Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become the preferred minimally invasive procedure for evaluating mediastinal and hilar lymphadenopathy, pulmonary masses, and lung cancer staging. Rapid On-Site Evaluation (ROSE) is a cytopathology technique performed immediately after specimen collection to assess sample adequacy and provide preliminary cytological interpretation. The integration of ROSE into EBUS-TBNA has been proposed to improve specimen quality, decrease inadequate sampling, optimize the number of needle passes, and facilitate ancillary molecular testing. However, published studies have demonstrated variable results regarding its influence on diagnostic accuracy, procedure duration, healthcare costs, and patient outcomes. This review summarizes current evidence regarding the role of ROSE during EBUS-guided aspiration procedures. Available literature indicates that ROSE significantly improves specimen adequacy, reduces repeat procedures, enhances communication between bronchoscopists and cytopathologists, and increases confidence during difficult sampling. Nevertheless, high-volume centers with experienced operators may achieve excellent diagnostic performance even without ROSE, suggesting that its greatest value exists in resource-limited settings, complex lesions, training environments, and institutions performing molecular testing. Future integration of digital cytopathology, telecytology, and artificial intelligence is expected to expand the clinical utility of ROSE while improving workflow efficiency.