Open Surgery in the Robotic Era: National Trends and Training Implications from Two Decades of American Board of Urology Case Logs

PURPOSE: Minimally invasive surgery (MIS) has rapidly transformed the surgical management of urologic diseases, with robotic-assisted techniques increasingly replacing open approaches (OA). We aimed to characterize trends in OA versus MIS across major urologic oncologic procedures and evaluate surgeon-specific factors associated with surgical approach. MATERIAL AND METHODS: Operative logs from American Board of Urology examinees from 2000-2023 were examined for radical nephrectomy (RN), partial nephrectomy (PN), radical nephroureterectomy (RNU), radical prostatectomy (RP), and radical adrenalectomy (RA) and categorized by surgical approach. Approach proportions were assessed over time and stratified by individual procedure, surgeon gender, geographic region, certification status, and fellowship training. RESULTS: A total of 54,972 procedures were analyzed, of which 23% were OA and 77% were MIS. While surgical volume increased more than tenfold from 2003-2005 to 2021-2023, the proportion of OA declined from 75% to 9.9%. Declines in OA were observed across all procedures. Surgeon factors including age, sex, and fellowship training were associated with OA. Regional variation in the United States was identified, with the Southeast demonstrating the highest proportion of OA. CONCLUSIONS: Open surgery in urologic oncology has declined dramatically over the past two decades and now represents a minority of cases. While this transition reflects advances in surgical technology and patient care, it raises important concerns regarding declining exposure to OA during training. As robotic surgery continues to dominate contemporary practice, targeted efforts may be necessary to ensure adequate training and competency in open surgical techniques.