Risk Prediction Tools for Estimating Surgical Difficulty and Perioperative and Postoperative Outcomes Including Morbidity for Major Urological Surgery: A Concept for the Future of Surgical Planning.

Risk assessment plays a critical role in surgical decision-making and influences patient care, resource allocation, surgical planning, and postoperative outcomes. Accurate stratification facilitates better treatment selection and planning, and identification of teaching cases. Existing tools such as POSSUM and the Surgical Apgar Score are widely used but focus primarily on general surgery and often lack urology-specific considerations or integration of intraoperative factors. Urological surgery requires a dedicated tool that accounts for preoperative factors (eg, prostate size, tumour extent), intraoperative findings (eg, fibrosis, adhesions), and patient-specific complexities. We propose a comprehensive scoring system for risk and surgical difficulty that ranges from 0 (no risk) to 100 (procedure abandonment or death) covering five parameter categories: preoperative patient characteristics; intraoperative patient factors; preoperative organ-specific parameters; intraoperative organ-specific factors; and unexpected postoperative conditions. The aims of the proposed system are to improve surgical planning, enhance risk prediction, and identify suitable teaching cases. By incorporating surgeon-specific factors such as case volume and learning curves, the system stratifies procedures by difficulty and can facilitate comparisons between surgeons and hospitals. The system can also promote transparency in patient counselling and may improve the quality of patient consent. Once validated, the scoring system could be integrated into standard practice to improve surgical care, resource allocation, and research efforts. Despite challenges such as comprehensive data collection, this tool offers significant potential to enhance surgical outcomes and multidisciplinary decision-making. Patient Summary Risk assessment is essential in helping surgeons and anaesthetists to make better decisions before, during, and after surgery. The aim of our work is to create a tool that predicts potential risks and challenges during surgery and makes it easier to prepare for these challenges. This tool can improve management of resources and surgical planning, and may ensure smooth recovery after an operation. Finally, it could also help patients and their families to understand the potential risks involved, giving them clearer information about what to expect and making the process more transparent and reassuring.