*Purpose: Small capacity, defunctionalized urinary bladders present a challenge in pediatric kidney transplantation due to the inability to perform an adequate anti-reflux ureterocystostomy in a traditional manner and due to the postoperative challenges of maximizing renal perfusion with high volume fluid resuscitation in a small bladder.

*Methods: A single center, retrospective review from 2002 to 2014 was conducted. Inclusion criteria included pediatric kidney recipients with small capacity, defunctionalized bladders that had not undergone prior augmentation, did not have neurogenic bladders, and did not require pre-operative catheterization. Sixteen patients were identified with bladder volumes less than 30 ml. Four patients were excluded as they had less than five years of posttransplant bladder volume follow-up. All patients underwent renal transplant with intravesical trough ureteral implantation as previously described. Bladder capacity at one year, five years, and ten years posttransplant were evaluated.

*Results: The average age at transplant was 1.3 years, and the average weight of our patient population was 12.3 kg. Five patients had congenital nephrotic syndrome necessitating bilateral nephrectomies, four had bilateral nephrectomies secondary to autosomal recessive polycystic kidney disease, one patient had Prune Belly syndrome, one patient had posterior ureteral valves, and one patient had bilateral Wilm’s tumors status post nephrectomies. The average pretransplant bladder volume was 16 ml and 10% of expected volume for age. At one year posttransplant, the average bladder volume was 36% of expected. Bladder capacity continued to improve with increased time from transplant with 49% of expected volume at five years post-transplant. Eight of the twelve patients were followed out to ten years and average bladder capacity reached 88% of expected. Average glomerular filtration rate (GFR) was 101.5 mL/min/1.73 m2 at five years. For those followed out to ten years, GFR at ten years averaged 85.5 mL/min/1.73 m2.

*Conclusions: The use of native, small capacity, nonaugmented, defunctionalized bladders in pediatric kidney transplantation is a safe approach with long-term follow-up showing successful recovery of bladder capacity.

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