The appropriate management of the urinary bladder in patients requiring a renal transplant is significantly different in children than in adults. The etiology of end-stage renal disease (ESRD) in 13 of 50 children (26%) transplanted since 1985 was obstructive uropathy/dysplasia. Five of these children had small-capacity, poorly compliant bladders. Our current approach is to restore bladder compliance, improve emptying, and transplant into the restored bladder rather than divert. Pretransplant gastrocystoplasty was performed in three children and the donor ureter was implanted into the augmented bladder. One child awaits transplantation following his bladder augmentation. Bladder function is followed postoperatively by voiding cystourethrography (VCUG) and urodynamics. All of the children who have received transplants into augmented bladders are infection-free, voiding per urethra, and have functioning allografts. We recommend: (1) an initial VCUG in all children; (2) complete urodynamics, if appropriate; (3) urological reconstruction to include augmentation prior to transplantation; (4) transplantation into the reconstructed bladder; and (5) comprehensive follow-up including regular urodynamic assessment.