Ten-year fellowship trainee trends for open and minimally invasive pediatric pyeloplasty in the United States.

BACKGROUND: The Anderson-Hynes dismembered pyeloplasty remains the gold-standard surgical repair of ureteropelvic junction obstruction in children. While open pyeloplasty (OP) has proven excellent long-term durability in function and drainage. Contemporary urology trainees may have more experience with minimally invasive surgery than open surgery for common urologic procedures. Increasing robotic expertise has driven adoption of minimally invasive pyeloplasty (MIP) in younger patients, potentially shifting trainee experience away from open surgery. OBJECTIVE: We report US pediatric urology fellowship trainee experience with OP and MIP over the past decade, hypothesizing that the shift toward minimally invasive approaches has reduced open surgical training. STUDY DESIGN: The Accreditation Council for Graduate Medical Education (ACGME) defines case minima for surgical specialties and annually reviews graduate case log data to assess the breadth and depth of procedural training. Deidentified ACGME case log data for all pediatric urology fellows from 2014 to 2024 were divided into three periods (2014-2017, 2017-2021, 2022-2024). Total case counts for OP (CPT 50400/50405) and MIP (CPT 50544) were recorded; ureterocalicostomy (50750) and ureteropyelostomy (50740) were excluded. The proportions of OP versus MIP cases were compared across periods using the chi-square test. RESULTS: The proportion of MIP cases increased progressively from 54.9% (2014-2017) to 58.2% (2018-2021) to 75.5% (2022-2024) (p < 0.001), rising from 48.1% in the initial year to 77.3% in the final year. DISCUSSION: The significant decline in OP cases reflects a growing limitation in open surgical experience for pediatric urology fellowship trainees, while the concomitant increase in MIP cases presents an opportunity to refine minimally invasive techniques in smaller infants. Notably, OP CPT codes 50400 and 50405 are catalogued as 'Pyeloplasty' without specifying an open approach, and the robotic modifier for case reporting was removed in 2019. As a result, underreporting or misclassification of laparoscopic cases as open cannot be excluded, particularly in the most recent study period, potentially biasing toward underestimation of the true decline in OP training experience. CONCLUSION: Over the last decade, there has been a significant trend favoring MIP over OP in US pediatric urology fellowship training, most pronounced in the most recent three-year period. This shift may jeopardize mastery of OP during fellowship. If proficiency with OP remains important in practice, training paradigms should prioritize enhancing trainee exposure to open surgical techniques.