Conservative versus endoscopic initial management of pediatric ureterocele: A systematic review and meta-analysis.

OBJECTIVE: To evaluate outcomes of conservative versus endoscopic initial management in pediatric ureterocele through a systematic review and exploratory meta-analysis, with emphasis on secondary surgical intervention and clinically relevant postoperative outcomes. METHODS: A systematic review was conducted according to PRISMA 2020 guidelines. PubMed/MEDLINE, Embase, Scopus, and reference lists were searched for studies published from 1990 onward evaluating pediatric ureterocele managed initially with conservative observation and/or endoscopic puncture or incision. Comparative studies, retrospective cohorts, and case series with extractable data were eligible. Studies including single-system, duplex-system, intravesical, and ectopic ureteroceles were included. The primary outcome was secondary surgical intervention after initial management. Secondary outcomes included de novo vesicoureteral reflux (VUR), febrile urinary tract infection (UTI), and treatment success. Risk of bias was assessed using established tools for observational studies. RESULTS: Twenty-five studies met inclusion criteria. Most were retrospective cohorts or case series with heterogeneous anatomical subtypes, patient populations, and outcome definitions. Sample sizes ranged from 9 to 287 patients. Four studies provided direct comparative data suitable for quantitative synthesis of the primary outcome. In a random-effects exploratory meta-analysis, no statistically significant difference was identified between initial observation and endoscopic treatment regarding the risk of secondary intervention (RR 0.40, 95% CI 0.13-1.24; I2 = 36.5%). Across observational cohorts, selected low-risk patients managed conservatively frequently avoided surgical intervention during follow-up, whereas endoscopic decompression remained effective in symptomatic or higher-risk patients, although repeat procedures or delayed reconstruction were required in a subset. Secondary outcomes, including de novo VUR and febrile UTI, could not be quantitatively synthesized because of inconsistent definitions and reporting across studies. CONCLUSIONS: Current evidence remains limited by retrospective study design, substantial anatomical heterogeneity, and confounding by indication. Although definitive comparative conclusions cannot be drawn, available data suggest that individualized management strategies may be appropriate in selected patients. Management decisions should be individualized according to anatomy, clinical presentation, obstruction, infection risk, and renal functional characteristics. Further prospective multicenter studies are needed to better define optimal patient selection criteria.