Since January 1, 1985, we have performed 73 renal transplants in 66 patients with abnormal bladders who had end-stage renal failure as a consequence of urologic abnormalities (mean age 32 years). Their outcome is compared with 58 renal transplants in 54 patients (mean age 40 years) who had renal failure from primary vesicoureteric reflux or renal dysplasia and whose bladder function was considered to be normal. There is no difference in actuarial graft survival in the two groups at 10 years (abnormal 66%, normal bladders 61%), although longer follow-up is showing an advantage for normal bladders, with a kidney half-life of 29 to 33 years compared with 15 years for the abnormal bladder group. Similarly, actuarial patient survival at 10 years is 86% in both groups. Current renal function is better in the group with normal bladders. At latest follow-up, the abnormal, unaugmented bladder group (n=34) has been followed for 92 (87) months (mean [median]) and has a plasma creatinine of 178 (161) micromol/L, whereas the normal bladder group (n=33) has been followed for 104 (93) months and has a creatinine concentration of 143 (140) micromol/L. A strict policy, since 1991, of prophylactic antibiotics for the first 6 months has halved the subsequent incidence of urinary tract infection. Urinary tract infections only produced problems in patients with abnormal bladders. Renal transplantation into the abnormal lower urinary tract is successful but requires careful preoperative evaluation and posttransplant follow-up.