This article is based on our experience in managing exstrophy over a period of 40 years in two large tertiary care hospitals in India. Our patients include those presenting at all ages, even as young adults, and also a large number of failed exstrophy, including dehisced bladder repairs, incontinence, infection, upper tract deterioration and calculi. Most of our patients have undergone a two-step reconstruction. Bladder turn-in with concomitant epispadias repair was done at presentation, avoiding the first three months of life. The second and final reconstruction at around 5 years of age included bladder augmentation, Mitrofanoff channel, ureteric reimplantation, and bladder neck plasty/closure. We have simplified the bladder turn-in by using a rectus muscle flap instead of bony approximation of the pubis. Our preferred method of bladder augmentation was the ileocecal segment with “in situ” appendix wrapped by an ileal “fundoplication”—the “donut” augmentation. Follow-up results in 100 consecutive children have shown useful dryness on CIC in 95% and significant improvement of vesicoureteral reflux, hydroureteronephrosis, and eGFR.