Posterior urethral valves (PUV) are the most common cause of congenital bladder outlet obstruction in males and account for approximately 15% of pediatric renal transplant recipients. Despite successful valve ablation in infancy, 50–60% of patients can develop valve bladder syndrome, characterized by persistent storage and voiding dysfunction that critically impacts long-term renal function and transplant outcomes. This chapter provides evidence-based guidance for preparing PUV patients for renal transplantation, emphasizing the essential role of urodynamic evaluation, aggressive bladder management, and optimization of storage pressures below 40 cm H₂O. Key management strategies include pharmacological therapy with anticholinergics, clean intermittent catheterization, and consideration of augmentation cystoplasty when conservative measures fail. With appropriate bladder optimization, PUV patients can achieve transplant outcomes comparable to nonurological causes of end-stage renal disease, with 5-year graft survival rates of 85% for living donors and 75% for deceased donors. Successful outcomes require multidisciplinary collaboration and lifelong surveillance of bladder function.