesion sampling, fiducial marker placement for stereotactic body radiotherapy, and investigational therapeutic applications. However, current evidence is largely derived from observational studies and single-arm prospective cohorts, with limited randomized data directly comparing RAB with transthoracic biopsy approaches. Outcomes are meaningfully influenced by lesion characteristics, operator experience, institutional volume, and availability of advanced imaging infrastructure. This review summarizes current evidence on RAB platforms, procedural optimization, diagnostic performance, safety, molecular tissue adequacy, and emerging applications, while explicitly addressing limitations, controversies, and areas requiring further investigation. This review was conducted and reported in accordance with PRISMA 2020 guidelines adapted for narrative reviews (SANRA framework).