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PubMed This is a summary of 18 peer-reviewed journal articles Updated
Pediatric Surgery

Surgical Strategies for Classic Bladder Exstrophy

At a Glance

Surgical repair for classic bladder exstrophy aims to close the abdomen, protect kidneys, and achieve continence. The main approaches include Complete Primary Repair (a single major surgery) and Modern Staged Repair (multiple steps). Pelvic osteotomy is often needed to ensure a successful closure.

Surgical repair for Classic Bladder Exstrophy (CBE) is a highly specialized field. The ultimate goals of any surgical plan are the same: safely closing the abdominal wall, protecting the kidneys, achieving urinary control (continence), and creating a natural appearance (cosmesis) [1][2]. To reach these goals, surgeons use several distinct strategies, often tailored to your child’s specific anatomy.

Two Major Surgical Philosophies

Most surgical teams follow one of two primary pathways for the initial repair of CBE.

  • Complete Primary Repair of Exstrophy (CPRE): This is a “single-stage” reconstruction where the surgeon closes the bladder, the abdominal wall, and the genitalia all in one major operation, typically shortly after birth [3].
    • Pros: Fewer total surgeries early in life and the potential for earlier bladder development [4].
    • Cons: Higher complexity and potential risks, such as penile disassembly, which in some cases can affect blood flow to the tissue [5][6].
  • Modern Staged Repair of Exstrophy (MSRE): This is a multi-step approach.
    • Step 1: The bladder and abdominal wall are closed (usually within the first 48–72 hours of life) [7].
    • Step 2: The genitalia are repaired (usually between 6 months and 2 years of age) [3].
    • Step 3: A bladder neck reconstruction is performed later (usually age 4 or 5) to help with potty training [3].
    • Pros: Breaks the process into manageable steps and avoids some of the risks of complete disassembly in the newborn period [6].

Specialized Techniques for Continence

Achieving urinary continence is one of the most challenging parts of the journey. Only about 25% of children with CBE will achieve “normal” voiding without additional help [8]. Two common techniques for improving control include:

  • The Kelly Procedure (Radical Soft-Tissue Mobilization - RSTM): This technique involves a deep “mobilization” of the muscles and tissues surrounding the bladder and pelvis. By bringing these muscles closer together, surgeons aim to create a natural “loop” around the bladder neck to provide better control [9][10].
  • Young-Dees-Leadbetter (YDL) Reconstruction: This is a more traditional method where the surgeon reshapes the bottom of the bladder into a narrow tube to create resistance, helping the child hold urine [11][8].

The Role of Pelvic Osteotomy

Because the pelvic bones in children with CBE are naturally separated (pubic diastasis), there is significant tension on the repair [12]. An osteotomy is a procedure where an orthopedic surgeon carefully cuts or reshapes the pelvic bones so they can be brought together in the center [13][14].

  • Why it’s needed: It reduces the tension on the surgical site, significantly lowering the risk of the repair “popping open” (dehiscence) [7][15].
  • When it’s needed: While some newborns can be closed without it if their bones are very flexible, it is often considered a “key” component for a successful and lasting primary closure [7][16].

Each surgical journey is unique. Your surgical team will evaluate your child’s bladder plate size and bone flexibility to recommend the approach that offers the safest and most effective path forward [17][18].

Return to Validation & Orientation Overview

Common questions in this guide

Should my child have a single-stage or staged repair for bladder exstrophy?
The choice between a single-stage and staged repair depends on your child's specific anatomy, such as bladder plate size and bone flexibility. Your surgical team will recommend the safest and most effective approach based on these factors.
Why might my child need a pelvic osteotomy for bladder exstrophy?
An osteotomy involves an orthopedic surgeon cutting or reshaping the pelvic bones so they can be brought together. This reduces tension on the surgical repair site and significantly lowers the risk of the closure popping open.
What procedures are used to help achieve urinary continence?
Surgeons may use the Kelly Procedure to bring surrounding muscles together around the bladder neck, or the Young-Dees-Leadbetter reconstruction to reshape the bottom of the bladder into a narrow tube. Both techniques help increase resistance so the child can hold urine.
What happens if the primary bladder closure does not hold?
If the initial surgical closure does not hold, it is called dehiscence. This means the repair has popped open, which can complicate bladder development and require additional surgeries to safely close the abdominal wall and protect the kidneys.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Given my child's specific anatomy, do you recommend a single-stage (CPRE) or a staged (MSRE) approach?
  2. 2.What is your institutional success rate for primary closure, and what happens if the first closure does not hold?
  3. 3.If you recommend an osteotomy, which specific technique (anterior vs. posterior) will you use, and why is it necessary for my child?
  4. 4.Are you planning to perform a Kelly Procedure (RSTM) or a Young-Dees-Leadbetter reconstruction later to help with continence?
  5. 5.How do you balance the goals of cosmetic appearance with the functional goal of protecting the kidneys?

Questions For You

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References

References (18)
  1. 1

    Genetic Counseling for Bladder Exstrophy-Epispadias Complex.

    Reutter H, Holmdahl G

    European journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie 2021; (31(6)):468-471 doi:10.1055/s-0041-1740336.

    PMID: 34911128
  2. 2

    One-hundred-fifteen consecutive bladder exstrophies successfully closed in a single nationally commissioned centre.

    Mariotto A, Keene JD, Bendon AA, et al.

    Journal of pediatric urology 2025; (21(6)):1449-1457 doi:10.1016/j.jpurol.2025.06.017.

    PMID: 40615250
  3. 3

    Insights and outcomes of single-staged repair of female bladder exstrophy-epispadias complex without osteotomy: 15 Years experience of a single institution.

    Kajbafzadeh AM, Sabetkish S, Sabetkish N, et al.

    Journal of pediatric urology 2022; (18(3)):355-361 doi:10.1016/j.jpurol.2022.03.018.

    PMID: 35477666
  4. 4

    Complete Primary Repair of Bladder Exstrophy: Critical Analysis of the Long-term Outcome.

    Arab HO, Helmy TE, Abdelhalim A, et al.

    Urology 2018; (117()):131-136 doi:10.1016/j.urology.2018.03.044.

    PMID: 29649545
  5. 5

    Penile Disassembly in Complete Primary Repair of Bladder Exstrophy: Time for Re-evaluation?

    Kasprenski M, Maruf M, Davis R, et al.

    Urology 2020; (137()):146-151 doi:10.1016/j.urology.2019.12.020.

    PMID: 31887351
  6. 6

    Modified staged repair of bladder exstrophy: a strategy to prevent penile ischemia while maintaining advantage of the complete primary repair of bladder exstrophy.

    Chua ME, Ming JM, Fernandez N, et al.

    Journal of pediatric urology 2019; (15(1)):63.e1-63.e7 doi:10.1016/j.jpurol.2018.09.005.

    PMID: 30442544
  7. 7

    Cloacal Exstrophy Closure Without Osteotomy and Immobilization: A Recipe for Failure.

    Heap D, Haffar A, Crigger CB, et al.

    Journal of pediatric surgery 2025; (60(1)):161995 doi:10.1016/j.jpedsurg.2024.161995.

    PMID: 39442330
  8. 8

    Urinary Continence Outcomes in Classic Bladder Exstrophy: A Long-Term Perspective.

    Maruf M, Manyevitch R, Michaud J, et al.

    The Journal of urology 2020; (203(1)):200-205 doi:10.1097/JU.0000000000000505.

    PMID: 31437120
  9. 9

    The radical soft-tissue mobilization (Kelly repair) for bladder exstrophy.

    Leclair MD, Villemagne T, Faraj S, Suply E

    Journal of pediatric urology 2015; (11(6)):364-5.

    PMID: 26454452
  10. 10

    Mobilization of pelvic musculature and its effect on continence in classical bladder exstrophy: a single-center experience of 38 exstrophy repairs.

    Varma KK, Mammen A, Kolar Venkatesh SK

    Journal of pediatric urology 2015; (11(2)):87.e1-5.

    PMID: 25805044
  11. 11

    Primary female epispadias: Perineal approach or Kelly repair?

    Leclair MD, Faraj S, Villemagne T, et al.

    Journal of pediatric urology 2018; (14(1)):33-39 doi:10.1016/j.jpurol.2017.08.017.

    PMID: 29426576
  12. 12

    Pelvic Floor Anatomical Variations in Children With Exstrophy-Epispadias Complex Using Magnetic Resonance Imaging.

    Peng Z, Huang Y, Tang W, et al.

    Urology 2022; (165()):305-311 doi:10.1016/j.urology.2022.01.008.

    PMID: 35038493
  13. 13

    Bilateral Obturator Osteotomy: A Novel Osteotomy for Bladder Exstrophy Closure.

    Faraj S, Decante C, Alliot H, et al.

    Journal of pediatric surgery 2024; (59(9)):1841-1845 doi:10.1016/j.jpedsurg.2024.03.058.

    PMID: 38664181
  14. 14

    Assessment of the anterior osteotomy role in the restoration of normal pelvic floor anatomy for bladder exstrophy patients using pre and postoperative pelvic floor MRI.

    Aboul Ela W, El Zoheiry M, Shouman A, et al.

    Journal of pediatric urology 2020; (16(6)):835.e1-835.e9 doi:10.1016/j.jpurol.2020.09.004.

    PMID: 33023849
  15. 15

    Multi-staged vs Single-staged Pelvic Osteotomy in the Modern Treatment of Cloacal Exstrophy: Bridging the Gap.

    Haffar A, Hirsch AM, Crigger CB, et al.

    Journal of pediatric surgery 2023; (58(12)):2308-2312 doi:10.1016/j.jpedsurg.2023.09.003.

    PMID: 37777362
  16. 16

    Predictors of a successful primary bladder closure in cloacal exstrophy: A multivariable analysis.

    Jayman J, Tourchi A, Feng Z, et al.

    Journal of pediatric surgery 2019; (54(3)):491-494 doi:10.1016/j.jpedsurg.2018.06.030.

    PMID: 30029844
  17. 17

    Study of Surface Area of Opened Bladder Converted into Bladder-plate in Cadavers and Comparison with Bladder-plate Surface Area in Clinical Cases of Bladder Exstrophy.

    Kumari P, Rai RK, Gupta A, et al.

    Journal of Indian Association of Pediatric Surgeons 2025; (30(6)):696-701 doi:10.4103/jiaps.jiaps_118_25.

    PMID: 41293513
  18. 18

    Continence after BNR in the complete repair of bladder exstrophy (CPRE): A single institution expanded experience.

    Di Carlo HN, Manyevitch R, Wu WJ, et al.

    Journal of pediatric urology 2020; (16(4)):433.e1-433.e6 doi:10.1016/j.jpurol.2020.05.011.

    PMID: 32546418

This page explains surgical strategies for classic bladder exstrophy for educational purposes only. Always consult your pediatric urologist and surgical team for medical advice tailored to your child's unique anatomy.

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