In this chapter, we will try to outline the possible reasons for failed closures, the types of outcomes that constitute failure, the early and late management of failed closure, including principles of redo closures, and the outcomes of redo exstrophy closures.

Some surgeons believe that when the primary repair is done in newborns, liga­mental laxity allows the pelvis to be closed without signicant tension. Osteotomy becomes mandatory once exstrophy repair is delayed beyond 72h, in cases of poorly malleable pelvis and when the pubic diastasis is more than 4cm [9, 10]. A rm anterior pelvic ring resulting from osteotomy supports the urethral suspension and contributes in preventing bladder prolapse or dehiscence [8]. Gearhart has reported in his study of 170 failed repairs that osteotomy had been done in only 29% at the time of the primary repair [11]. The rate of failure of abdominal wall closure and bladder closure has diminished to less than 5% at experienced centres with the incorporation of osteotomy in the repair of bladder exstrophy. Various types of oste­otomies have been described, like posterior iliac, anterior osteotomy of the superior pubic rami, anterior diagonal iliac, modied Salter’s innominate and vertical iliac ramotomy [8]. The combined transverse innominate and vertical iliac osteotomy have been shown to have lower rates of dehiscence and prolapse compared to other osteotomies [10]. The benets of osteotomy far outweigh the complication rate of 4% shared collectively by the various osteotomies [8]. At the authors’ institute, all primary repairs are done after 3months of age with osteotomy in all cases. The dehiscence rate has been less than 2%, and there have been very few complications.