Robotic, laparoscopic, and open nephrectomy and 30-day pulmonary morbidity: a procedure-stratified cohort study with intraoperative ventilation data.

Previous studies of heterogeneous abdominal procedures have reported higher pulmonary-complication rates after robot-assisted surgery, but whether this applies to nephrectomy is uncertain. We evaluated surgical approach and 30-day postoperative pulmonary complications (PPCs) after partial and radical nephrectomy. We studied 1,503 adults undergoing robotic, laparoscopic, or open nephrectomy from 2008 to 2025. Procedure-stratified logistic regression assessed a prespecified PPC composite. The partial-nephrectomy model included tumor complexity and clinical covariates. Sparse-data and additional sensitivity analyses were performed. Minute-level ventilation data were analyzed descriptively. Overall PPC incidence was 4.5% (68/1,503). In partial nephrectomy, robotic surgery was associated with lower adjusted PPC odds than laparoscopy (adjusted odds ratio [aOR], 0.26; 95% CI, 0.08-0.87) and open surgery (aOR, 0.18; 95% CI, 0.07-0.43). Firth penalization and the additional sensitivity analyses yielded similar estimates. Adjusted PPC risks were 2.5% for robotic, 8.2% for laparoscopic, and 11.2% for open partial nephrectomy. Most PPCs were low grade. In radical nephrectomy, open surgery did not differ from laparoscopy; no inference was possible for the 18 robotic radical cases with no events. Robotic cases had longer intubation and higher airway pressures, but similar tidal volumes and oxygenation. Robotic partial nephrectomy was associated with lower adjusted odds of a 30-day PPC composite. The observational design does not establish a pulmonary mechanism or robotic superiority, and clinically significant events were sparse. Multicenter validation is required.