Robotic bronchoscopy: Evolution of advanced diagnostic technologies for pulmonary lesions

Lung cancer is among one of the most commonly diagnosed malignancies and is the leading cause of cancer-related mortality in both men and women globally, with an estimated 1.8 million deaths annually. Moreover, it is also the leading cause of cancer related deaths in the United States (U.S.), with an estimated 127,000 deaths annually. Approximately 50% of patients who undergo chest Computed Tomography (CT) are found to have a pulmonary nodule (PN), albeit 95% of these PNs are subsequently found to be benign. Further complicating the challenge of timely detection of lung cancer, is made more difficult by the fact that most patients are totally asymptomatic in early stage of disease. However, given that sponsored studies by National Cancer Institute (NCI) and other organizations showed a 20% reduction in lung cancer specific mortality with low dose CT scanning in patients at risk, it is reasonable to assume that clinicians will confront this clinical scenario more frequently. Consequently, due to these significant findings, the United States Preventive Services Task Force (USPSTF) recommended annual screening of high-risk patients. Therefore, as result of these recommendations, 240,000 new lung cancers were diagnosed in the U.S. in 2020, with an estimated 238,000 new cases in 2023. Given the multitude of challenges, the practice guidelines and recommendations for the management of these PNs are often tailored to available resources and trained personnel familiar with the various techniques and technologies. This review will discuss the evolution of various advancements when tissue biopsy is required: from sputum cytology, nonguided bronchoscopy, percutaneous CT guided biopsy, guided advanced bronchoscopic techniques such as endobronchial ultrasound (EBUS), radial Endobronchial Ultrasound (rEBUS) to the latest advancement of robotic-assisted bronchoscopy (RAB). Furthermore, as many of the aforementioned techniques require anesthesia, as integral members of the multidisciplinary team, anesthesiologists are often in the unique position of facilitating diagnosis and subsequent treatment by other subspecialists when providing anesthetic care for these patients with PNs. Additionally, the common anesthetic considerations and implications for the preoperative, intraoperative, and postoperative periods will be elucidated further, with special emphasis on the unique considerations for RABs. Combined hybrid procedures with RAB, EBUS and surgery will also be reviewed, as they offer potential reduction in time of diagnosis to definitive treatment. Lastly, the strategies employed to mitigate some of the commonly encountered challenges faced by anesthesiologists when caring for these patients will also be reviewed.