Bladder exstrophy is a rare congenital malformation of the urinary tract. As the name implies, the main manifestation of bladder exstrophy is the exposure of the bladder outside the body, but bladder exstrophy actually encompasses much more than just the exposure of the bladder. Typical manifestations of bladder exstrophy include marked separation of the pubic symphysis, non-closure of the pelvic ring, abdominal wall defects, open bladder and exposed mucosa, and supraurethral cleft. The incidence in neonates is 1 in 10-50,000. There are far more male cases than female. Normally, the bladder is a closed bladder-like organ with the urethra attached below, which leads to the external urethral opening and is the outlet for urine. In the case of bladder exstrophy, on the other hand, imagine having a knife that starts at the external urethral opening and cuts completely upward to the bladder, with the bladder and urethra completely turned over and exposed like an open book. The illustration shows a typical bladder exstrophy. As the bladder is exposed, it is inevitably accompanied by urinary incontinence, and the urine flowing from the ureter drains directly into the open bladder, which can easily bring about urinary tract infection and local rupture. Some children fail to be seen in the neonatal period and come to the clinic at an older age. Most of them have a very poor quality of life with significant thickening of the bladder mucosa and contact pain, ulceration of the surrounding skin, and also abnormal pelvic development leading to abnormal walking gait. How is bladder exstrophy treated? Although this major deformity has been documented in the remains of Assyrian civilization as early as 2000 BC, the complexity of its treatment was not fully understood until a long time after the development of modern medicine due to its low incidence, and many patients ended up without any improvement. In the 1900s, some physicians recognized the use of cystectomy to improve the discomfort associated with bladder exstrophy, but it did not allow the child to regain bladder function and often resulted in serious infections, and the survival rate of children with bladder exstrophy was very low. It was not until after the 1960s that modern techniques for repairing bladder exstrophy were gradually developed, and by the end of the last century (1990s), modern staged repair of bladder exstrophy was gradually developed, making it possible to achieve a greater improvement in the appearance and quality of life of patients with bladder exstrophy. Modern surgery for bladder exstrophy is divided into three major components. The first stage of surgery focuses on closing the pubic symphysis and closing the exposed bladder so that the bladder exstrophy becomes a simple supraurethral cleft; the second stage, on the other hand, is to repair the supraurethral cleft so that the penis obtains a relatively satisfactory appearance; and the third stage, on the other hand, is to surgically improve the bladder’s control of urination according to the developing bladder to try to obtain a bladder function that approximates that of a normal person. The above staged surgery is for typical male bladder exstrophy, while the surgical components of atypical bladder exstrophy and female bladder exstrophy vary slightly depending on the condition and the outcome of the initial surgery. Some children in the neonatal period may also undergo multiple surgical procedures in one stage depending on their condition. The goal of surgery is to promote controlled bladder reconstruction while preserving kidney function, maximizing the structural and functional repair of the external genitalia, and improving quality of life. Is it important to close the pelvis? The goal of our initial surgery is to close the bladder. The bladder is a soft structure, but it is generally not possible to heal an ectopic bladder by simply suturing the bladder. The bones are like the foundation of the bladder and sutures to the bladder and abdominal wall will not heal without relative closure of the pelvis. Therefore, unless the pelvis can be closed directly during the neonatal period when it is still relatively elastic, in all other cases, pelvic osteotomies and fixation are required to varying degrees to restore the pelvic structure and aid bladder healing. Therefore, modern bladder exstrophy surgery is performed with multidisciplinary cooperation among urology, orthopedics, anesthesia, and nursing. Pelvic osteotomy is the process of breaking the bone at the appropriate place and then achieving a closed pelvis with postoperative fixation and traction to achieve new healing of the bone and facilitate pelvic shaping. The figure shows the style after pelvic osteotomy and external fixation. What should I do if I find bladder exstrophy? Early medical attention is still the most important task. As we mentioned in the basic presentation of bladder exstrophy, the important problem of bladder exstrophy is the separation of the pubic symphysis and the abnormalities of the pelvic structure, which is one of the reasons why early diagnosis and treatment of bladder exstrophy can be relatively satisfactory. The pelvic structure of the newborn is still soft, and within 72 hours of birth the unclosed pelvis can be closed relatively easily using the flexibility of the newborn pelvis itself, and the closed bladder can function relatively satisfactorily. Beyond this time frame, pelvic osteotomy or even external pelvic fixation is usually required to close the pelvic ring, which is much more invasive. Therefore, it is recommended that children with bladder exstrophy be transported immediately at birth to a regional medical center with diagnostic and treatment capabilities, a requirement made less difficult by the rapid development of our highway and high-speed rail networks. Although bladder exstrophy is difficult to diagnose prenatally, if it is detected at birth, the child can still be transported immediately to the appropriate medical center and receive a high level of care. If the child does not receive surgery within 72 hours of birth due to geographic or the child’s own limitations, he or she should also be seen as early as possible and undergo standard surgery as required by modern treatment protocols.