The achievement of satisfactory continence in the management of classical bladder exstrophy remains a surgical challenge. This may be particularly difficult in the patient with a small bladder capacity after initial closure. The 12-year experience at our institution with bladder exstrophy is reviewed and attention is focused on the approach to those patients with a small bladder capacity. A total of 155 children with bladder exstrophy were treated. Of these 155 patients 28 boys were believed to have a bladder capacity inadequate for satisfactory bladder neck reconstruction (less than 60 cc). All patients have undergone staged reconstruction with a urethroplasty for epispadias and they are available for evaluation. After a median interval of 22 months bladder capacity increased by a median 54.5 cc. No child had hydronephrosis after the epispadias repair or bladder neck reconstruction. Of the 28 patients 25 have undergone bladder neck reconstruction with a median followup of 4.5 years and 88 per cent (22 of 25) demonstrate continence with a dry interval greater than 3 hours. Another 2 patients have been rendered continent following bladder augmentation. These results demonstrate that satisfactory continence is an achievable goal in the exstrophy patient with a small bladder capacity when bladder neck reconstruction is preceded by epispadias repair.