Renal Transplantation in Recipients With Modified Lower Urinary Tract: A Systematic Review and Implications for Adult Transplant Practice.

Background: Adults with a modified lower urinary tract (MLUT) represent a growing but understudied population in renal transplantation. Concerns regarding long-term graft survival, infection, and urological morbidity persist, yet adult-specific outcome synthesis and clinically useful guidance are lacking. Methods: We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of studies reporting posttransplant outcomes in adults with abnormal or surgically MLUT anatomy. Primary outcomes were 1- and 5-y graft and patient survival. Secondary outcomes included urological complications. Given substantial heterogeneity, data were synthesized narratively. Results: Twenty-four studies, including 511 MLUT recipients, were identified. Most were retrospective single-center series, and only a minority included comparator cohorts. Several studies included mixed adult-pediatric cohorts where adult-only outcomes could not be separated. Across comparative studies, 1-y graft survival appeared broadly similar between MLUT and control recipients, whereas 5-y graft survival was more often lower in MLUT cohorts. Patient survival was comparable, although long-term comparative data were limited. Urological morbidity was consistently greater in MLUT recipients, particularly recurrent urinary tract infection and the need for further urological intervention. Conclusions: Renal transplantation in selected adults with MLUT is achievable with acceptable early outcomes, but the burden of urological morbidity is substantial, and longer-term graft outcomes are less favorable. These findings support careful pretransplant lower urinary tract assessment and highlight the need for pragmatic optimization pathways, although higher-quality prospective data remain necessary.