Introduction:

Open surgery is increasingly replaced by minimally invasive techniques. The associations between surgical approach (open or minimally invasive) and surgeon factors have not been investigated. We performed a contemporary review of American Board of Urology (ABU) data to evaluate for surgeon factors associated with the use of open surgical approach across urologic oncology procedures.  

Methods:

Operative logs from the 2003-2023 ABU examinees were obtained and records for radical nephrectomy (RN), partial nephrectomy (PN), radical nephroureterectomy (RNU), radical prostatectomy (RP), and adrenalectomy (RA) were identified and categorized by open approach (OA) and minimally invasive surgery (MIS) using CPT codes. We included patients ≥ 18 years of age. Surgeon specific factors analyzed included surgeon gender, geographic location, certification status (new versus recertification), and fellowship type. The raw counts and proportions of OA and MIS procedures were calculated over time across all surgeries and within each specific surgery. A logistic regression was used to assess associations between surgeon factors and surgical approach. A multivariable model was then created including surgeon factors and adjusted for log year. 

Results:

The utilization of OA steadily decreased among all oncologic procedures. Across the period, female surgeons reported proportionally more OA (32.5%, 366/1,127) compared to males (23%, 12,366/53,832). This gender difference became more pronounced in recent years (Figure 1A).  

All regions demonstrated a decrease in OA over time (Figure 1B). Regionally, the Southeast performed the least MIS surgeries for PN RNU, and RA, whereas Mid-Atlantic performed the most. Re-certification examinees more frequently performed OA (Figure 1C). For example, for RP, examinees completing re-certification reported 17.2% OA versus 8.7% for first certification. Oncologic fellowship-trained urologists performed more MIS than OA (Figure 1D).  

For both univariable and multivariable analysis, utilization of OA was significantly associated with surgeon gender, certification status, fellowship, and region. On multivariate analysis for utilization of OA surgery, female surgeons had 1.65 times the odds compared to males (p<0.01) and surgeons undergoing re-certification had 1.7 times the odds compared to first certification (p<0.01).

Conclusion:

Open surgery utilization has been decreasing steadily in the past two decades. Our analyses indicate that open surgery use was associated with older surgeons (recertifying rather than new certifications) and female surgeons reported proportionally more OA. Interestingly, the Southeast accounted for the least MIS procedures compared to other US regions, while Mid-Atlantic accounted for the most. Despite the increase in the use of MIS techniques, Urologic Oncologists account for ≥25% of open urologic oncology procedures.

Funding: N/A