Bladder exstrophy is a challenge to the paediatric urologist; here in the UK, repairs are now undertaken at two centres in order to concentrate experience. The ultimate aim is to achieve urinary continence and volitional voiding. In this study, John Gearhart’s Baltimore group present the outcomes of 432 patients with classic bladder exstrophy who underwent successful bladder closure and subsequent continence procedures between 1975 and 2017. Overall, 309 (71.5%) had a successful primary closure (94.4% success at the author’s institution). The median age at the first continence procedure was 5.9 years, and 274 of 432 (63.3%) initially underwent a bladder neck reconstruction. However, of these patients, 112 (40.9%) went on to other procedures including augmentation, continent catheterisable stoma, bladder neck closure, ureterosigmoidostomy, and incontinent conduit diversion. Only 162 of 432 (37.5%) maintained their bladder neck reconstruction at last follow-up. Data was available for 350 patients overall (some had less than three months of follow-up from the last procedure and therefore continence was not assessed). For those who had bladder neck reconstruction alone, data was available for 142 patients. Continence was defined as a dry interval of three or more hours without leakage at night while sleeping and was 91 of 142 (64.1%). Only 80 of the 91 were voiding spontaneously per urethra. This is a large study and demonstrates that only a proportion (approaching one quarter) will achieve urinary continence and volitional voiding per urethra. The remaining patients require a variety of reconstructive surgeries to protect the kidneys and achieve ‘continence’. The authors should be praised in that they included all successful bladder closures and subsequent continence procedures (which were not necessarily undertaken at their institution).