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[DESCRIPTION]
<p><strong>Background</strong></p>
<p>Advances in bronchoscopy and CT-guided lung biopsy have improved the evaluation of small pulmonary lesions (PLs), leading to an increase in preoperative histological diagnosis.</p>
<p>We aimed to evaluate the efficacy and safety of transbronchial lung biopsy using radial endobronchial ultrasound and virtual bronchoscopic navigation (TBLB-rEBUS&amp;VBN) with CT-guided transthoracic needle biopsy (CT-TNB).</p>
<p><strong>Method</strong></p>
<p>A systematic search was performed in five electronic databases, including MEDLINE, EMBASE, Cochrane Library Central Register of Controlled Trials, Web of Science, and Scopus, for relevant studies in May 2016; the selected articles were assessed using meta-analysis. The articles were limited to those published after 2000 that studied small PLs ≤ 3 cm in diameter.</p>
<p><strong>Result</strong></p>
<p>From 7345 records, 9 articles on the bronchoscopic (BR) approach and 15 articles on the percutaneous (PC) approach were selected. The pooled diagnostic yield was 75% (95% confidence interval [CI], 69-80) using the BR approach and 93% (95% CI, 90-96) using the PC approach. For PLs ≤ 2 cm, the PC approach was superior to the BR approach. However, for PLs &gt; 2 cm but ≤ 3 cm, the diagnostic yield using the BR approach was increased to 81% (95% CI, 75-85). Complications of pneumothorax and hemorrhage were rare with the BR approach but common with the PC approach.</p>
<p><strong>Conclusion</strong></p>
<p>CT-TNB was superior to TBLB-rEBUS&amp;VBN for the evaluation of small PLs. However, for lesions greater than 2 cm, the BR approach may be considered considering its diagnostic yield of over 80% and the low risk of procedure-related complications.</p>

[BEFORE_START]
<p>When comparing the diagnostic yields of different methods, the lesions should be limited to those ≤ 3 cm in diameter, as established by previous publications. In this analysis, PLs up to 3 cm in diameter were considered.</p>
<p>The purpose of this meta-analysis was to compare the efficacy and safety of TBLB with rEBUS and VBN (TBLB-rEBUS&amp;VBN), a BR approach, with CT-TNB, a PC approach, for tissue diagnosis of small PLs.</p>

[GUIDELINES]
<p><strong>Inclusion and exclusion criteria</strong></p>
<p>The following inclusion criteria were used to select studies on TBLB-rEBUS&amp;VBN: </p>
<p>1. rEBUS with a GS was used for the diagnosis of peripheral pulmonary lesions (PPLs).<br /> 2. Virtual bronchoscopy was used as a navigational method.</p>
<p>3. A PPL was defined as an endobronchial lesion not detected by bronchoscopy, and the size of these lesions was limited to ≤ 3 cm in diameter.</p>
<p>4. The final diagnosis was confirmed using the biopsy specimen or surgical specimen; in cases of diagnostic ambiguity, the final diagnosis was established at the clinical follow-up.</p>
<p> </p>
<p>The following inclusion criteria were used to select studies on CT-TNB:<br /> 1. CT-guided transthoracic needle aspiration or biopsy, including conventional CT-guided transthoracic needle biopsy, CT fluoroscopy-guided transthoracic biopsy, and C-arm cone-beam CT-guided transthoracic biopsy, was used for the diagnosis of PL.<br /> 2. The biopsy target was a small PL ≤ 3 cm in diameter for which bronchoscopic biopsy was considered unfeasible based on the imaging information. The target lesion was described as a PPL, solitary pulmonary nodule (SPN), pulmonary nodule, ground glass opacity, or PL.</p>
<p>3. The final diagnosis was confirmed using the biopsy specimen or surgical specimen; in cases of diagnostic ambiguity, the final diagnosis was established at the clinical follow-up.</p>
<p> </p>
<p>The following exclusion criteria were used when selecting studies on TBLB-rEBUS&amp;VBN or CT-TNB:</p>
<p>1. Studies using non-human subjects, studies analyzing other methods of biopsy, studies written in a language other than English, or studies of an inappropriate type (case report, case series, letter, and review);</p>
<p>2. Central bronchial lesions evaluated by routine bronchoscopy;</p>
<p>3. Electromagnetic navigational bronchoscopy (ENB) procedure in TBLB;</p>
<p>4. Studies devoted to topics other than diagnostic outcomes with or without adverse events.</p>

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