Posterior Urethral Valves and Kidney Transplantation: Optimizing the Lower Urinary Tract to Protect the Allograft.

Abstract

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. Contemporary 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.