Purpose of Review <p>The purpose of this review is to highlight contemporary changes in the management of pediatric neurogenic bladder, using spina bifida as the reference population. Advances in early diagnosis, pharmacotherapy, and surveillance strategies have altered traditional treatment paradigms, with a growing emphasis on bladder preservation and prevention of upper urinary tract deterioration.</p> Recent Findings <p>Recent literature demonstrates an increased reliance on medical management as first-line therapy. Anticholinergic agents remain the cornerstone of treatment, with expanding use of beta-3 adrenergic agonists as adjuncts or alternatives. Intradetrusor onabotulinumtoxinA has emerged as an effective option for refractory detrusor overactivity, offering improved bladder compliance and continence outcomes. While these strategies may delay or reduce the need for surgical reconstruction, their long-term impact on rates and timing of lower urinary tract reconstruction remains unclear and warrants ongoing investigation.</p> Summary <p>Multiple clinical guidelines now support structured, proactive management incorporating early clean intermittent catheterization, pharmacologic therapy and routine urinary tract surveillance. Imaging and urodynamics play a critical role in monitoring renal health and bladder dynamics. However, there remains uncertainty regarding the optimal protocol for longitudinal follow-up, including frequency and modality of evaluation. Future research should focus on standardizing surveillance strategies and determining how evolving medical therapies influence long-term surgical needs and patient outcomes.</p>