Introduction: Renal transplantation is the best available therapy for most ESRD patients. Patient population with ESRD represents a unique challenge in preparing for KT. The underlying urologic pathology can adversely affect the outcome of KT. Thus there may be a need for a pre-transplant procedure to optimize the UT prior to transplantation aiming to improve the transplant outcome and graft survival such as pre-transplant nephrectomy, bladder augmentation or urinary diversion. Objective: This retrospective study to evaluate the outcomes of renal transplantation in obstructive uropathy and dysfunctional urinary bladder patients. This included an assessment of needed pre-transplant procedures that aimed at preparing the UT for the renal allograft. We also aim to assess the complications specific to this patient population and their impact on graft function and survival. Patients and Methods: Between January 2007 and December 2011, 145 kidney transplantations were performed in King Fahd Urology and Nephrology Unit of Cairo University, including 25 transplantations on patients with lower urinary tract pathology (24 males and 1 female with the mean age 19.28± 7.16 years at time of the transplantation. The etiology of the abnormal lower urinary tract was neurogenic bladder in 6 patients, posterior urethral valves in 5, uretheral strictures in 5, urolithiasis in 5, VUR in 3 and PBS in 1. There were 25 ancillary procedure performed with 5 patients undergoing more than 2 procedures albeit sequential (either prior to or after the kidney transplant). Pre-transplantation nephrectomy, augmentation ileocystoplasty, ulgeration of PUV, VIU and urethroplasty were done in 16 (64%), 4 (16%), 5 (20%), 4 (16%) and 1(4%), respectively. Results: Mean follow-up for our patients was 24.96±11.95 months (3-53). All of our patients were alive with functioning grafts at the end of the last recorded follow-up. Mean serum creatinine at 3, 6 and 9 months, and 1, 2, 3 and 4 years was 0.99mg/dL, 1.16mg/dL, 1.17mg/dL, 1.14mg/dL, 1.27mg/dL, 1.08mg/dL, 1.11mg/dL, respectively. Post-transplantation follow up revealed UTI in 4 (16%) cases. patient age and post-transplantation UTI had a significant impact on serum createnine at 1 year post transplantation (p<0.04 and p <0.01, respectively). No correlation was found between serum creatinine at 2 years post-transplantation and any of the patients or disease variables. Conclusion: The pre-transplantation goal of the urologist is to confirm an optimal condition of the UT, which should be sterile, continent, and compliant before KT. Dialysis duration, the cause of ESRD, the type of ancillary procedure performed and it timing did not have any significant impact on mean serum creatinine at 1 and 2 years following transplant. Age and post-transplant UTI had a significant impact on serum creatinine at one year but not at two years following transplantation.