Comparative Analysis of Efficacy and Safety of Frame-based, Frameless, and Robot-assisted Stereotactic Brain Biopsies: A Systematic Review and Meta-analysis

Introduction: For fifty years frame-based stereotactic brain biopsy has been the 'gold standard' because of its high diagnostic yield and safety, especially for complex or deep-seated lesions. During the past 10 years, frameless and robotic alternatives have emerged. In this study, we evaluate these three methods and compare outcomes, diagnostic yield, and safety.

Methods: PubMed, Cochrane, Scopus, and Web of Science databases were screened for studies reporting data on diagnostic yield, postoperative hemorrhage, neurological deficits, and mortality following frame-based, robot-assisted, or neuronavigation-assisted frame-less biopsies. Meta-analysis with random-effect modeling was performed to compare diagnostic yield, operative duration, length of stay, complications, and mortality.

Results: A total of 92 studies were included with 9801 patients in the frame-based group, 2665 patients in the robot-assisted, and 1862 patients in the frame-less group. Pooled diagnostic yield rates were 97% (96% - 98%, I²[Higgins inconsistency index] = 49%) in robot-assisted, 95% (94% - 96%, I² = 74%) in frame-based, and 94% (91% - 96%, I² = 55%) frame-less group with a statistically significant difference (p < 0.01, I² = 71%). Pooled rates of symptomatic hemorrhage (0.005% vs 0.009% vs 0.007, p=0.71, I2=34%), asymptomatic hemorrhage (4% vs 3% vs 3%, p=0.64, I2=93%), transient neurological deficit (3% vs 2% vs 2%, p=0.5, I2=72%), permanent neurological deficit (0.001% vs 0.001% vs 0.0002, p=0.78, I2=47%), and mortality (0% vs 0.001% vs 0.006%, p< 0.01, I2=10%) were similar between groups. The mean pooled total operative duration including anesthesia, system setup, patient registration, trajectory planning, and skin-to-closure time was significantly shorter in the robot-assisted group (76.6 vs 132.7 vs 97.3 mins, p< 0.01).

Conclusion : These results suggest that robot-assisted biopsy is not inferior in diagnostic yield and safety to the gold standard frame-based as well as neuronavigation-assisted frame-less biopsy methods.