A best evidence topic in transplant surgery was written according to a structured protocol. The question addressed was: In adults undergoing renal transplantation, does pyeloureterostomy, as compared to ureteroneocystostomy, improve clinical outcomes? A total of 235 articles were identified using the search protocol described, of which six represented the best evidence available to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. These included one prospective cohort study, three retrospective cohort studies and two case series. The largest of the five cohort studies demonstrated significantly reduced levels of complications with pyeloureterostomy as compared to ureteroneocystostomy. The consensus from the remaining trials was that pyeloureterostomy is a safe but underused technique. However, the majority of the evidence pertaining to pyeloureterostomy and ureteroneocystostomy was archaic, with four of the six dating from pre-1990. Furthermore, the most recent articles (reported in 2010 and 2013) provide only level three and four evidence respectively, and contain important flaws with regard to patient-cohort allocation inherent to the study design. For these reasons we are cautious in recommending pyeloureterostomy over ureteroneocystostomy with the current evidence base, but would like to emphasise that pyeloureterostomy remains a safe surgical option which should form part of the modern transplant surgeon's reconstructive repertoire, particularly when managing patients in which multiple complications are anticipated, or when there is fear of ureteral vascular compromise, such as with cadaveric kidneys. We call for larger scale prospective trials to aid clarification of the roles of pyeloureterostomy and ureteroneocystostomy in renal transplant surgery and to enrich this prescient field with much needed 21st century evidence.