During the last 18 years we treated 22 patients with cloacal exstrophy of whom 13 were referred for further treatment after initial treatment elsewhere. One patient underwent cystectomy with ileal conduit urinary diversion soon after birth and 9 of the remaining 21 underwent initial closure without osteotomy. Of these 9 patients significant complications developed in 8 (89%) after bladder closure, including dehiscence in 6 (1 underwent 2 unsuccessful closures), a vesicocutaneous fistula and postoperative ventral hernia in 1, and bladder prolapse in 1. In contrast, complications developed in only 2 of the 12 patients (17%) who underwent osteotomy at the time of initial closure, including bladder dehiscence in 1 and significant prolapse in 1. Patients who underwent osteotomy and those who did not were similar in terms of the size of omphalocele, presence of myelomeningocele and time of primary closure. We also found that osteotomy or failed closure has no effect on the eventual continence of cloacal exstrophy patients. While osteotomy is not the only variable involved in successful cloacal exstrophy closure, our results indicate the need for osteotomy in these patients to increase the success rate at the time of initial bladder closure.