Abstract Background Large language models (LLMs) demonstrate increasing potential in healthcare applications, yet their clinical utility in specialized pediatric medicine remains inadequately characterized. This study evaluated LLM performance in pediatric urology to establish evidence-based implementation frameworks. Methods We conducted a two-phase evaluation of thirteen current-generation LLMs between January and April 2025. Phase 1 assessed clinical decision support using 180 standardized cases stratified by complexity (126 routine, 54 complex) based on European Association of Urology pediatric guidelines. Phase 2 evaluated patient education effectiveness across four common pediatric urological conditions. Performance was measured using mathematical similarity metrics and standardized expert evaluation by seven board-certified pediatric urologists employing a validated 100-point scoring system. Results LLMs demonstrated superior performance in routine clinical scenarios compared to complex cases (76% vs. 41% accuracy, respectively). OpenAI’s GPT-4o3 achieved the highest performance in complex cases (61.4 ± 3.1 vs. 51.8 ± 3.7 for other models, p < 0.001), with significantly lower hallucination rates (0.05 ± 0.02 vs. 0.18 ± 0.04, p < 0.001). Patient education materials showed strong content alignment (78% similarity with reference standards) and appropriate readability levels. Diagnostic confidence demonstrated strong correlation with actual performance (r = 0.82, p < 0.001). Conclusions LLMs show promise as supportive tools in pediatric urology, particularly for patient education and routine clinical scenarios. However, significant limitations in complex case management necessitate careful implementation with mandatory physician oversight. A tiered approach prioritizing patient education while restricting complex clinical decisionmaking represents the most appropriate implementation strategy.