Robotic-assisted bronchoscopy (RAB) for diagnosing lung cancer
Scottish Health Technologies Group (SHTG)
Recommendations for NHSScotland
Robotic-assisted bronchoscopy (RAB) should be available as a diagnostic biopsy option for patients with pulmonary lesions identified on computed tomography (CT) imaging that are suspected of being lung cancer. RAB should be the preferred biopsy technique for patients with small (<20mm) peripheral lesions that are not suitable for sampling using conventional techniques.
Access to RAB should be equitable and consistent across Scotland, ensuring all eligible patients have access regardless of geographic location. Successful introduction of RAB will require comprehensive training for clinicians in the safe and effective use of this technology and adequate infrastructure for the decontamination, sterilisation and ongoing quality assurance of reusable RAB bronchoscopes.
The use of RAB should be accompanied by systematic data collection and analysis to inform future decision making regarding its role within Scottish lung cancer diagnostic pathways.
NHSScotland is required to consider the Scottish Health Technologies Group (SHTG) recommendations.
How the Council reached the recommendation
- The Council agreed that RAB offers a high diagnostic yield and low complication rates, making it an effective and safe diagnostic option for patients. The Council felt that RAB was likely to be especially beneficial for patients with hard-to-reach lesions that are not accessible using conventional biopsy techniques. Introducing RAB would offer extra diagnostic capacity inadvance of the rollout of a national lung cancer screening programme to help improve the early diagnosis of lung cancer in Scotland.
- A clinical expert advised the Council that published studies comparing RAB with conventional biopsy techniques were likely to include two different patient populations because people with small, peripheral nodules that did not have a bronchus sign would not be considered for biopsy using conventional techniques but would be suitable for biopsy using RAB.
- The Council acknowledged that interpreting the evidence on RAB was difficult because of variations in the definitions of diagnostic yield used across the published studies. A clinical expert advised that efforts continue to be made at an international level to agree a strict definition of diagnostic yield which would help improve consistency in definitions and reporting across future studies.
- Council members expressed strong objections to having the economic analysis data redacted because of the need for pricing confidentiality. Members felt that this made it impossible to judge the appropriateness of the analysis and its conclusions. The Council agreed to limit the conclusion of the economic analysis to exploratory or indicative only.
- A clinical expert and patient group representative explained to the Council that people with small (<20 mm) lung lesions were often put on a ‘watch and wait’ list. Patients on these lists received a CT scan after 3 months, 1 year, 2 years and would be discharged from the list after 3 years if their pulmonary nodule remained stable. If the nodule was found to be growing during this time, the patient would begin treatment with surgery or radiotherapy without a confirmed diagnosis. This causes some patients and their families a great deal of anxiety, distress and confusion.
- The Council recognised the importance of RAB to patients who may not be able to have a timely biopsy using conventional techniques. This issue was highlighted by a presentation to Council by the Roy Castle Lung Cancer Foundation.
- The Council observed that Scotland does not currently have a lung cancer screening programme or RAB, both of which are available in England. They acknowledged that this leads to inequities in access to healthcare for people with a high risk of lung cancer living in different parts of the United Kingdom (UK).
- The Council noted that a national lung cancer screening programme for Scotland is planned to begin in late 2027. The introduction of this programme is expected to generate an increase in the number of patients requiring diagnostic biopsies for small nodules suspected of being early-stage lung cancer. The Council recognised that, without RAB in place ahead of the programme’s launch, services may be unable to manage the resulting demand, leading to significant delays for patients awaiting biopsy.
- The Council acknowledged that the Ion™ RAB device is the only platform currently available for purchase in Scotland. The Council also noted that most of the published evidence on RAB related to the Ion™ platform and that the findings of studies on the Ion™ platform may not generalise to the Monarch™ or Galaxy™ platforms.
- The Council discussed how many RAB devices would be needed across NHSScotland. It was agreed that this was not the responsibility of the Council, but that RAB devices would not be needed in every hospital. The Council flagged that a minimum caseload is likely to be required to maintain an acceptable level of expertise in using RAB.
- The Council highlighted the value of gathering and analysing data on the use of RAB in Scotland in a way that could be shared and compared with registry data from England or Europe.
Date of publication: 15 May 2026