State of the Art: Robotic Bronchoscopy

Ergonomics in bronchoscopy

PURPOSE OF REVIEW

This study examines ergonomic considerations in bronchoscopic procedures, surveying existing research, injury rates, contributing factors, and practical ergonomic controls.

RECENT FINDINGS

The field of ergonomics examines the relationship between workers and their workplace to enhance productivity and minimize injuries. Bronchoscopists may face ergonomic hazards due to extended periods of maintaining fixed positions, repetitive actions, and the design of both tools and procedure spaces. Studies on the ergonomics of bronchoscopy have revealed a wide range of musculoskeletal issues among practitioners. Those new to the field, including trainees and early-career professionals, may be particularly vulnerable to injuries compared to their more experienced counterparts. Implementing a systematic approach, such as that proposed by the National Institute for Occupational Safety and Health, could help reduce physical stress, discomfort, and the likelihood of musculoskeletal disorders for bronchoscopists.

SUMMARY

Bronchoscopists increasingly face ergonomic issues in their practice. Despite available measures to address these problems, the field lacks uniform ergonomic guidelines for bronchoscopy. To safeguard bronchoscopists' health and safety from the outset of their careers, more studies and training focused on ergonomics in bronchoscopy are needed.

Peripheral pulmonary lesion: novel approaches in endoscopic guidance systems and a state-of-the-art review

Diagnosis of peripheral pulmonary lesion (PPL) is the most challenging field in bronchoscopy and interventional pulmonology, which concerns early lung cancer diagnosis. Despite novel techniques and new approaches to the periphery of the lung, almost 25% of PPLs remain undiagnosed. Bronchoscopy with guide systems, virtual and/or electromagnetic navigation, robotic bronchoscopy, and transparenchymal nodule approaches tend to provide a higher percentage of reaching the lesion, but the diagnostic yield rarely exceeds 75%, regardless of the instruments used. Further studies are needed to evaluate what the main constraints of this discrepancy are and if a combined use of these techniques and instruments can provide an increased diagnostic yield.

Economic Value of Bronchoscopy Technologies that Improves Sensitivity for Malignancy for Peripheral Pulmonary Lesions

Rationale: Although previous studies have assessed the clinical or economic value of specific technologies, the economic value of improving sensitivity for malignancy in lung cancer diagnoses broadly across technologies is unclear. Objectives: To identify the economic value of improving sensitivity of bronchoscopy biopsy for the diagnosis of lung cancer. Methods: A decision analytic model was developed to quantify the economic value of increased sensitivity for malignancy for bronchoscopy biopsy of peripheral pulmonary lesions. Primary clinical outcomes included time to diagnosis and survival. Economic outcomes included 1) net monetary benefit (NMB), defined as the health benefits measured in quality-adjusted life-years (QALYs) times willingness to pay ($100,000/QALY) net of changes in medical costs; and 2) incremental cost-effectiveness ratio. A decision tree modeling framework with two Markov module branches was developed. The two Markov modules corresponded to patients with cancer who were 1) diagnosed and treated or 2) undiagnosed and remained untreated. Outcomes were measured from a U.S. payer perspective over 30 years. Results: Improving sensitivity for malignancy by 10 percentage points decreased average time to diagnosis for patients with lung cancer by 0.85 month (4 wk) and increased survival by 0.36 year (19 wk) because of faster treatment initiation. Overall health outcomes improved by 0.20 QALYs per patient. Cost increased by $6,727 per patient primarily through increased treatment costs among those diagnosed with cancer. Increasing sensitivity for malignancy by 10 percentage points improved NMB by $8,729 over 30 years (incremental cost-effectiveness ratio of $34,052), driven largely by improved sensitivity to early-stage cancer (stage-specific NMB, I/II, $19,805; III, $2,101; IV, -$1,438). Forty-two percent of overall NMB ($3,668) accrued within 5 years of biopsy. The relationship between change in sensitivity and NMB was approximately linear (1% vs. 10% sensitivity improvement corresponded to NMB of $885 vs. $8,729). The model was most sensitive to cancer treatment efficacy and follow-up time after a negative result. Conclusions: Increasing sensitivity of malignancy by 10 percentage points resulted in a $8,729 improvement in net economic value. Health systems can use this information when making decisions regarding the value of new bronchoscopy technologies.

Advances of surgical robotics: image-guided classification and application

Surgical robotics application in the field of minimally invasive surgery has developed rapidly and has been attracting increasingly more research attention in recent years. A common consensus has been reached that surgical procedures are to become less traumatic and with the implementation of more intelligence and higher autonomy, which is a serious challenge faced by the environmental sensing capabilities of robotic systems. One of the main sources of environmental information for robots are images, which are the basis of robot vision. In this review article, we divide clinical image into direct and indirect based on the object of information acquisition, and into continuous, intermittent continuous, and discontinuous according to the target-tracking frequency. The characteristics and applications of the existing surgical robots in each category are introduced based on these two dimensions. Our purpose in conducting this review was to analyze, summarize, and discuss the current evidence on the general rules on the application of image technologies for medical purposes. Our analysis gives insight and provides guidance conducive to the development of more advanced surgical robotics systems in the future.

Work-Related Musculoskeletal Injury Rates, Risk Factors, and Ergonomics in Different Endoscopic Specialties: A Review

Endoscopy-related musculoskeletal injuries (ERIs) are frequent among gastrointestinal, pulmonary, nasal, and urologic endoscopists, impacting the healthcare system. The present review aims to compare the ERI rates, risk factors, and ergonomic recommendations in the different endoscopic fields. A review was conducted using PubMed and Cochrane Library for articles based on surveys and published until 10 January 2024. Demographic, work, and ERI data from 46 publications were included, covering 10,539 responders. The ERI incidence ranged between 14% and 97%, highlighting the need of intervention independent of the specialties. The neck, back, and shoulder were the most frequent ERI locations, while gender, age, years of experience, and procedure volume the most common risk factors. Ergonomic recommendations suggest concentrating on endoscope design changes, especially in gastrointestinal endoscopy, to increase the comfort, adaptability of the equipment in the operating room, and workflow/institutional policy changes. The inclusion of an ergonomic timeout guarantees the correct equipment positioning, the neutralisation of the endoscopist's posture, and an indirect break between procedures. Ergonomic training to increase awareness and best practice should be promoted, also using new technologies. Future research should concentrate on intervention and comparative studies to evaluate to which extent prevention measures and newly designed equipment could reduce ERI incidence.

Robotic bronchoscopic needle-based confocal laser endomicroscopy to diagnose peripheral lung nodules

BACKGROUND AND OBJECTIVE

Robotic bronchoscopy has demonstrated high navigational success in small peripheral lung nodules but the diagnostic yield is discrepantly lower. Needle based confocal laser endomicroscopy (nCLE) enables real-time microscopic imaging at the needle tip. We aim to assess feasibility, safety and needle repositioning based on real-time nCLE-guidance during robotic bronchoscopy in small peripheral lung nodules.

METHODS

Patients with suspected peripheral lung cancer underwent fluoroscopy and radial EBUS assisted robotic bronchoscopy. After radial EBUS nodule identification, nCLE-imaging of the target area was performed. nCLE-malignancy and airway/lung parenchyma criteria were used to identify the optimal sampling location. In case airway was visualized, repositioning of the biopsy needle was performed. After nCLE tool-in-nodule confirmation, needle passes and biopsies were performed at the same location.

MEASUREMENTS AND MAIN RESULTS

Twenty patients were included (final diagnosis n = 17 (lung) cancer) with a median lung nodule size of 14.5 mm (range 8-28 mm). No complications occurred. In 19/20 patients, good quality nCLE-videos were obtained. In 9 patients (45%), real-time nCLE-imaging revealed inadequate positioning of the needle and repositioning was performed. After repositioning, nCLE-imaging provided tool-in-nodule-confirmation in 19/20 patients. Subsequent ROSE demonstrated representative material in 9/20 patients (45%) and overall diagnostic yield was 80% (16/20). Of the three patients with malignant nCLE-imaging but inadequate pathology, two were diagnosed with malignancy during follow-up.

CONCLUSION

Robotic bronchoscopic nCLE-imaging is feasible and safe. nCLE-imaging in small, difficult-to-access lung nodules provided additional real-time feedback on the correct needle positioning with the potential to optimize the sampling location and diagnostic yield.

A Millimeter-Scale Soft Robot for Tissue Biopsy Procedures

While interest in soft robotics as surgical tools has grown due to their inherently safe interactions with the body, their feasibility is limited in the amount of force that can be transmitted during procedures. This is especially apparent in minimally invasive procedures where millimeter-scale devices are necessary for reaching the desired surgical site, such as in interventional bronchoscopy. To leverage the benefits of soft robotics in minimally invasive surgery, a soft robot with integrated tip steering, stabilization, and needle deployment capabilities is proposed for lung tissue biopsy procedures. Design, fabrication, and modeling of the force transmission of this soft robotic platform allows for integration into a system with a diameter of 3.5 mm. Characterizations of the soft robot are performed to analyze bending angle, force transmission, and expansion during needle deployment. In-vitro experiments of both the needle deployment mechanism and fully integrated soft robot validate the proposed workflow and capabilities in a simulated surgical setting.

Hyperelastic Modeling and Validation of Hybrid-Actuated Soft Robot with Pressure-Stiffening

Soft robots have gained popularity, especially in intraluminal applications, because their soft bodies make them safer for surgical interventions than flexures with rigid backbones. This study investigates a pressure-regulating stiffness tendon-driven soft robot and provides a continuum mechanics model for it towards using that in adaptive stiffness applications. To this end, first, a central single-chamber pneumatic and tri-tendon-driven soft robot was designed and fabricated. Afterward, the classic Cosserat's rod model was adopted and augmented with the hyperelastic material model. The model was then formulated as a boundary-value problem and was solved using the shooting method. To identify the pressure-stiffening effect, a parameter-identification problem was formulated to identify the relationship between the flexural rigidity of the soft robot and internal pressure. The flexural rigidity of the robot at various pressures was optimized to match theoretical deformation and experiments. The theoretical findings of arbitrary pressures were then compared with the experiment for validation. The internal chamber pressure was in the range of 0 to 40 kPa and the tendon tensions were in the range of 0 to 3 N. The theoretical and experimental findings were in fair agreement for tip displacement with a maximum error of 6.40% of the flexure's length.

Robotics in the diagnosis and staging of lung cancer

The diagnosis of peripheral small lung lesions by electromagnetic navigational bronchoscopy is still inferior to computed tomography (CT) guided percutaneous transthoracic needle lung biopsy. Robotic bronchoscopy is a new technology that may be a potential breakthrough in the diagnosis of small lung lesions. Real-time tools such as electromagnetic navigation, radial-endobronchial ultrasound, and cone beam CT may further improve the diagnostic yield rate may further improve the diagnostic yield rate. In this article, we reviewed early experience of robotic bronchoscopy for diagnosis and staging of lung cancer.

Robotic Assisted-Bronchoscopy With Cone-Beam CT ICG Dye Marking for Lung Nodule Localization: Experience Beyond USA

Electromagnetic navigation bronchoscopy (ENB)-guided indocyanine green (ICG) fluorescence dye marking of subsolid, small and deep lung lesions facilitates subsequent minimally invasive lung resection surgeries. The novel robotic-assisted bronchoscopy (RAB) platform can improve the accuracy and yield of ENB biopsy, and the use of RAB has been extended to ICG dye marking. However, performing this procedure in the hybrid operating room guided by cone-beam CT (CBCT) with immediate proceed to lung surgery has not been well reported. We studied the safety, feasibility and clinical outcomes of 5 consecutive cases performed between December 2021 and March 2022. Navigation success was 100% while localization success using ICG was 80%. The benefits and pitfalls of robotic bronchoscopy procedures, and challenges of combining with hybrid operating room CBCT were discussed in detail. In conclusion, robotic-assisted bronchoscopy is a promising and useful tool for ICG fluorescence dye-marking, providing accurate navigation, superior maneuverability and improved ergonomics compared to conventional bronchoscopy-guided ENB procedures. Learning curve is reasonable, but meticulous system set up to incorporate the robotic system into existing CBCT platform may be required to ensure a smooth procedure.

Intratumorally anchored cytokine therapy

INTRODUCTION

On-target, off-tumor toxicity severely limits systemic dosing of cytokines and agonist antibodies for cancer. Intratumoral administration is increasingly being explored to mitigate this problem. Full exploitation of this mode of administration must include a mechanism for sustained retention of the drug; otherwise, rapid diffusion out of the tumor eliminates any advantage.

AREAS COVERED

We focus here on strategies for anchoring immune agonists in accessible formats. Such anchoring may utilize extracellular matrix components, cell surface receptor targets, or exogenously administered particulate materials. Promising alternative strategies not reviewed here include slow release from the interior of a material depot, expression following local transfection, and conditional proteolytic activation of masked molecules.

EXPERT OPINION

An effective mechanism for tissue retention is a critical component of intratumorally anchored cytokine therapy, as leakage leads to decreased tumor drug exposure and increased systemic toxicity. Matching variable drug release kinetics with receptor-mediated cellular uptake is an intrinsic requirement for the alternative strategies mentioned above. Bioavailability of an anchored form of the administered drug is key to obviating this balancing act.

Image-Guided Robotics for Standardized and Automated Biopsy and Ablation

Image-guided robotics for biopsy and ablation aims to minimize procedure times, reduce needle manipulations, radiation, and complications, and enable treatment of larger and more complex tumors, while facilitating standardization for more uniform and improved outcomes. Robotic navigation of needles enables standardized and uniform procedures which enhance reproducibility via real-time precision feedback, while avoiding radiation exposure to the operator. Robots can be integrated with computed tomography (CT), cone beam CT, magnetic resonance imaging, and ultrasound and through various techniques, including stereotaxy, table-mounted, floor-mounted, and patient-mounted robots. The history, challenges, solutions, and questions facing the field of interventional radiology (IR) and interventional oncology are reviewed, to enable responsible clinical adoption and value definition via ergonomics, workflows, business models, and outcome data. IR-integrated robotics is ready for broader adoption. The robots are coming!

Advanced bronchoscopic techniques for the diagnosis and treatment of peripheral lung cancer

Lung cancer is the leading cause of cancer related deaths worldwide. As a result of the increasing use of chest CT scans and lung cancer screening initiatives, there is a rapidly increasing need for lung lesion analysis and - in case of confirmed cancer - treatment. A desirable future concept is the one-stop outpatient bronchoscopic approach including navigation to the tumor, malignancy confirmation and immediate treatment. Several novel bronchoscopic diagnostic and treatment concepts are currently under evaluation contributing to this concept. As the majority of suspected malignant lung lesions develop in the periphery of the lungs, improved bronchoscopic navigation to the target lesion is of key importance. Fortunately, the field of interventional pulmonology is evolving rapidly and several advanced bronchoscopic navigation techniques are clinically available, allowing an increasingly accurate tissue diagnosis of peripheral lung lesions. Additionally, multiple bronchoscopic treatment modalities are currently under investigation. This review will provide a concise overview of advanced bronchoscopic techniques to diagnose and treat peripheral lung cancer by describing their working mechanisms, strengths and weaknesses, identifying knowledge gaps and indicating future developments. The desired one-step concept of bronchoscopic 'diagnose and treat' peripheral lung cancer is on the horizon.