Among the many considerations for surgeons at the time of bladder exstrophy repair is whether or not to perform ureteral reimplantation at the time of initial closure. Due to the anterior herniation of the bladder in bladder exstrophy, the ureter inserts poste­riorly into the bladder and closer to the bladder neck. There is a signicantly shorter intramural tunnel. VUR is present in a large proportion of bladder exstrophy patients after initial bladder closure, with estimates of >75% prevalence postoperatively, Dickson [9]. Recurrent pyelonephritis within this population typically affects 20–50% of patients in the 90-day postoperative period, even with the use of continuous antibi­otic prophylaxis, Braga [3], Grady [14]. In certain surgical approaches, such as Young­Dees-Leadbetter bladder neck reconstruction or Kelly radical soft tissue mobilization, ureteral reimplantation may be required to facilitate reconstruction without undue risk of ureteral obstruction, Dickson [9], Tourchi [25]. With complete primary repair of exstrophy (CPRE), there is better bladder urinary cycling due to enhanced sphincter tone at the bladder neck. However, longer periods of urine holding and bladder pres­sure can also result in worsening VUR.This results in a pressure pop-off mechanism for the bladder and can compromise bladder distension during cycling and can result in worsening hydronephrosis. There may be a theoretical improvement in bladder cycling from bilateral ureteral reimplant (BUR) to facilitate better bladder distension during the dry intervals between voiding. Ureteral reimplant has also reduced hydro­nephrosis that is secondary to VUR.Lastly, correction of VUR will reduce the inci­dence of UTI.There is some evidence for larger bladder capacity at age 4years in children closed with a CPRE-BUR combined approach, Ramji [22].