Bladder exstrophy is a complex and challenging congenital anomaly to “fix,” and each surgery to achieve one goal may have other unintended consequences and complications. The goals of surgery initially focus on restoring normal anatomy with an internalized bladder and reconstructing a more normal appearance for the genitalia. Next, the focus shifts to urinary function, to prevent urinary tract infections and to preserve renal function, and ultimately to achieve continence, or dryness, while ensuring protected renal function. Finally, in adulthood, the focus shifts to optimizing sexual function and fertility. While these aims can be approached separately, each is interrelated. The ability to achieve the goals of the surgery depends often on the definitions applied for “success.” There are certain parameters that are often used to define success—such as dry intervals or the need to catheterize—but surgeons must partner with patients to determine which outcomes are most important to each individual patient. This chapter is intended to bring focus to the questions of what, when, and why to achieve continence.