Assessment of narrative operative reports for Wilms tumor resection using consensus-based component criteria at Tikur Anbessa Specialized Hospital

Wilms tumor is the most common pediatric renal malignancy, and accurate operative documentation is essential for staging, treatment planning, and outcome assessment. Narrative reports, however, often omit key oncologic details, particularly in low-resource settings. To assess surgical characteristics and evaluate the completeness of narrative operative reports among children undergoing Wilms tumor resection at Tikur Anbessa Specialized Hospital. A retrospective cross-sectional study was conducted among children who underwent Wilms tumor surgery. Sociodemographic, surgical, and intraoperative data were extracted from medical records. Report completeness was evaluated across predefined documentation components and categorized as clearly documented, ambiguous, or not documented. Descriptive statistics were used for analysis. One hundred fifty Children with Wilms tumor undergoing surgery at TASH over five years were analyzed. The median age was 3 years (IQR 2–4), with 66.7% aged 1–4 years; males comprised 51.3%. Most tumors had intact capsules (96.7%), but vascular extension was common, including renal vein involvement (72.7%) and inferior vena cava involvement (14.7%). Radical ureteronephrectomy was performed in 96% of cases, and lymph node sampling in 85.3%. Intraoperative complications occurred in 10.7%, with tumor rupture being the most frequent. Narrative reports were complete for basic identifiers (100%) but frequently omitted oncologic variables: tumor size (23.3% missing), lymph node counts (44.7%), IVC involvement (53.3%), and specimen orientation (65.3%). Blood loss and transfusion status were incompletely recorded in 29.3% and 40.7% of cases, respectively. Surgical management adhered to oncologic principles, but narrative reports showed major deficiencies in documenting tumor-specific and intraoperative variables, potentially compromising staging and decision-making. Implementation of standardized synoptic operative reporting systems, supported by training and regular audits, is recommended to improve documentation quality and reliability.