EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Objectives: We aimed to review the current evidence on kidney transplant in patients with posterior urethral valves, focusing on transplant-specific lower urinary tract assessment, bladder optimization, graft outcomes, infection burden, and long-term follow-up.
Materials and Methods: We searched peer-reviewed literature indexed in PubMed and major guideline sources through March 2026, focusing on studies that addressed posterior urethral valves, valve bladder dysfunction, and kidney transplantation. Contem-porary cohort studies, critical reviews, pediatric urology and transplant literature, and guideline-based statements were prioritized. In accordance with journal policy, donors considered in the reviewed transplant literature were either deceased donors or living related donors.
Results: Available evidence indicated that posterior urethral valves are not a contraindication to kidney transplant when the lower urinary tract is systematically evaluated and optimized. Low-pressure urine storage and reliable bladder emptying are central determinants of graft protection. Vesicoureteral reflux should be actively assessed and, when clinically significant, treated in the context of native kidney function, infection burden, and bladder strategy; in poorly functioning refluxing native kidneys, native nephroureterectomy may be more appropriate than anti-reflux correction. Clean intermittent catheterization, with or without a catheterizable channel, is often graft-protective, whereas augmentation cystoplasty should be reserved for selected hostile bladders refractory to conservative treatment. The timing of reconstruction and native upper-tract surgery should be individualized according to bladder phenotype, residual urine output, donor type, and anticipated wait time.
Conclusions: Kidney transplant in patients with posterior urethral valves can achieve durable allograft function when bladder phenotyping, stepwise optimization, reflux management, infection prevention, donor-specific surgical planning, and lifelong follow-up are integrated into care. Clinically significant vesicoureteral reflux should prompt consideration of anti-reflux surgery or native nephroureterectomy according to kidney function, residual diuresis, and reconstructive timing. A multidisciplinary strategy extending through transition to adult services offers the best opportunity to protect the allograft.

Key words : Clean intermittent catheterization, Lower urinary tract dysfunction, Renal transplant, Valve bladder

Posterior urethral valves (PUVs) are the commonest cause of congenital bladder outlet obstruction in boys and an enduring cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD). Even after technically successful valve ablation, many patients continue to carry a dual burden: congenital dysplasia or reduced nephron endowment on the one hand and a dynamically abnormal bladder on the other. This combination explains why a substantial proportion of patients progress to kidney replacement therapy during childhood, adolescence, or early adulthood.^1-3
For the transplant physician, the challenge is not merely replacing renal function. The graft is placed into a lower urinary tract, which may store urine at high pressure, empty incompletely, expose the graft to recurrent infection through residual urine or vesicoureteral reflux (VUR), or behave differently after restoration of normal diuresis. Historically, PUVs were considered a high-risk diagnosis for kidney transplant, but contemporary evidence has suggested that the diagnosis itself is less important than the quality of lower urinary tract assessment and subsequent management.^1,4,5
The natural history of PUV is highly heterogeneous. Large contemporary cohort data have confirmed that the renal risk remains elevated for decades. In a population-based cohort, children with PUV had a markedly increased long-term risk of major adverse kidney events compared with the general population, reinforcing the concept that PUV is a lifelong condition rather than a purely pediatric disorder.² Bladder dysfunction is likewise common after valve ablation, with systematic review data suggesting persistent lower urinary tract abnormalities in more than half of patients.⁶
This review focused specifically on kidney transplant in patients with PUV. The aim was to synthesize clinically relevant evidence on pretransplant evaluation, bladder optimization, surgical reconstruction, graft outcomes, urinary tract infection (UTI), and long-term follow-up and to translate that evidence into a practical framework for transplant-oriented care.

Scope and Literature Basis

In this narrative review, we reviewed peer-reviewed literature indexed in PubMed and major guideline sources through March 2026, focusing on studies specifically addressing PUV, valve bladder dysfunction, and kidney transplant. Priority was given to contemporary cohort studies, critical reviews, pediatric urology and transplant literature, and guideline-based statements relevant to lower urinary tract assessment and graft protection. The conceptual framework was also interpreted in the context of the established transplant-urology principles summarized in the chapter “Transplantation and the Abnormal Bladder” from Kidney Transplantation: Principles and Practice.⁷ In accordance with journal policy, donors referenced in the reviewed transplant literature were limited to deceased donors or living related donors; living unrelated donor transplants were not included. Because the available evidence is dominated by retrospective single-center series with heterogeneous definitions and follow-up, conclusions should be interpreted as pragmatic rather than definitive.

Why Kidney Transplantation in Posterior Urethral Valves Is Different

The transplant relevance of PUV derives from the interaction of 3 pathophysiological domains. First, many boys with PUV are born with congenital renal dysplasia or reduced nephron mass, so kidney failure is not simply a consequence of postnatal obstruction. Second, bladder behavior evolves over time: infants may initially demonstrate poor compliance and detrusor overactivity, whereas older children and adolescents often present with large-capacity bladders, incomplete emptying, and myogenic failure. Third, restoration of high urine output after transplant can unmask or amplify dysfunction that appeared clinically quiescent in the oliguric or anuric phase before transplant.^3-5,8
This helps explain a clinically important paradox. Some patients with PUV have acceptable transplant outcomes despite severe lower urinary tract abnor-malities when the abnormalities are proactively managed, whereas others lose graft function in the setting of recurrent febrile UTI, persistent reflux, high intravesical pressures, or inadequate emptying.^1,9,10 In other words, PUV should be seen as a risk framework that mandates structured lower urinary tract phenotyping rather than as an automatic contraindication to transplant.
Several long-term studies have supported this view. Early comparative data from Salomon and colleagues did not show inferior 5- or 10-year graft survival in patients with PUV relative to controls but highlighted the role of posttransplant bladder dysfunction in late deterioration.¹¹ Later series of transplant into dysfunctional lower urinary tracts similarly showed that acceptable graft survival was achievable when the lower tract was investigated and reconstructed where necessary.^12,13

Pretransplant Lower Urinary Tract Assessment

A transplant-focused evaluation should define whet-her the bladder is safe for low-pressure storage and reliable emptying and whether the patient and family can sustain the required long-term manage-ment. The work-up usually combines clinical history, bladder diaries, urine cultures, ultrasonography, voiding cystourethrography when indicated, and urodynamic assessment in selected or high-risk cases.^1,4,14
Key clinical questions include the frequency of febrile UTI, daytime and nighttime incontinence, voiding symptoms, straining, sensation of incomplete emptying, constipation, prior vesicostomy or diversion, and adherence to catheterization. History alone is insufficient because oligoanuria may mask true bladder behavior before transplant. Once urine production increases after graft implantation, poor compliance, detrusor overactivity, or incomplete emptying may become clinically obvious.¹⁵
Although no universally accepted transplant-specific urodynamic threshold exists, the principles are clear: a hostile bladder is characterized by impaired compliance, elevated filling pressure, detrusor overactivity associated with leakage or reflux, high residual urine, or an inability to empty dependably at safe pressure. Video urodynamics can be particularly helpful when anatomy, reflux and storage pressures must be interpreted together.¹⁴
Risk stratification should also incorporate renal prognosis and long-term vulnerability. Nadir crea-tinine after valve ablation remains one of the strongest markers of future CKD and ESRD, and should be interpreted alongside recurrent UTI, proteinuria, hypertension, and imaging evidence of dysplasia.^3,8 However, transplant planning requires moving beyond prediction of renal failure to active charac-terization of the bladder environment in which the graft must function.

Vesicoureteral Reflux and Infection Risk

Vesicoureteral reflux deserves explicit consideration in PUV transplant candidates because it is not merely an anatomic finding. In the valve bladder, reflux may reflect the combined effect of congenital ureterovesical junction abnormality, high filling pressure, detrusor overactivity, incomplete emptying, and recurrent infection. After valve ablation, persistent high-grade VUR can therefore contribute to febrile UTI, pyelonephritis, upper-tract dilatation, and, after transplant, ascending infection involving the graft. The clinical priority is not to correct every radiographic refluxing unit automatically but to identify reflux that is high-grade, infected, pressure-driven, associated with poor drainage, or likely to expose the future allograft to recurrent pyelonephritis.^1,4,7
Management should be individualized and coordinated with the overall bladder strategy. In a poorly functioning or nonfunctioning native kidney, correction of reflux into an end-stage renal unit may be unnecessary and may not reduce infectious risk sufficiently. In this setting, native nephroureterectomy should be considered, particularly when high-grade reflux is associated with recurrent febrile UTI, pyelonephritis, residual infected urine, or a poorly draining dilated ureter. Ureteric reimplantation is more relevant when the native renal unit has meaningful residual function or when preservation of urine output is desirable. In patients requiring bladder reconstruction, anti-reflux surgery or native nephroureterectomy can be combined with augmen-tation or continent catheterizable-channel formation when appropriate. In selected cases, reflux may be treated during transplant or after graft implantation, particularly when the diagnosis becomes clinically relevant only after restoration of urine output. The operative plan should integrate urodynamic findings, infection history, residual urine, the need for clean intermittent catheterization (CIC), native renal function, residual diuresis, and whether transplant is expected soon or after a prolonged waiting period.

Pretransplant Bladder Optimization

Bladder optimization should be stepwise and indivi-dualized. In many patients, first-line management consists of timed voiding, treatment of constipation, anticholinergic therapy for overactivity or poor compliance, alpha-blockade in selected voiding dysfunction, and close surveillance of post-void residual urine.^4,5,15 These measures are often sufficient in patients with manageable storage pressures and adequate emptying.
Clean intermittent catheterization is central when spontaneous emptying is incomplete or unsafe. European Association of Urology guidance and transplant series alike have indicated that CIC, with or without overnight drainage in selected patients who are polyuric, may delay dialysis dependence and is compatible with good long-term graft outcomes.^1,16,17 Importantly, CIC should not be seen as a marker of failure; rather, CIC is often the most effective graft-protective intervention available. The major limitation is adherence, which frequently worsens during adolescence and transition to adult care.¹⁸
When urethral catheterization is painful, difficult, or socially unsustainable, a catheterizable continent channel (Mitrofanoff procedure) can improve adhe-rence and independence. In a comparative pediatric transplant series, a pretransplant Mitrofanoff procedure in boys with PUV was associated with higher pretransplant febrile UTI rates, reflecting case complexity, but posttransplant UTI rates and graft outcomes were not inferior; notably, progression to ESRD and need for dialysis appeared delayed in the Mitrofanoff group.¹⁶ Similarly, longer-term data have suggested that optimized bladder dysfunction treatment with CIC, with or without the Mitrofanoff procedure, may improve long-term graft survival despite a greater UTI burden.¹⁹
The role of augmentation cystoplasty remains nuanced. Routine preemptive augmentation is not supported. Some valve bladders that appear small and poorly compliant before transplant improve once normal diuresis is restored, whereas others remain unsafe and clearly require reconstruction.^17,20 Capozza and colleagues argued against automatic augmentation before transplant and recommended reassessment after restoration of urine output where feasible.¹⁷ Contemporary series have indicated that augmentation, when performed for a genuinely hostile bladder refractory to conservative therapy, does not inherently worsen graft survival.^21-23 The trade-off is a higher burden of bacteriuria and recurrent UTI, particularly when catheterization adherence is poor.^20,21

Timing of Bladder Reconstruction and Donor Type

The timing of bladder reconstruction and native upper-tract surgery is one of the most important transplant-specific decisions. In candidates awaiting a deceased donor kidney, the wait time may be long and unpredictable. This interval can be used to optimize the lower urinary tract, demonstrate adherence to CIC, treat constipation and recurrent infection, assess residual diuresis, correct clinically significant VUR or perform native nephroureterectomy, and undertake augmentation or catheterizable-channel construction when a hostile bladder cannot be made safe by conservative measures. Pretransplant reconstruction has the advantage of creating a stable, low-pressure reservoir before graft implantation, but such recons-truction can also expose patients with advanced CKD or on dialysis to additional surgery and may increase bacteriuria or mucus-related complications. Importantly, in patients with an augmented bladder, a small amount of residual native urine output may help dilute and flush mucus; therefore, the decision to remove a refluxing native unit before deceased-donor transplant should balance infection risk against the potential benefit of residual diuresis.
In living donor transplant, the date of graft imp-lantation is more predictable, allowing bladder reconstruction and native nephroureterectomy to be sequenced deliberately. When a refluxing ipsilateral native unit is poorly functioning and clinically significant, native nephroureterectomy may be performed before graft implantation or, in select cases, through the same incision at the time of transplant. If bladder augmentation, catheterizable-channel formation, or another reconstructive pro-cedure is planned, native nephroureterectomy can also be combined with that operation. The contralateral refluxing unit, when clinically relevant, can be managed as a staged procedure, often laparoscopically, depending on infection history, residual function, and surgical anatomy. When the bladder is clearly hostile, reconstruction should be completed sufficiently before transplant to allow healing, training in catheterization, and reassessment. Conversely, if urodynamic risk is borderline and the bladder is small mainly because of prolonged oliguria, a planned living donor schedule may support cautious deferral with early post-transplant reassessment after diuresis is restored. For the present review, and in accordance with journal policy, we included only donations discussed as deceased donors or living related donors; in jurisdictions where living unrelated donation is ethically and legally permitted, the same bladder-safety principles apply, but such donor categories were not included in our review.
Thus, the decision is best framed as a combined donor, bladder, and native upper-tract algorithm rather than a fixed rule. Reconstruction should be performed before transplant when storage pressure, VUR, infection, or emptying failure would predictably endanger the graft. Anti-reflux reconstruction is reasonable when a refluxing renal unit remains useful, whereas native nephroureterectomy may be preferable when reflux involves an end-stage native kidney that mainly functions as a reservoir for infected urine. Surgery may be deferred when the bladder is expected to remodel after restoration of urine output, residual native diuresis is clinically useful, and close posttransplant urological surveillance is feasible. Simultaneous or staged anti-reflux surgery or nephroureterectomy should be considered when VUR is clinically significant and contributes to infection risk.
Figure 1 presents a pragmatic transplant-oriented management pathway for patients with PUVs.

Kidney Transplant Outcomes in Posterior Urethral Valves

Kidney transplant in patients with PUVs is feasible and often successful, but outcomes must be interpreted through the lens of study design. Many published reports are small retrospective cohorts, some spanning eras with different immunosuppression, surgical techniques, and bladder management paradigms.^9,24
Older comparative studies were reassuring. Salo-mon and colleagues found similar graft survival between boys with and without PUV, while emphasizing that deterioration was often linked to lower urinary tract dysfunction rather than the original diagnosis.¹¹ Hebenstreit and colleagues likewise reported no significant difference in long-term graft survival or function compared with nonurologic transplant controls, although UTI was more common in the PUV group.²⁴
Recent data have refined this picture. In a dedica-ted 2024 review of opportunities for improvement in transplant recipients with PUV, Silverii and colleagues described a cohort with substantial heterogeneity in bladder management, including CIC, urinary diversion, and augmentation, illustrating both the feasibility of transplant and the ongoing need for struc-tured bladder follow-up.⁹ In Amesty and colleagues, optimized management of bladder dysfunction, especially CIC with or without the Mitrofanoff procedure, was associated with favorable long-term graft survival despite increased frequency of recurrent UTI.¹⁹ In contrast, broader outcome data on congenital anomalies of the kidney and urinary tract from McKay and colleagues suggested worse long-term graft survival in patients PUV than among patients with other congenital anomalies, indicating that long-term vulnerability persists even in the modern era.²⁵
The most consistent adverse event across studies was infection. Patients with PUV, especially those with persistent VUR, residual urine, catheterization, continent channels, or augmentation, experience more bacteriuria and febrile UTI than many other pediatric transplant recipients.^19,20,24 Nevertheless, infection does not automatically translate into inferior graft survival when the bladder is low pressure, clinically significant reflux has been corrected, controlled, or eliminated by native nephro-ureterectomy when appropriate, emptying is dependable, and episodes are recognized and treated early. This distinction is clinically crucial: higher risk of UTI is expected, but uncontrolled bladder dysfunction, pressure-driven reflux, infected poorly draining native upper tracts, and poor adherence to care are the greater threats to the allograft.
Table 1 summarizes key studies on kidney transplant outcomes in PUVs.

Posttransplant Surveillance and Transition to Adult Care

The posttransplant period is the period when lower urinary tract dysfunction proves its practical importance. The restored graft produces continuous urine flow, which can expose inadequate storage or emptying and precipitate recurrent pyelonephritis, hydronephrosis, graft dysfunction, or progressive scarring. Surveillance should therefore be proactive rather than reactive.^1,13
Clinical follow-up should include assessments of blood pressure, proteinuria, serum creatinine, UTI history, continence status, bowel habit, post-void residual assessment when relevant, and periodic renal/bladder ultrasonography. Urodynamics are not required at a fixed universal interval but should be repeated when symptoms evolve, hydronephrosis appears, recurrent infection develops, continence deteriorates, or graft function declines without another clear explanation.^1,14
Adolescence, with transfer of patients to adult services, represents a particularly hazardous interval. Nonadherence to CIC, anticholinergics, bowel regimens, and infection prophylaxis tends to increase, whereas the memory of childhood reconstruction may be incompletely handed over to adult providers. Adult-focused literature on patients with a history of PUV has shown that bladder and kidney vulnera-bilities persist well beyond pediatric follow-up.^2,18 For transplant recipients, this finding argues strongly for structured transition pathways that explicitly document voiding method, urodynamic phenotype, prior augmentation or Mitrofanoff procedure, reflux history, and UTI pattern.
A multidisciplinary model is therefore essential. Pediatric urologists, transplant nephrologists, transplant surgeons, specialized nurses, radiologists, and, later, adult reconstructive or functional urologists should act as a continuous network rather than isolated consultants. This principle is repeatedly echoed in both recent PUV outcome studies and guideline documents.^1,4,26

Evidence Gaps and Future Directions

Despite decades of clinical experience, the evidence base remains limited. Most transplant studies in PUV are retrospective, single-center, and vulnerable to selection bias. Definitions of “hostile bladder,” recurrent UTI, bladder dysfunction treatment success, and graft outcome are inconsistent. The field also lacks standardized thresholds for transplant-oriented urodynamic risk, making interstudy comparisons difficult.^9,15
A number of practical questions remain unre-solved. These questions include the optimal timing of urodynamics relative to transplant, which patients benefit most from nocturnal drainage, when VUR should be corrected before versus during or after transplant, when native nephroureterectomy is preferable to anti-reflux reconstruction, whether augmentation should preferentially be performed before or after transplant in borderline cases, how residual native urine output should influence decisions in patients with augmented bladders, how donor type and wait time should influence surgical sequencing, and how best to stratify infection risk in patients with continent catheterizable channels. Imp-roved understanding of patient-reported outcomes is also needed, including catheterization burden, continence, body image, and quality of life.
Future progress will likely depend on multicenter registries that combine transplant outcomes with detailed lower urinary tract phenotyping. The most informative studies will be those that move beyond the binary presence or absence of PUV and capture compliance, residual urine, catheterization strategy, augmentation status, reflux grade and treatment, native nephroureterectomy, residual diuresis, UTI phenotype, donor type, timing of reconstruction, and adherence over time. In parallel, transition medicine deserves dedicated study because many preventable late complications arise after transfer to adult care rather than during childhood follow-up.

Kidney transplant in patients with PUVs is both feasible and worthwhile, and good long-term allograft function can be achieved. The central clinical message is that graft protection depends less on the historical label of PUV than on whether the lower urinary tract is systematically characterized, optimized, and moni-tored throughout life. A stepwise strategy based on bladder risk assessment, low-pressure storage, reliable emptying, active management of clinically significant VUR, aggressive UTI prevention, and selective reconstruction offers the best chance of durable graft survival. Routine preemptive augmen-tation is not justified, but augmentation, anti-reflux surgery, native nephroureterectomy, or catheterizable diversion should be used decisively when conser-vative therapy cannot create a safe bladder or when reflux into a poorly functioning native kidney maintains infection risk. The timing of reconstruction and native nephroureterectomy should be indivi-dualized according to bladder phenotype, infection burden, reflux status, residual diuresis, expected wait time, and donor type. Because bladder behavior and adherence evolve over time, lifelong multidiscip-linary follow-up and structured transition to adult care are indispensable.

Volume: 24 Issue: 7 July 2026

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