Efficacy and safety of radial probe endobronchial ultrasound–transbronchial lung biopsy in peripheral pulmonary lesions without guide sheath and fluoroscopy

Background: Radial probe endobronchial ultrasound–transbronchial lung biopsy (rEBUS-TBLB) enables accurate and safe sampling of small peripheral pulmonary lesions (PPLs) inaccessible to conventional flexible bronchoscopy. Although widely adopted and effective, the standard approach using fluoroscopic guidance and a guide sheath (GS) has limitations, including reduced instrument flexibility, greater procedural complexity, and higher demands for equipment and radiation safety. Objective: This study aimed to evaluate the diagnostic efficacy and safety of rEBUS-TBLB technique performed without the use of a GS or fluoroscopy in patients with PPLs. Design: This was a prospective, interventional, non-controlled study conducted in 67 patients with PPLs of unknown etiology that could not be accessed by flexible bronchoscopy for diagnostic sampling. All patients were admitted to the Department of Respiratory Medicine, Military Hospital 175, between February 2024 and March 2025. Methods: rEBUS-TBLB was performed by two experienced pulmonologists. Primary outcomes included the specimen acquisition rate, number, and quality, while secondary outcomes comprised diagnostic yield, complication rates, and the association of chest CT and rEBUS lesion characteristics with diagnostic performance. Data were collected at admission and throughout hospitalization using a standardized medical record format. Results: The mean age of the patients was 62.03 ± 9.8 years, with a male-to-female ratio of 2.7:1. Solid nodular lung lesions accounted for 73.1% of cases. The mean lesion size was 42 ± 14 mm, and the mean distance from the lesion to the pleura was 8.5 ± 12 mm (range, 0–45 mm). All lesions were sampled using rEBUS-TBLB, with ⩾3 specimens obtained in 90% of cases. Histopathological diagnoses were achieved in 74.6% of cases, of which 84% were lung cancer and 16% were tuberculosis. The most common complication observed was mild localized bleeding. Conclusion: The rEBUS-TBLB technique, even without GS and fluoroscopy support, remains a highly effective and safe diagnostic approach for PPLs, particularly for malignant lesions and those ⩾20 mm in size. This technique may be appropriate for wider implementation in hospitals with limited equipment and financial resources, provided that flexible bronchoscopy systems, rEBUS equipment, and adequately trained personnel are available. Trial registration: The study was approved by an independent ethics committee (Ethics Committee of Military Hospital 175, No. 2637/QĐ-BV) and conducted in accordance with the Declaration of Helsinki and Guidelines for Good Clinical Practice.