Background: Temporal lobe epilepsy (TLE) accounts for approximately 20% of pediatric epilepsy cases. Of those, many are considered medically intractable and require surgical interventions. In this study, we hypothesized that mesial temporal sclerosis (MTS) was less common in patients who had undergone surgery for intractable pediatric TLE than in adult series. We further hypothesized that there was a radiological and pathological discordance in identifying the cause of pediatric TLE. Methods: We retrospectively reviewed the charts of pediatric patients with TLE who had undergone surgical treatments as part of the University of Alberta’s Comprehensive Epilepsy Program between 1988 and 2018. Along with preoperative magnetic resonance imaging (MRI) reports, post-surgical pathology results and seizure outcomes were studied Results: Of the 83 pediatric patients who had undergone temporal lobe epilepsy surgery, 28% had tumors, 22% had dual pathologies, 18% had MTS, 11% had focal cortical dysplasia, and 22% had other pathologies. In addition, for 36% of these patients, discordance between their pre-surgical MRI reports and post-surgical pathology reports were found. Conclusions: This was one of the largest retrospective cohort studies of pediatric patients who had undergone surgery for intractable TLE. This study showed that tumors, and not MTS, were the most common pathology in surgical pediatric TLE.