Robotic vs. laparoscopic inguinal hernia repair in patients with chronic kidney disease: a propensity score-matched analysis

Abstract

CKD patients are susceptible to pneumoperitoneum-induced renal injury; comparative outcomes of robotic versus laparoscopic inguinal hernia repair are unknown. Retrospective propensity score-matched cohort using TriNetX (184 HCOs; 2015-2026). CKD adults undergoing robotic or laparoscopic inguinal hernia repair were matched 1:1 on 61 covariates (1,693 per arm at 1 month; 1,659 at 6 months). Primary outcomes were AKI and MACE; secondary outcomes were metabolic acidosis, urinary retention, hyperkalemia, and post-operative eGFR and creatinine. Cox regression, Kaplan-Meier, and competing-risk CIF were used, with E-values for unmeasured confounding. At 1 month, robotic repair had higher AKI (5.0% vs. 2.9%; HR 1.74, 95% CI 1.22-2.47; p = 0.002) and MACE (2.5% vs. 1.4%; HR 1.84; p = 0.017). At 6 months, AKI persisted (HR 1.41; p = 0.002) and urinary retention emerged (HR 1.33; p = 0.039); MACE (p = 0.112) and acidosis (p = 0.199) did not. New-onset hyperkalemia was lower with robotic (HR 0.58; p = 0.045). eGFR MDRD declined less at 1 month (Δ - 1.28 vs. - 3.21; p = 0.049); 6-month creatinine was lower (p = 0.013). CIF (deaths 1.5% vs. 1.9%) confirmed AKI; KM overstated 6-month incidence by 1.1-1.9 points. 1-month AKI E-value 2.87 (CI 1.74). Robotic inguinal hernia repair in CKD was associated with higher AKI and early MACE in the all-events analysis, but the incident AKI signal was borderline and post-operative laboratory renal function favored the robotic arm. This discordance may reflect differential ascertainment at robotic-predominant academic centers. These hypothesis-generating findings do not establish a renal safety advantage for either approach; prospective validation with KDIGO-defined AKI endpoints is required.