Status of robotic and manual devices for advanced colonoscopy: Trends and applications of robotics in colonoscopy

Abstract

The development of colonoscopy technology aims to enhance diagnostic accuracy while speeding up procedures, improving patient comfort, and addressing the technical limitations of standard endoscopy. The latest technological advancements include robotic and manually assistive systems, which provide better navigation, real-time feedback, and automated capabilities. This review compares the current status of manual and robotic assistive devices in colonoscopy, including their underlying mechanisms, clinical performance, and adoption status. A narrative review of the literature was conducted, examining commercially available and investigational devices that enhance colonoscope navigation, reduce patient discomfort, and automate endoluminal procedures. The devices were classified into two groups: Manual assistive systems (ScopeGuide, Third Eye Retroscope, NaviAid) and robotic platforms (Endotics, NeoGuide, Invendoscope, Aer-O-Scope). The clinical performance was evaluated by cecal intubation rates (CIR), adenoma detection rates (ADR), procedural times, and complication profiles. Manual assistive systems showed gradual improvements in loop reduction, retroflexion, and positional feedback with CIRs ranging from 93% to 100% and variable ADR outcomes depending on operator training and use patterns. The robotic colonoscopes showed CIRs ranging from 82% to 98%, and some platforms (Endotics and Aer-O-Scope) achieved reduced patient discomfort and minimal sedation use. Several devices have received Food and Drug Administration and European Conformity clearances, but their adoption remains limited because of their high costs, technical complexity, and insufficient large-scale validation. Also, the available evidence is limited by heterogeneity and the predominance of small, early-stage studies. Overall, the integration of robotic and manually assistive devices in colonoscopy shows promise as they may provide better ergonomics, reduced pain, and potential quality metric improvements. These findings suggest potential benefits in improving colorectal cancer detection, patient comfort, and procedural accessibility. However, despite technological advances, conventional colonoscopy remains highly effective, while current robotic platforms are limited by high costs and a lack of clear superiority, contributing to their restricted clinical adoption. The future development should concentrate on real-world usability, device standardization, and head-to-head comparative trials to validate clinical value. Ultimately, widespread adoption will require clear clinical benefit and economic justification beyond current standards.

Key Words: Colonoscopy; Robotic colonoscopy; Manual assistive colonoscopy; Advanced colonoscopy; Cecal intubation; Adenoma detection

Core Tip: Conventional colonoscopy remains limited by patient discomfort, loop formation, and operator dependence, prompting the development of manual assistive and robotic technologies. This review summarizes current advanced colonoscopy devices, comparing their mechanisms, clinical performance, and real-world adoption. Manual assistive devices provide gradual improvements with minimal workflow disruption, while robotic systems demonstrate promising reductions in pain and sedation requirements but face cost and implementation barriers. Although widespread clinical adoption remains limited, ongoing advances in automation, magnetic navigation, and artificial intelligence suggest a future role for hybrid and robotic systems in improving procedural quality and patient experience.

INTRODUCTION

Colorectal cancer (CRC) is the second most common cause of cancer-related death worldwide and a major contributor to global disease burden[1]. Early detection and prevention through screening programs are critical to reducing incidence and mortality[2]. Colonoscopy remains the gold standard for CRC screening, surveillance, and polypectomy, given its ability to directly visualize the colonic mucosa, detect adenomas, and perform therapeutic interventions in a single session[3].

Despite its proven efficacy, conventional colonoscopy presents several limitations. The procedure of intubation fails in 5%-10% of cases especially when patients have complex anatomy or previous surgical interventions[4]. Patient discomfort from loop formation and torque transmission leads to suboptimal compliance which requires sedation or anesthesia in many cases[5]. The technique and experience level of operators produce inconsistent results in adenoma detection and procedure time duration[6].

The well-documented limitations of conventional colonoscopy such as loop formation and torque transmission and operator variability have led to the development of assistive and robotic platforms during the past two decades[7]. The development of manual devices ScopeGuide, NaviAid and third eye retroscope (TER) aimed to assist operators with loop reduction and insertion and retroflexion in challenging anatomical situations[8]. The mechanical aids require operator expertise for operation but they do not have autonomous capabilities. The development of robotic platforms has surpassed traditional limitations through automated propulsion systems (Endotics, Aer-O-Scope) and joystick control systems (Invendoscope) and biologically inspired locomotion and magnetic navigation systems (NeoGuide, Endoo MFE)[8]. The systems work to decrease patient pain during procedures while enhancing procedural reliability and reducing the steep learning curve of traditional colonoscopy[7].

Advanced colonoscopy refers to the use of specialized endoscopic tools and procedural innovations that aim to overcome the limitations of standard colonoscopy, particularly in patients with difficult anatomy, prior abdominal surgeries, or incomplete prior examinations[9]. This includes robotic systems together with manual assistive devices which help improve scope navigation and reduce looping and enhance patient comfort.

The review examines advanced colonoscopy platforms which enhance navigation and propulsion and insertion control through shape-sensing scopes and automated propulsion and joystick-based or magnetically guided systems. These platforms aim to boost completion rates while minimizing operator variability and enabling therapeutic interventions for difficult cases[10].

OBJECTIVE OF THIS REVIEW

The narrative review organizes both manual assistive technologies and robotic colonoscopy platforms through control mechanism and propulsion system categories. We also evaluate clinical performance results while discussing real-world implementation obstacles and future developments. Our aim is to provide clinicians, researchers and developers with essential information about current colonoscopy technology status and future development potential for enhanced procedural quality and safety and standardization.

SEARCH STRATEGY

This narrative review was conducted through a focused search of the PubMed database to identify relevant literature on robotic and manual assistive technologies in colonoscopy. The search included articles published between 2000 and 2025 using combinations of keywords such as “robotic colonoscopy”, “assistive endoscopy”, “colonoscopy devices”, “self-propelled endoscopes”, and “advanced endoscopic navigation systems”.

All study designs were considered, including randomized controlled trials, observational studies, feasibility studies, technical reports, and review articles. Studies were selected based on their relevance to the development, clinical application, and technological advancement of colonoscopic platforms. Given the heterogeneity of the available literature, including variability in study design, sample size, and stage of technological development, a narrative approach was adopted to allow a comprehensive and clinically meaningful synthesis.

Devices were included if they demonstrated clinical applicability, technological innovation, or historical significance in the evolution of the field, including systems that are no longer commercially available. As this is a narrative review, a formal systematic review protocol, predefined study selection criteria, and quantitative data extraction were not applied. The aim was to provide an integrated overview of existing platforms, current trends, and future directions in advanced colonoscopy.

MANUAL ASSISTIVE TECHNOLOGIES FOR COLONOSCOPY

The recognized limitations of conventional colonoscopy include its challenges with difficult anatomy and loop-prone segments but manual assistive devices helps overcome these mechanical barriers without requiring robotic integration[11]. These issues become difficult to handle when patients have redundant colon or have undergone previous abdominal surgeries or experience painful colonic angulation.

To address these procedural barriers, a range of manual assistive devices have been developed that aim to reduce loop formation, improve real-time scope tracking, and facilitate advancement with less operator force. These devices serve as an intermediate technological step between standard colonoscopy and fully robotic systems[12].

The following section examines the manual assistive technologies including ScopeGuide (Olympus), TER and NaviAid focusing on their operational mechanisms, practical applications and real-world usage constraints.

ScopeGuide (Olympus)

Principle of function: The ScopeGuide system by Olympus is a manual assistive technology that uses electromagnetic sensors embedded along the insertion tube of the colonoscope to generate a real-time three dimensional (3D) image of the scope’s shape inside the colon. The external receiver detects electromagnetic fields and displays the rendered path on a monitor, allowing the endoscopist to visualize the formation of loops or sharp angulations during the procedure[12].

Clinical advantages: The ScopeGuide system enhances procedural navigation especially in patients with redundant colon or in cases where looping is a persistent challenge. The system provides real-time visualization of the scope path which enables endoscopists to correct excessive loop formation early thus reducing the need for sedation and external abdominal pressure[12].

In a prospective randomized trial involving 300 patients who received elective colonoscopy showed that ScopeGuide failed to enhance cecal intubation time when compared to standard colonoscopy procedures (mean 4.6 minutes vs 4.3 minutes; P = 0.46) and did not decrease the requirement for manual pressure or position adjustments (manual pressure: 16.7% vs 19.1%, P = 0.65; position change: 11.4% vs 8.8%, P = 0.56)[13]. The ScopeGuide system showed it enabled patients to need less midazolam sedation during the procedure (3.9 mg vs 4.7 mg, P = 0.003)[13]. CIR was reported at 96.8% in clinical settings, with no significant improvement over standard colonoscopy[13]. Although the study was limited to experienced endoscopists, the authors noted that ScopeGuide may hold particular value in training environments or in patients with previously incomplete or technically challenging colonoscopies[13].

Limitations: Despite these advantages, ScopeGuide does not offer propulsion assistance and is entirely dependent on the skill of the operator to advance the scope. It also adds cost and is limited to use with compatible Olympus colonoscopes. It improves scope handling but does not address other challenges such as mucosal visibility or therapeutic access.

Current use: The ScopeGuide system holds Food and Drug Administration (FDA) clearance and European Conformity (CE) marked. It is incorporated into teaching hospitals and high-volume centers use it as part of their standard procedures. The training program benefits from this tool as it enables residents to see loop dynamics and master effective scope manipulation techniques[12].

Third Eye Retroscope

The Third Eye Retroscope (TER) functions as a disposable device which enables retrograde viewing to improve mucosal visualization during colonoscopy procedures[14,15]. The catheter enters the working channel of a standard colonoscope before extending to form a 180° bend which generates a continuous video image of the mucosa located behind the folds while providing simultaneous rear-facing views to the traditional forward-facing scope image[14,15]. The dual-view setup displays images in a split-screen format to enhance the detection of lesions which hide behind haustral folds.

Clinical performance: Multiple prospective studies have shown that the TER increases adenoma detection rate (ADR) during colonoscopy. The prospective multicenter study by DeMarco et al[16] found that the TER increased ADR by 16% and overall polyp detection by 14.8% compared to standard colonoscopy. Having higher ADR has been associated with reduced CRC incidence and interval cancer risk. Waye et al[17] found significant improvements in a multicenter trial of 249 subjects where TER led to the detection of 15 additional adenomas with a relative increase of 11.0% and increased the detection of larger adenomas (≥ 6 mm and ≥ 10 mm) by 25.0% and 33.3%, respectively. The TERRACE study by Siersema et al[18] found a 23.2% net increase in ADR with TER compared to standard colonoscopy, with the greatest benefit seen in patients undergoing surveillance (35.7% increase) and diagnostic workup (55.4% increase). The data suggest that TER can improve the detection of clinically relevant lesions, particularly in patients at risk of missed pathology.

Limitations: The practical limitations of TER exist despite its improved visual field capabilities. The working channel of the colonoscope becomes occupied by TER which prevents simultaneous operation of suction, flushing and therapeutic tools. The TER needs to be taken out before any intervention then reinserted which extends both procedure duration and operational complexity. Operators who lack experience with split-screen retrograde views may find image interpretation challenging. The device has not gained widespread use because of its operational challenges and high price point and the requirement to remove it for therapeutic procedures[19].

Current status: Despite its novel design, widespread adoption of the TER was limited due to workflow complexity, cost, and the need to remove the device for therapeutic interventions[19].

NaviAid™ G-EYE™ balloon colonoscope

Principle of function: The NaviAid™ G-EYE™ system functions as a balloon-assisted colonoscope which enhances mucosal visualization and lesion detection through mechanical fold flattening during withdrawal procedures[19]. The G-EYE system features a re-inflatable balloon attached to a standard colonoscope which remains deflated during insertion but inflates during withdrawal to spread folds and maintain scope stability[19]. The technique enhances the detection of concealed polyps while reducing the occurrence of scope slippage and looping[19].

The NaviAid system demonstrates better results in adenoma and polyp detection (ADR/PDR) than standard colonoscopy during both model simulations and human clinical trials. The NaviAid system identified 91.7% of hidden polyps in a simulated colon model whereas standard colonoscopy detected only 45.8% (P < 0.0001)[19]. The system achieved an ADR of 48.0% in a 1000 patient international multicenter randomized controlled trial while standard colonoscopy reached 37.5%[20]. The use of NaviAid balloon-assisted colonoscopy led to significantly better detection rates for both hidden polyps (88.0% vs 25.0%) and visible polyps (100.0% vs 75.0%) (P < 0.0001 for both comparisons)[21]. The device proves effective in reducing blind spots while enhancing the detection of sessile or flat lesions.

Limitations: The NaviAid G-EYE system lacks the capability to help users insert or propel the device. The balloon inflation and deflation process requires manual intervention which creates additional procedural steps and learning difficulties. The system faces difficulties when users attempt to navigate through highly angulated segments or severe cases of colonic redundancy because propulsion assistance would be more effective in these situations. The system needs compatible colonoscopes and its use may result in higher costs and longer device preparation times[19].

Current use: The NaviAid G-EYE colonoscope received both CE-marked and FDA clearance which allows its clinical application across Europe and the United States and other international territories. The system operates at specific medical facilities which aim to boost detection rates and procedural success[21]. The system underwent initial testing at Israeli hospitals before researchers confirmed its safety and effectiveness. The medical community now views this system as a useful addition to standard colonoscopy procedures as it provides better visualization without forcing a complete transition to robotic systems[21].

ROBOTIC COLONOSCOPY DEVICES AND PLATFORMS

Robotic colonoscopy platforms represent a major advancement in endoscopic technology. They aim to reduce operator dependence, improve patient comfort, and standardize procedural outcomes. These systems use different actuation and control mechanisms which include joystick-guided motors, balloon propulsion, magnetic navigation and biologically inspired locomotion to move through the colon with less force and looping and pain.

Robotic colonoscopy systems can be conceptually categorized based on the degree of automation: Partially robotic systems assist scope advancement but still rely on endoscopist control (e.g., joystick propulsion or balloon actuation). Fully robotic platforms operate with minimal human input, often incorporating pre-programmed pathways or autonomous navigation algorithms. The Invendoscope and Aer-O-Scope are partially robotic systems that assist with scope propulsion but still require active endoscopist control through joystick or pressure-guided interfaces. The Endoo MFE, Endotics, and NeoGuide systems are semi- or fully autonomous systems that use shape-sensing technology, magnetic guidance, or artificial intelligence (AI)-assisted navigation to automate scope advancement with minimal operator input.

In this section, we group robotic colonoscopy systems into five categories based on their propulsion or navigation mechanism: (1) Electromechanical Robots (e.g., Invendoscope); (2) Self-Propelling (Worm-like) Devices (e.g., Endotics); (3) Balloon-Driven Systems (e.g., Aer-O-Scope); (4) Segmented/Shape-Sensing Systems (e.g., NeoGuide); and (5) Magnetically Navigated Robots (e.g., Endoo MFE).

The following subsections outline the principle of each system’s function, key performance metrics, limitations, and current clinical status.

Electromechanical robots (e.g., invendoscope)

The Invendoscope SC20 is a computer-assisted colonoscope utilizing an inverted sleeve mechanism driven externally by motorized wheels, allowing the scope to “grow” into the colon rather than being manually advanced[22]. The device consists of a flexible shaft measuring 2.1 meters in length, equipped at the distal end with imaging sensors, LED illumination, and the capability for 180° deflection with a 114° field of view. Control is facilitated through a joystick rather than traditional dials, enabling precise manipulation and potentially reducing operator learning curves. The SC20 achieved FDA clearance and CE-mark certification between 2016 and 2018 and experienced brief adoption in Europe and the United States. However, its substantial length and complexity of robotic tip control led to its discontinuation and replacement by the SC200 and SC210 models which are single-use, manually inserted colonoscopes lacking robotic locomotion[23].

Clinical efficacy of the Invendoscope SC20 was demonstrated in two key trials. Groth et al[22] conducted a study in Germany involving 61 healthy volunteers undergoing screening colonoscopy with the SC20, achieving a cecal intubation rate (CIR) of 98.4% (95%CI: 91.2%-99.9%) and a median cecal intubation time of 15 minutes. Sedation was required in fewer than 5% of patients[22]. Another study by Rösch et al[24] involving 34 healthy, unsedated volunteers reported an overall CIR of 82% (95%CI: 66%-92%), with notable improvement from 79% in initial prototypes to 90% in later versions. Average cecal intubation times ranged from 20 minutes to 26 minutes, and 92% of subjects reported minimal discomfort (mean discomfort score of 1.96 on a scale of 1-6). Although no complications occurred, technical failures in 15% of cases prompted further refinements[24].

Endotics system (robotic colonoscope - manual mode)

The Endotics System (ERA Endoscopy, Italy) is a CE-marked robotic colonoscopy platform designed to address patient discomfort, looping, and intubation failure—common challenges in conventional colonoscopy. It is a disposable, self-propelled endoscope operated via a handheld console, using inchworm-like locomotion to advance through the colon without external pushing. This approach significantly reduces stress on the mesenteries and minimizes loop formation[25].

In a prospective clinical trial involving 40 patients who underwent both conventional and robotic colonoscopy, Cosentino et al[25] reported a 90% reduction in mesenteric stretching forces with the endotics device compared to standard scopes. Patient-reported pain scores were markedly lower with endotics (mean pain score: 0.9 vs 6.9; discomfort: 1.1 vs 6.8 on a 0-10 scale), with 70% of patients rating the experience as virtually painless (pain score < 1)[25]. Reduced discomfort and sedation requirement may improve patient tolerance and expand feasibility in outpatient settings, particularly in patients at higher anesthesia risk.

Diagnostic performance was favorable. Endotics demonstrated its ability to detect two tiny polyps and angiodysplasias which conventional colonoscopy missed while maintaining bowel architecture for better mucosal visualization[25]. The low CIR of 27% in this initial trial resulted from the operators’ limited experience with the robotic device. The learning curve proved to be brief because the study participants achieved better completion results throughout the research duration[25].

The endotics system achieved a 93.1% success rate in cecal intubation during a real-world study of 102 patients who had incomplete colonoscopies according to Tumino et al[26]. The system enabled complete colon inspection in almost all cases with an average intubation time of 51 minutes. The procedure did not require sedation and no serious adverse events occurred[26].

Additionally, the endotics probe’s adaptability to tortuous anatomy and its minimal insufflation requirement make it a valuable option in patients with redundant colon, strong looping tendencies, or high pain sensitivity. The therapeutic channels were absent in earlier versions but the newer models now include biopsy capability[26].

Tumino et al[26] conducted a prospective study of 55 patients who received robotic colonoscopy with the endotics system and achieved a 92.7% CIR. The procedure received positive tolerance from patients since 92.7% reported mild discomfort and 29% needed minimal sedation[27]. No serious adverse events occurred. The system performed polypectomy procedures in five cases while most patients received discharge within thirty minutes[27].

In summary, the endotics system provides a promising solution for painless diagnostic colonoscopy through minimal invasiveness especially for patients who have had previous incomplete procedures or anatomical challenges. The platform shows positive results in clinical trials and real-world studies regarding intubation success and patient comfort but remains restricted to selected European centers. The platform faces challenges because of extended procedure times and restricted therapeutic functions and high costs of disposable components which prevent its widespread adoption. The system marks an essential advancement toward developing automated endoscopy systems that benefit patients.

Balloon-driven systems (e.g., Aer-O-Scope)

The Aer-O-Scope is a single-use, self-propelling colonoscope driven via a pneumatic mechanism[28]. It incorporates two balloons with one inflating at rectal entry to seal the anus, and a second positioned behind the camera head. Carbon dioxide insufflation creates pressure between the balloons, propelling the scope forward to the cecum, after which the pressure is reversed for device withdrawal. The Aer-O-Scope provides a 360° omnidirectional optical view, supported by an automated system that regulates intraluminal pressure. Despite FDA and CE approvals, including the most recent Aer-O-Scope 3 model in 2023, adoption has been limited, prompting subsequent development of simpler, manually inserted single-use colonoscopes without balloon propulsion[23].

Two clinical trials evaluated the Aer-O-Scope in human subjects. Vucelic et al[28] assessed the device in 12 healthy, unsedated subjects who underwent colonoscopy followed by standard colonoscopy for safety validation. An 83% CIR was achieved, with an average cecal intubation time of 14 minutes and no complications[28]. Gluck et al[29] conducted a larger multicenter trial with 56 subjects, demonstrating a CIR of 98.2% (95%CI: 90.4%-99.9%) and an average cecal intubation time of 11 minutes. While no mucosal injuries or significant adverse events occurred, polyp detection sensitivity was comparatively modest at 87.5% against conventional colonoscopy[29].

NeoGuide endoscopy system (segmented/shape-sensing robotic platform)

The NeoGuide endoscopy system emerged as one of the first robotic systems to solve traditional colonoscopy mechanical issues including loop formation and poor scope control and patient discomfort[30]. The early 2000s saw the development of NeoGuide which features a multi-segmented colonoscope that uses shape-sensing technology to create 3D maps of the colon during insertion[30]. The system enables the endoscope shaft to track the path of the tip which reduces the stretching or looping of bowel wall tissue[30].

The device features a real-time shape-sensing system and computer-assisted controls which produce a continuous 3D model of the colonoscope’s configuration. The operator uses a control handle to steer the tip while the shaft automatically adjusts its path to minimize torque-based maneuvers[31]. The shape-locking mechanism of this design works to improve navigation through angulated or redundant colons while simultaneously reducing patient discomfort and sedation requirements[32].

Eickhoff et al[30] conducted a prospective first-in-human trial which demonstrated that the NeoGuide system successfully reached the cecum in all ten patients within 20.5 minutes on average. The procedures were finished with minimal sedation and no adverse events occurred during the study[30]. The system demonstrated its ability to adapt to individual patient anatomy by preventing any looping during all procedures[30].

Striegel et al[31] conducted preclinical in vitro tests which showed NeoGuide achieved 96%-99% accuracy in detecting tip position and loop formation through angular and positional measurements. The system’s tip tracking showed strong agreement with actual colonoscope insertion shapes which validated its real-time mapping functionality[31].

The NeoGuide system achieved promising results but never entered commercial production. The system faced challenges because of its complex manufacturing process and demanding training requirements and insufficient evidence showing it outperformed standard colonoscopes. The NeoGuide endoscopy system became one of the first robotic platforms to achieve segmental control and tip-following architecture although its development stopped after its initial demonstration[32].

The NeoGuide endoscopy system introduced shape-sensing technology and loop-reducing robotic colonoscopy which demonstrated strong technical potential and achieved high completion rates during initial clinical trials. The system is no longer under development but its fundamental innovations have shaped the design of multiple contemporary endoscopy systems which aim to enhance colon navigation.

Endoo magnetic flexible endoscope (Endoo MFE)

The Endoo MFE platform is an academic robotic colonoscopy system that uses magnetic actuation to reduce patient discomfort and improve maneuverability[33]. It consists of a flexible endoscope with an internal permanent magnet embedded at the tip, which is controlled by an external robotic arm holding an actuating magnet[33]. This configuration enables contactless, front-pull navigation through magnetic coupling, minimizing the need for external pushing or torque-based maneuvers and reducing colon wall stress[33].

The system architecture includes a 7-degree-of-freedom robotic arm, real-time localization algorithms, and autonomy modes ranging from manual joystick control to semi-autonomous lumen-following[33,34]. The tethered internal probe integrates a camera, insufflation, and a working channel, and is designed for single use, addressing reprocessing complexity and cross-contamination risks associated with conventional endoscopes[33,34].

The Endoo MFE system demonstrated promising performance in preclinical trials that used a human-based colon phantom[33]. The front-pull magnetic actuation mechanism of the system enabled cecal intubation in 90% of cases while reducing colon wall stress which could decrease the risk of perforation and patient discomfort compared to standard colonoscopes[33].

The benchtop performance benchmark developed by Martin et al[34] demonstrated that Endoo MFE provides safer mucosal contact forces and wall trauma reduction compared to traditional push-based navigation methods. The system achieved 100% task completion under semi-autonomous control and 96% under intelligent teleoperation in loop-prone colon phantom models[34]. Obstein et al[35] performed the first-in-human Phase 1 clinical trial of the Endoo MFE platform in five unsedated patients who underwent routine CRC screening during 2025. The MFE system operated without adverse events or patient discomfort while all patients completed the procedure while awake and alert[35]. The trial established safety and tolerability and ergonomic feasibility of magnetic robotic colonoscopy[35].

Earlier iterations of the platform also demonstrated safe magnetic guidance and orientation control in human cadaveric models, as described by Obstein et al[35], highlighting its ergonomic advantages and the feasibility of integrating robotic control into gastrointestinal (GI) endoscopy workflows. The initial prototypes concentrated on locomotion and safety but the current versions include advanced computer vision and AI-enhanced control for real-time lumen recognition and adaptive path planning[33].

The Endoo system exists as an investigational device which has not obtained CE or FDA clearance for clinical implementation. The system requires specific infrastructure and its robotic base system costs money while operators need training to use magnetic navigation. The Endoo MFE demonstrates a major conceptual advancement toward non-contact low-force magnetically navigated colonoscopy which would improve patient comfort and decrease sedation requirements[33-35].

A comparative summary of manual assistive and robotic colonoscopy platforms, including their mechanisms, clinical performance, and regulatory status, is presented in Table 1.

Table 1 Comparison of manual and robotic assistive devices in colonoscopy.

	Category	Propulsion/navigation	Therapy capable	Clinical performance	Study design	Regulatory status
ScopeGuide	Manual assistive	Electromagnetic shape-sensing	Yes (via standard endoscope)	96.8% CIR[13]	RCT	FDA-cleared & CE-marked
Third Eye Retroscope	Manual assistive	Retrograde visualization (insertable catheter)	No (blocks working channel)	ADR ↑ by 11%-23%[16-18]	RCT; prospective	Not commercially available
NaviAid G-EYE	Manual assistive	Balloon (withdrawal phase)	Yes	ADR 48% vs 37.5%[20]	RCT	FDA-cleared & CE-marked
Invendoscope	Robotic	Inverted sleeve + joystick control	Yes	CIR: 82-98.4%[22,24]	Prospective; pilot	FDA-cleared (SC20); Discontinued & replaced by SC210 (manual)
Endotics	Robotic	Inchworm, self-propelled	Limited (biopsy)	27%-93.1% CIR[25,26]	Prospective; retrospective	FDA-cleared & CE-marked
Aer-O-Scope	Robotic	Pneumatic balloon system (self-propelled)	No (diagnostic only)	CIR: 83%-98.2%; Cecal time: 11-14 minutes[28,29]	Prospective; pilot	FDA-cleared & CE-marked; Limited adoption
NeoGuide	Robotic	Segmental, shape-sensing	Yes	100% (n = 10)[30]	Prospective; feasibility	Not commercially available
Endoo MFE	Robotic	Magnetic + robotic arm	No	100% completion (n = 5), 1st-in-human trial[34]	Preclinical; experimental	Investigational

CIR: Cecal intubation rate; ADR: Adenoma detection rate; FDA: Food and Drug Administration; CE: European Conformity.

REAL-WORLD EVIDENCE & CURRENT ADOPTION

While several devices demonstrate promising technical performance, the variability in study design and outcome reporting, along with the predominance of small and early-stage studies, limits the ability to draw definitive comparative conclusions across platforms.

Improvements in ADR are associated with reduced CRC incidence and advanced neoplasia risk, with studies showing a decrease in cancer incidence from 40.7 to 31.8 per 100000 person-years and a 1.48-1.66 fold increased risk of advanced neoplasia in lower ADR groups[36,37]. These findings align with current international guidelines, which emphasize maintaining high-quality colonoscopy performance metrics including ADR and CIR as key determinants of CRC prevention, underscoring the need for continued technological innovation to meet and sustain these standards[2,3]. Several robotic platforms have demonstrated reduced sedation requirements, including reports of no sedation use with Endotics and less than 5% with invendoscope, suggesting potential improvements in patient tolerance and procedural feasibility[13,22,26,27,30,35].

Limited clinical integration

Over the past two decades, multiple assistive and robotic colonoscopy platforms have been introduced. However, their practical implementation in clinical settings remains limited. The ScopeGuide system stands out as the only meaningful adoption among these platforms because it helps both residents learn and practitioners control procedures through its real-time loop visualization feature in academic and training centers. The Endotics system holds CE-mark approval but European medical facilities use it only for patients who need follow-up colonoscopies after previous incomplete procedures and most countries consider it investigational. The NaviAid G-EYE™ balloon-assisted colonoscope received FDA and CE approval but its real-world adoption remains limited to specific geographic areas despite showing better detection results in clinical trials. Despite rapid technological development, most robotic colonoscopy platforms remain in early stages of clinical evaluation, with limited high-quality evidence and slow adoption in practice, partly due to cost-related barriers and the lack of demonstrated superiority over conventional colonoscopy[32].

Discontinued or dormant platforms

Several promising technologies have failed to reach commercialization or have since been discontinued. NeoGuide, one of the earliest shape-sensing platforms, demonstrated excellent feasibility but was ultimately abandoned due to production complexity and lack of therapeutic advantage. The TER showed improved adenoma detection but was limited by working channel occupation and cost. The Invendoscope, formerly FDA-cleared, was withdrawn and absorbed into Ambu’s development pipeline. These cases underscore the difficulty of translating prototype success into sustained clinical use.

Barriers to adoption

The adoption barriers exist across economic and technical and procedural domains. The high prices of devices together with disposable scope costs and proprietary base systems create financial barriers that exceed the costs of reusable conventional colonoscopes. The therapeutic channels in many robotic platforms are absent which restricts their use to diagnostic procedures only. The use of joystick control and 360° vision and magnetic actuation in complex interfaces leads to training needs and extended procedure times and decreased efficiency in busy centers. The lack of large-scale or multicenter trial evaluations for most devices prevents them from becoming part of guidelines and reimbursement pathways.

Guideline position and outlook

To date, no major GI society has endorsed any robotic platform for routine colonoscopy, largely due to limited high-quality evidence and lack of demonstrated superiority over standard practice. Manual assistive technologies, by contrast, have seen more meaningful integration into clinical workflows. The NaviAid G-EYE system and ScopeGuide have found adoption in academic and screening centers that focus on loop reduction and adenoma detection improvement. These technologies provide small performance improvements that do not disrupt standard workflows which makes them suitable for broad implementation. Moving forward, the evolution of colonoscopy may be driven less by fully robotic systems and more by hybrid approaches, such as modular assistive tools, disposable platforms, and AI-augmented conventional scopes which improve performance while preserving procedural familiarity and efficiency.

EMERGING TRENDS AND FUTURE DIRECTIONS

The current robotic colonoscopy platforms encounter significant obstacles for adoption but researchers in advanced endoscopy keep evolving it. AI integration represents a primary innovative direction for both manual and robotic colonoscopy systems. The application of computer aided detection and computer aided diagnosis algorithms enhances real-time polyp recognition and histologic prediction in current medical practice. Future AI modules will advance beyond image enhancement capabilities to include autonomous navigation and loop prevention and adaptive scope control features which could decrease operator dependence and procedural variability.

In parallel, there is increasing interest in disposable and modular colonoscopy systems. The platforms work to decrease infection risks while improving logistics and lowering expenses related to reprocessing and maintenance. Ambu and other companies work on developing single-use colonoscopes but most of these products exist in prototype or pilot testing stages.

Another area of growth is capsule or tethered endoscopy, particularly with magnetic control. The Endoo MFE system demonstrates how magnetic propulsion combined with external robotic guidance will enable painless sedation-free colonoscopy in upcoming years. The technology has the potential to provide remote or tele-operated colonoscopy services which would expand healthcare access in underserved and low-resource areas.

Finally, ongoing work is being done to integrate therapeutic capabilities into robotic platforms, addressing one of the major limitations of many early-generation systems. Several active development programs focus on achieving the high-value goal of enabling biopsy and polypectomy and mucosal resection within robotic and capsule platforms.

The current trends indicate that robotic colonoscopy will continue to advance although its widespread adoption remains restricted at present. The future of advanced colonoscopy will combine automated systems with artificial intelligence and user-supportive technologies to improve safety measures and operational efficiency and clinical results.

LIMITATIONS

This review has several limitations. The available evidence is heterogeneous, with significant variability in study design, sample size, patient populations, and clinical indications, which limits the ability to directly compare performance metrics across different devices. In addition, much of the current data is derived from early-phase studies, feasibility trials, and small clinical series, which may affect generalizability. The narrative nature of this review, while appropriate given the evolving and diverse body of literature, may also introduce selection bias and does not allow for quantitative synthesis. Finally, the lack of large-scale randomized controlled trials and standardized outcome reporting further limits the strength of conclusions regarding comparative effectiveness and real-world applicability.

CONCLUSION

The development of advanced colonoscopy platforms through manual assistive tools and robotic systems aims to solve the ongoing challenges of conventional colonoscopy including loop formation and patient discomfort and incomplete intubation. The clinical adoption of ScopeGuide and NaviAid technologies has been restricted while robotic systems continue as investigational products or have been discontinued because of high costs and operational complexities and workflow disturbances.

Nevertheless, these innovations have expanded the boundaries of what is technically feasible in gastrointestinal endoscopy. However, despite these advances, current robotic platforms remain limited by high costs, technical complexity, and a lack of robust comparative evidence, restricting their widespread clinical adoption. At present, conventional colonoscopy remains the standard of care, with assistive technologies offering incremental rather than transformative benefits. Future progress will depend on well-designed large-scale randomized controlled trials, real-world validation, and cost-effectiveness analyses to establish clear clinical value and support broader implementation.