Highlight
This prospective clinical study evaluates radiation exposure differences between conventional fluoroscopy-guided bronchoscopy and robotic-assisted bronchoscopy (RAB).
Robotic bronchoscopy using C-arm-based tomosynthesis (CABT) delivers significantly higher radiation doses to bronchoscopists compared to conventional bronchoscopy or RAB with standard C-arm fluoroscopy.
Radiation exposure to supporting staff remains minimal across all procedural modalities.
Patient factors such as BMI greater than 35 significantly increase radiation dose metrics during procedures.
Study Background
Bronchoscopy is essential for pulmonary diagnostics, particularly for biopsy of peripheral lung nodules. Conventional bronchoscopy often uses fluoroscopic guidance, which exposes bronchoscopists and staff to ionizing radiation. Advances have introduced robotic-assisted bronchoscopy platforms that aim to improve lesion localization and diagnostic yield, frequently utilizing enhanced imaging modalities including tomosynthesis to optimize navigation. However, comparative data on radiation safety between conventional and robotic approaches are limited, particularly concerning potential operator exposure increases associated with additional imaging.
Study Design
This single-center, prospective study analyzed radiation doses received during 54 fluoroscopy-guided bronchoscopies: 15 performed with conventional bronchoscopy and 39 with robotic assistance (RAB). The RAB cases were divided into those using C-arm-based tomosynthesis (CABT; n=27) and standard C-arm fluoroscopy (CF; n=12). Radiation exposure was measured according to International Commission on Radiological Protection (ICRP) and National Council on Radiation Protection and Measurements (NCRP) guidelines, focusing on operator dose to the skin under the thyroid collar, and doses to nursing, anesthesia, pathology, and technician staff. Patient and procedural variables such as BMI, nodule characteristics, and procedure time were also recorded. The primary endpoint was operator radiation exposure per case among the three groups.
Key Findings
The median total radiation exposure during RAB with CABT was 0.237 mSv per case, significantly higher than both conventional bronchoscopy (0.065 mSv) and RAB with CF (0.02 mSv) (p=0.025). No statistically significant difference was seen between conventional bronchoscopy and RAB with CF (p=0.33), indicating that robotic bronchoscopy using standard fluoroscopy does not increase radiation exposure compared with conventional approaches.
Operator skin dose beneath the thyroid collar was notably increased with RAB CABT at 0.0022 mSv/min (p=0.007), while exposures remained negligible under conventional and RAB CF techniques. Radiation doses to support staff were minimal and not significantly different across all procedure types.
Among patient-related variables, a BMI greater than 35 was associated with significantly elevated Dose-Area Product (DAP) per minute (5.1 Gy·cm2, p=0.0067), highlighting the impact of patient body habitus on radiation exposure during fluoroscopically guided procedures. Other factors such as nodule size, CT pattern, and lesion location did not influence radiation dose.
Expert Commentary
This rigorous prospective evaluation addresses an important safety concern as robotic bronchoscopy becomes more widespread. While RAB offers improved lesion access and procedural reproducibility, enhanced imaging with tomosynthesis can substantially increase operator radiation dose. This finding underscores the need to balance diagnostic benefit with occupational hazard and to adhere to dose optimization principles.
The absence of increased dose with RAB using standard fluoroscopy may reassure centers adopting robotic platforms without tomosynthesis. However, the higher radiation burden with CABT mandates consideration of protective strategies such as improved shielding, protocol modification, or limiting the number of such procedures annually in line with regulatory guidelines.
Limitations include the single-center design and modest sample size, particularly in the RAB CF subgroup. Long-term clinical outcome correlation and multi-institutional studies would further validate these findings.
Conclusion
This prospective study demonstrates that robotic bronchoscopy employing C-arm-based tomosynthesis markedly increases radiation exposure to bronchoscopists compared with conventional bronchoscopy or robotic bronchoscopy with standard fluoroscopy. Operator and staff safety remains paramount, necessitating rigorous radiation protection measures and regulatory compliance. Robotic bronchoscopy with standard fluoroscopic guidance does not elevate radiation dose above conventional methods, supporting its safe implementation. Attention to patient factors such as BMI, which influence radiation dose, remains crucial in procedural planning.
Future research should focus on optimizing imaging protocols to minimize exposure while sustaining diagnostic performance, alongside continued surveillance of occupational dose trends as bronchoscopy technology evolves.
Funding and Clinical Trial Information
The referenced study by Ravikumar et al. was published in Chest in July 2026. Funding sources and trial registration details were not explicitly stated in the available extract.