The philosophy of bladder exstrophy reconstruction is based on the principle of anatomical and functional restoration in terms of normal micturition, sexuality, and preservation of upper tracts. Anatomical knowledge of the urogenital diaphragm and location of the external urethral sphincter enables an innervation-preserving reconstruction. Subperiosteal safe radical corporal detachment is possible with an accurate knowledge of the course of neurovascular bundle of corpora cavernosa in relation to ischiopubic ramus. Corporal-urethral separation with aesthetic skin management is guided by the axial pattern of blood supply and fascial planes. With the novel midline scrotoperineal approach, all the muscles of urogenital diaphragm are exposed in an innervation-preserving safe plane, along with exposure of attachment of corpora cavernosa to ischiopubic ramus. The preservation of innervation and vascularity improved functional outcomes after reconstruction. Midline approximation of abdominal wall structures with the help of osteotomy combined with umbilicoplasty, abdominoplasty, and urethroplasty results in improved overall aesthetic appearance with satisfactory length of reconstructed penis. By applying this technique in patients with good bladder plates, it has been possible to achieve satisfactory continence with dry intervals of 1.5–2 hours, midstream-holding capacity, and preserved upper tracts in about two-thirds of patients.