Impact of a systematic assessment of pediatric urological complications and unexpected events

Abstract

Introduction: Pediatric urology is a technically demanding specialty with a high risk of complications. However, structured and comprehensive reporting of surgical and non-surgical adverse events remains limited. This study aimed to assess the incidence, nature and severity of unexpected events in pediatric urological cohort and to evaluate the applicability of the Clavien-Dindo classification in this cohort.

Methods: From 2017 to 2022, all surgical and non-surgical complications, including organizational and management-related events, were prospectively documented in a tertiary pediatric surgical department. Events were graded using a modified Clavien-Dindo classification and discussed in regular morbidity and mortality conferences. The study cohort was stratified by procedure type and complication severity.

Results: A total of 1392 patients underwent 2123 urological procedures, during which 449 adverse events were recorded. Of these, 270 patients (19.4 %) experienced at least one complication, and 28 patients (2 %) had three or more. Overall, 54 % of events were minor (grade I-IIIa) and 46 % were major (grade IIIb-V). Catheter-related issues (16.4 %) and organizational problems (15 %) were the most frequent. One-third of events were unrelated to surgery. Hypospadias repairs, particularly proximal forms, were associated with the highest complication rates. Sentinel events were rare but included six deaths unrelated to surgery. Based on these findings, eight targeted standard operating procedure (SOP) changes were implemented, with qualitative improvements observed in our institution.

Conclusion: This large-scale prospective analysis identified a high incidence of complications in pediatric urology, one-third of which were non-surgical in origin. The routine use of general anesthesia in pediatric patients likely led to an overestimation of severity using the Clavien-Dindo classification, underscoring its limitations in this context. Our findings demonstrate the value of continuous, structured complication monitoring as a tool for quality improvement and emphasize the need for pediatric-specific grading systems that better reflect the true burden of morbidity in this vulnerable population.

Keywords: Adverse events; Clavien-Dindo; Complications; Pediatric urology.