Robotic-assisted Bronchoscopy and Cone-beam CT

摘要

The combination of robotic-assisted bronchoscopy (RAB) and cone-beam computed tomography (CBCT) is an emerging novel technology that can be used for diagnosing peripheral lung lesions. The ability to diagnose and stage a suspected, peripheral, difficult to reach lung lesions in a single procedure made RAB with CBCT an interesting procedure of choice. Overall, RAB has been increasingly utilized for the evaluation of challenging lung lesions, otherwise difficult to reach and sample effectively. Despite advancements in technology and improved diagnostic yields over previous approaches, computed tomography to body divergence remains one of the major limitations for any electromagnetic navigation bronchoscopy (ENB) case where virtual targeting may be affected. Combining the use of ENB with radial probe endobronchial ultrasound (RP-EBUS) and fluoroscopy can aid in lesion diagnosis.1 In the literature, diagnostic yields ranging from 71% to 90% with the use of CBCT in conjunct with ENB with or without RP-EBUS have been in published.1–4 This experience was performed as a single-center retrospective study, consecutive patients in which RAB (Monarch; Auris, Redwood City, CA) was utilized to diagnose challenging lung lesions. This was conducted as a QI project, as part of a review of an internal interventional pulmonology database—consent was waived per institutional review board. The ability of the robotic platform to reach challenging areas of concern is facilitated primarily by proprietary fused navigational technology, leveraging airway optical recognition, electromagnetics, and robotic kinematic information. This approach resulted in real-time correction of airway pathways aimed at successful target localization. For these combined cases, RAB+CBCT candidacy was evaluated by a lung nodule multidisciplinary team based on case complexity, size, and target location, among other factors. These cases required intubation and general anesthesia, as per usual protocol at our institution for bronchoscopic procedures that require chemical paralysis. We performed an initial CBCT spin before RAB navigation, to evaluate target stability or enlargement and to check isocentering. After successfully navigating to the target lesion, RP-EBUS (Olympus, PA) was performed in all patients to evaluate ultrasonograpic imaging, and then a biopsy instrument was to the target lesion. A fine needle (PeriView, Olympus, PA) was then advanced into the target and the instrument position was visualized with the use of a CBCT spin to determine the location with respect to lesion and adjustments made if necessary. For case selection, we established certain criteria prompting consideration for a combined approach based on combinations of the following factors: (1) nearest airway >2 cm from target lesion, (2) noncentral lesions with contraindications for transthoracic needle aspiration, (3) suspected difficulty to locate with traditional bronchoscopic approaches, (4) lung lesions located in the middle or outer third of the lung with the need for endobronchial ultrasound staging, (5) distal lesions without a suspected endobronchial component and no bronchus sign, (6) target location beyond the fourth-generation bronchus, (7) at least intermediate suspicion for lung cancer or other etiologies that required tissue acquisition. For this study, we analyzed: (1) feasibility; (2) navigation success; (3) navigation time and total procedure time; (4) tool in lesion confirmation; (5) intraprocedural and postprocedural complications; (6) systems accuracy and precision. Feasibility was defined as the ability for these technologies to function as intended within the required procedural space, without significant interference or prohibitive maneuvering of any equipment tool in lesion confirmation was performed by visualizing any tool (radial probe, forceps, needle) in contact with targeted area—irrespective of RP-EBUS signal. A total of 20 pulmonary lesions suspected of being malignan