The extraperitoneal approach and positioning of the vascular anastomoses, invariably to the distal aorta and inferior caval vein has been shown to represent a technically feasible, safe, and successful procedure for transplanting adult renal grafts to children under 5 years of age weighing less than 10 kg. Since it offers additional advantages compared to the transperitoneal approach we recommend the extraperitoneal approach in the pediatric living-related renal transplantation setting as the standard procedure.