To evaluate longitudinal trends in the Urology In-Service Examination (ISE) from 2016 to 2023 and identify changes in performance patterns over time.

Retrospective cohort analysis of aggregate ISE scores provided by the American Urological Association. Mean percent-correct scores across postgraduate years (PGY1-5) and subtopics were analyzed from 2016 to 2023. 2020 was used as a temporal marker for the onset of the COVID-19 pandemic in sub-analyses. Two-sample t  tests determined statistical significance ( α  ≤ 0.05).

A total of 680 scores were analyzed. Mean scores increased with PGY level (43%-46% in PGY1 to 68%-71% in PGY5) but declined over time. Linear trend analysis showed a statistically significant decline for PGY2-5, with the steepest and strongest correlation seen in PGY3-5. Subtopic declines were most notable in calculous disease (64.2% to 56.1%, P  = .01) and physiology/immunology/adrenal (70.2% to 56.5%, P < .001), both affecting all PGY levels. Additional decreases were noted in pediatrics (PGY2-4), congenital anomalies/embryology/anatomy (PGY1-2, 4), and imaging (PGY3-4). In contrast, PGY1 scores in fluid & electrolytes/transplant/hypertension/vascular/nephrology improved modestly (50.5% vs 56.0%, P  = .05). Performance on 217 repeated questions was stable (69.3% vs 69.7%).

Mean ISE performance declined from 2016 to 2023 across all PGY levels, with the greatest decreases observed in general urology subtopics. Scores after 2020 were lower across most PGY levels and content domains, while performance on repeated questions remained stable. These trends may reflect increased examination difficulty, expanded content, changes in question composition, evolving study strategies, and variability in clinical exposure rather than diminished knowledge.