Urinary fistula is a common complication after kidney transplantation and may lead to graft loss and patient death. Its current incidence ranges from 1.2% to 8.9%. From December 1993 to April 2007, 1223 kidney transplant procedures were performed by our kidney transplantation team. In 948 recipients (group 1), we performed an extravesical ureteroneocystostomy, and in 275 recipients (group 2), a terminoterminal ureteroureterostomy (UU). We observed urinary fistulas in 43 patients (3.5%), with mean onset at 6 days (range, 3-20 days) posttransplantation. Urinary fistula was significantly more common in group 1 compared with group 2 (4.1% and 1.5%, respectively; P < .05). The distal ureteral necrosis was the major frequent cause of urinary fistula (n = 34; 76.7%), which required either a second ureteroneocystostomy or UU using the native ureter. Of these 21 fistulas, including 10 recurrent fistulaes, were successfully treated with pedicled omentum covering the anastomotic stoma. Conservative treatment with a stent and Foley catheter drainage for 1 to 2 weeks was successful in 8 patients. All patients with a urinary fistula regained normal graft function except 1 in whom transplant nephrectomy was necessary because of pelvic and ureteral necrosis. There was no recipient loss secondary to urinary fistula. In conclusion, UU can decrease the incidence of urinary fistula after kidney transplantation. Most urinary fistulas require surgical management; and pedicled omentum is useful to repair the fistula.