to enable the utility and insertion of the ancillary tools, losing the white light real-time vision but preserving location by the continuous, real-time feedback of the shape-sensing technology.

Both systems will provide distance from the catheter tip to the lesion, allowing for controlled transbronchial needle aspiration and setting the extension distance of biopsy needle, forceps, or brush.

In patients with implantable cardiac pacemakers or de brillators, using electromagnetic navigation with the Monarch Robotic System is not advisable. Considering its excellent reach and stability, a recent publication proposed that the Monarch Robotic Bronchoscopy System be used without using electromagnetic guidance in this patient population [8].

Ancillary imaging like fuoroscopy, cone-­ beam CT (Fig. 26.11), or radial US can be utilized during the procedure. Real-time feedback of tissue/cells acquisition through Rapid-on-site cytological Evaluation (ROSE) is recommended.

Fig. 26.11  The Ion bronchoscope showing a needle within the lesion on cone-beam CT

Evidence-Based Review

Safety andFeasibility

Both current robotic systems are safe with low complication rates, and in general are very comparable to conventional fexible bronchoscopy safety’s pro le. The rst feasibility and safety study were performed by Rojas-Solano et al., in 2018 using the Monarch RAB system in 15 patients with suspicious Pulmonary nodules and bronchus sign. The average nodule size was 26 mm (10–63 mm). Biopsies were obtained in 93% of patients with no occurrence of pneumothorax nor signi cant bleeding [9].

Fielding et al., in 2019, reported the rst use of shape-sensing technology of the Ion Endoluminal Robotic System in the diagnosis of peripheral lung nodules in humans. He included 29 subjects with a mean lesion size of around 12 mm. The CT bronchus sign was absent in 41.4% of cases. In 96.6% of cases, the target was reached, and samples were obtained. No complications were noted in the study. The overall diagnostic yield was 79.3%, and a diagnostic yield for malignancy was 88%. This rst Ion study concluded that the system is safe and able to navigate to the very periphery of the lung, reaching small pulmonary nodules and, due to its stability, provided excellent diagnostic yield [10].

Chaddha et al., in 2019 (165 patients) study of the Monarch system, reported 3.6% overall pneumothorax incidence (2.4% required intervention) [11], and Chen et al., in a 2021 study of 54 patients, reported a 3.7% overall pneumothorax rate and only 1.9% required intervention [7].

In the case of the Ion Endoluminal Robotic System, Kalchiem-Dekel et al. in 2021 reported a 1.5% pneumothorax rate in a study that included 131 patients [12] and a 3.3% rate (0.4% requiring intervention for pneumothorax in a larger study that included 241 patients by Reisenauer et al. in 2022 [13]. There was no reported mortality in any of the studies.