Chronic rejection is the leading cause of graft loss (1) in kidney transplant recipients and therefore retransplantation has increasingly become a common procedure. Sometimes the procedure is complicated by other factors, which induces creativity. While scheduled to have a planned bilateral native nephrectomy for recurrent symptomatic hemorrhagic cysts, a 46-year-old man was called to receive his second cadaveric kidney transplant. The etiology of his renal failure was hypertension and his first cadaveric kidney transplant still in place functioned for 6 years and was lost to chronic rejection. The organs were en bloc kidneys from a 3-year-old boy trauma victim. Through a midline laparotomy bilateral native nephrectomies were performed. The right ileac fossa was occupied by the previous allograft, which we elected to leave in place since it was not symptomatic. Distal aorta and vena cava seemed suitable location for vascular anastomoses. There was immediate function from both kidneys. The transplant ureters were short and small compatible with donor’s age and the recipient’s bladder and ureters were small due to prolong nonfunctioning. Individual end-to-end anasthomosis seemed to offer the best result. The right native ureter was elected for upper moiety. The stump of the left native ureter was mobilized accompanying the gonadal vessels passed through the sigmoid colon mesentery and provided adequate length for the lower moiety. At the end of dissections all ureters were viable and bleeding from the ends. They were spatulated and anastomoses were stented (Fig. 1).FIGURE 1. Transposition of left ureter to right accompanying gonadal vessels. Inset renal scan demonstrates good function of both renal units.Foley catheter was left indwelling for 10 days and ureteral stents were removed 1 month following transplant. Nuclear renal scan at 3 months shows normal function and drainage. The recipient has normal serum creatinine. The blood supply of upper, mid, and distal ureter is from renal, gonadal, and vesical arteries, respectively. The ureter also receives feeding branches from abdominal aorta and common ileac artery (2). In our case on the left side while renal and gonadal arteries were disconnected from aorta it seemed that vesical arteries, branches from common ileac artery, and other sources of gonadal blood supply (cremastric and vasal arteries) in retrograde fashion provided additional supply for the ureter. Our experience shows that stump transureteroureterostomy is a valid option in unusual circumstances however ureter always should accompany the gonadal vessels. Reza Ghasemian Department of Urology Washington Hospital Center Washington, DC Elizabeth Bugarin Jimmy A. Light Transplantation Services Washington Hospital Center Washington, DC