Prone positioning in cone beam CT-guided robotic bronchoscopy case series: A strategy to minimize atelectasis and improve access to posteromedial lower lobe nodules

Affiliations

Advocate Lutheran General Hospital

Abstract

Background: Robotic-assisted bronchoscopy (RAB) combined with cone beam computed tomography (CBCT), augmented fluoroscopy (AF), and radial endobronchial ultrasound (EBUS) improves diagnostic yield for peripheral nodules but remains limited in posteromedial locations due to anesthesia-related atelectasis and computed tomography (CT)-to-body divergence. Prone positioning has been proposed to counteract these limitations by improving dorsal aeration and stabilizing lesion position. The objective of this study was to evaluate the feasibility of performing RAB with CBCT guidance in the prone position to improve access and diagnostic yield for lung nodules in the posteromedial lower lobes.

Methods: We retrospectively reviewed 28 patients who underwent RAB with CBCT-AF in the prone position for posteromedial lung nodules at a tertiary teaching hospital between June 2024 and July 2025. All patients underwent transbronchial biopsy with RAB/CBCT-AF and systematic mediastinal and hilar staging with EBUS-transbronchial needle aspiration (TBNA). Demographic, procedural, and pathology data were analyzed.

Results: The median age was 74.5 years, and the mean nodule size was 11 mm (range, 5-31 mm). Nodules were distributed between the right and left lungs, with two located in the right upper lobe (RUL); all were posteromedial. The mean procedure time, including CBCT spins and complete mediastinal staging, was 69.6 minutes (range, 41-108 minutes). Diagnostic tissue was obtained in 25 of 28 patients, corresponding to an overall diagnostic yield of 89.3%. Malignant diagnoses included adenocarcinoma (60%), squamous cell carcinoma (30%), and metastatic malignancy (10%). Benign diagnoses included granulomas and one cyst. Three cases (10.7%) were non-diagnostic and remain under CT surveillance. No major complications occurred.

Conclusions: Prone positioning combined with RAB, CBCT-AF is a feasible and safe approach for posteromedial lung nodules, achieving high diagnostic yield while minimizing anesthesia-related atelectasis and CT-to-body divergence. These findings support prone RAB with CBCT-AF as a valuable strategy for anatomically challenging nodules and justify further evaluation in multicenter prospective studies.

Type

Article

PubMed ID

41376911

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