Endoscopic treatment for primary vesicoureteral reflux in children: practical limits and clinical decision-making

Aim: To clarify the clinical benefits and limitations of endoscopic injection in children with primary vesicoureteral reflux (VUR) and to identify clinical situations in which earlier ureteral reimplantation should be considered. Methods: We conducted a focused narrative review of major clinical guidelines, randomized controlled trials, systematic reviews, comparative studies, and long-term cohort studies available through September 28, 2026. Radiographic resolution of VUR, recurrent febrile urinary tract infections (UTIs), renal outcomes, repeat interventions, and complications were evaluated separately. Results: Endoscopic injection can achieve radiographic resolution or downgrading of VUR and is generally associated with a short procedure and low morbidity. However, randomised trials have not shown a clear reduction in recurrent febrile UTIs or new renal scarring compared with continuous antibiotic prophylaxis. Treatment success is less predictable in children with grade V reflux, bilateral dilating reflux, or untreated bladder and bowel dysfunction. VUR may recur after initial radiographic resolution, and the relative benefits of repeat injections versus early ureteral reimplantation remain uncertain. Although ureteral reimplantation is more invasive, it generally provides more reliable anatomical correction and reduces the need for repeat interventions. Conclusions: Endoscopic injection should be considered a less invasive treatment option for carefully selected children rather than a universally equivalent alternative to ureteral reimplantation. Persistent high-grade or bilateral dilating VUR, breakthrough febrile UTIs, deterioration of renal function, obstruction, uncontrolled bladder and bowel dysfunction, or a poor response to the initial injection should prompt consideration of definitive surgical correction, after active treatment of bladder and bowel dysfunction.