The extraperitoneal approach was used for transplantation of adult renal grafts in eight children under 5 years, three of them weighing less than 10 kg. Usually, children of this size are approached transperitoneally. The modified procedure included partial mobilization of the right liver to provide enough space for retroperitoneal graft placement and positioning of the vascular anastomoses, invariably to the aorta and caval vein. With this regimen, no significant space problems were encountered in recipients as small as 9 kg, and particularly, neither arterial nor venous complications occurred. Currently, at a mean follow-up of 2.4 years, all patients are alive with well-functioning grafts. Thus, the extraperitoneal approach represents a feasible and successful procedure in the pediatric living related renal transplantation setting for recipients under 10 kg of weight.