Cloacal exstrophy (CE) is commonly referred to as the omphalocele, exstrophy of the bladder, imperforate anus, and spinal abnormalities (OEIS) complex, and represents the most severe presentation of the exstrophy spectrum. Patients will often present with a spectrum of colonic length that may be further reduced with initial management. It is a commonly held belief that patients will require permanent colonic stomas. The dramatic increase in survival rate in past decades has shifted towards giving patients the highest quality of life. Properly selected patients can be candidates for a pull-through procedure and thus the avoidance of a colonic stoma. The primary questions within this chapter involve the surgical management of the hindgut during the primary reconstruction procedure and the patient selection criteria regarding the pull-through procedure. Patients with cloacal exstrophy should receive an end-colostomy as the primary fecal diversion in the initial surgical reconstruction. Proper patient selection is critical when choosing to offer a pull-through procedure. Patients who are able to form solid stool with an acceptable colon length may be offered a pull-through procedure. Those with good neurologic function, appropriate sphincter location and strength, and no spinal abnormalities are more likely to have successful outcomes. The pull-through procedure should be delayed until the patient has developed appropriate psychosocial maturation.