Beyond the Operating Room? Cytology-Based Yield and Resource Utilization of Outpatient Versus Operating Room EBUS-TBNA Pathways

Background/Objectives: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can be performed via pathways that differ in anesthesia, setting, airway management, monitoring, recovery, and hospitalization. We compared an outpatient endoscopy suite pathway with sedation and spontaneous breathing, and an operating room pathway with general anesthesia and laryngeal mask ventilation, assessing cytology-based yield, sample adequacy, workflow, and costs. Methods: This single-center observational study included consecutive EBUS-TBNA procedures. Allocation was nonrandom and reflected workflow, operating room availability, complexity, airway/anesthetic considerations, and judgment. The primary endpoint was cytology-based diagnostic yield in the diagnostic cohort; staging outcomes included cytology distribution, sample adequacy, and positivity among adequate samples. Systematic diagnostic verification was not available for the entire cohort; however, postoperative nodal pathology was retrospectively retrieved when available in the staging cohort. Because verification remained incomplete and selectively available, sensitivity, specificity, negative predictive value, and overall diagnostic accuracy were not estimated. Results: Clinical outcome analyses included 447 procedures (319 diagnostic and 128 staging), while the administrative cost dataset included 533 completed procedures. Diagnostic yield was similar between pathways (108/229, 47.2% vs. 45/90, 50.0%; p = 0.740). In the staging cohort, sample adequacy was comparable (83/85, 97.6% vs. 39/42, 92.9%; p = 0.331), and positivity among adequate samples did not differ (21.7% vs. 20.5%; p = 1.000). Exploratory postoperative pathological nodal-stage data were available for 60/128 staging procedures; among 58 cases with interpretable EBUS-TBNA results, patient-level N-stage concordance was 44/58 (75.9%), and postoperative nodal upstaging occurred in 11/58 (19.0%). No prespecified intraprocedural composite adverse events were documented. Duration appeared shorter in operating room cases but, owing to incomplete differential recording, was descriptive only. Length of stay and costs were markedly higher in the operating room pathway. Conclusions: The pathways showed similar cytology-based outcomes but differed in hospitalization rates and costs. Nonrandom allocation and pathway heterogeneity preclude causal interpretation as a sedation-versus-general-anesthesia comparison. Prospective studies with standardized allocation, diagnostic verification, systematic capture of adverse events, and follow-up are warranted.