Abstract
<jats:p>Ureteral complications (UC) after kidney transplantation (KT) are relatively uncommon, but their clinical impact is more significant than their frequency. Delayed diagnosis may impair graft function and, in severe cases, may result in graft loss. Most clinically significant complications are related to the anatomical and vascular vulnerability of the transplant ureter. During procurement, the ureter loses its native collateral circulation and becomes dependent on small hilar and peripelvic vessels. This explains the close relationship between early urinary leakage, ureteral necrosis, and later ischemic stricture. Prevention is, therefore, the main principle of management. It depends on careful preservation of periureteral tissue, avoiding excessive ureteral length or tension, appropriate selection of ureteroneocystostomy technique, and prophylactic stenting when needed. Diagnosis should be prompt and structured. Clinical suspicion, biochemical analysis of drain or aspirated fluid, ultrasonography, cross-sectional imaging, and selective antegrade or retrograde studies are used together. Management should be individualized according to timing, location, severity, graft function, infection, bladder condition, and available reconstructive options. Low-volume leaks and selected short strictures may be treated with urinary diversion, drainage, stenting, or endourological intervention. However, extensive necrosis, recurrent obstruction, long strictures, or failed minimally invasive treatment require surgical reconstruction. Native ureter-based reconstruction remains an important graft-sparing option. Vesicoureteral reflux should be managed according to its clinical consequences rather than radiological presence alone. Long-term surveillance is essential, especially after leak, stricture treatment, or reconstruction, to maintain durable urinary drainage and protect graft survival.</jats:p>