In August 2025, Malaysia achieved a significant milestone in pediatric urology with the nation’s first successful Kelly procedure, a radical soft-tissue mobilization performed on a 2-year-old boy with bladder exstrophy.^1,2 Supported by a multidisciplinary team in Prince Court Medical Centre (PCMC) Kuala Lumpur, the complex operation was led by Dr. Roger Anthony Idi, Consultant Urologist, in collaboration with Professor Dr. Imran Mushtaq, a leading pediatric urologist from Great Ormond Street Hospital (GOSH), London.¹ This achievement marks a new era for Malaysian pediatric reconstructive surgery, bringing world-class expertise to local patients and reducing the need for families to seek care abroad.¹

Bladder exstrophy is a rare and severe congenital anomaly in which the bladder develops outside the body, leaving the internal urinary structures exposed.³ In the United States, it occurs in approximately 3.3 per 1,000,000 live births and is twice as common in boys as in girls, affecting both urinary and genital function.³ Children born with this condition face significant medical and psychosocial challenges, including incontinence, kidney complications, and the need for multiple surgeries throughout childhood.³ Early multidisciplinary management is therefore crucial to preserve renal function, restore continence, and improve quality of life.^2,3

Traditionally, bladder exstrophy has been treated using staged reconstructive approaches, which involve initial bladder closure, followed by subsequent procedures to correct the urethra and reconstruct the bladder neck to improve continence.^2,3 Pelvic osteotomy is typically performed in these traditional repairs to realign the separated pubic bones and reduce tension on the bladder and abdominal wall closure.² While these methods have advanced over the decades, many patients remain dependent on catheters or experience limited control of urination.³

The Kelly Procedure, originally conceptualized by Dr. John H. Kelly in the 1970s and later refined into its modern form in the 1990s, offers an innovative alternative that avoids cutting the pelvic bones.^2,4,5 It is typically performed after primary closure, once the bladder has been brought into the abdomen.² At this stage, the technique uses radical soft-tissue mobilization to reconstruct the bladder, bladder neck, and urethra, creating a functional urinary sphincter from the child’s native tissue.^1,2 This approach aims to achieve voluntary urinary control and preserve the natural anatomy, offering better functional and esthetic outcomes.^1,2 A long-term clinical audit of 31 patients diagnosed with bladder exstrophy and treated between 1980 and 2007 at the Royal Children’s Hospital, Melbourne reported that up to 70% of patients attain complete or partial continence following the Kelly Procedure—outcomes comparable to or better than those achieved with traditional staged repairs.⁵

The success of Malaysia’s first Kelly Procedure underscores the power of international collaboration and knowledge transfer.¹ Dr. Roger Anthony Idi emphasized that performing such a complex reconstructive surgery required meticulous planning and coordinated expertise. “This condition can be detected through antenatal scans, enabling early consultation and surgical planning,” he explained.

“From my experience, we still see children aged five or six presenting with untreated bladder exstrophy. Others had initial closure but never received the Kelly Procedure, resulting in lifelong continence issues.” Working alongside Prof. Imran Mushtaq, the team adopted the Kelly technique to ensure optimal anatomical restoration and functional outcomes.¹ According to Dr. Roger, “This approach enhances genital appearance and offers the highest continence rates compared to other surgical methods. By collaborating with global experts, we are strengthening our surgical capabilities and creating pathways to expand access to this level of care in the region.”

The successful completion of this operation marks a turning point for children born with bladder exstrophy in Malaysia, offering them the possibility of improved bladder function, continence, and a better quality of life.¹ Beyond its surgical achievement, this milestone represents progress in building local expertise and fostering sustainable pediatric urology programs that meet international standards.¹ “Moving forward, we hope to offer this procedure to more patients locally and across the region,” Dr. Roger said. “With continuous training and multidisciplinary collaboration, we can ensure that children born with this rare condition have access to the best possible care—right here at home.”

In an interview with Omnihealth Practice, Dr. Roger Anthony Idi discussed the challenges and advances in managing bladder exstrophy, highlighting innovative surgical techniques and long-term care considerations for affected patients.

Q1. How common is bladder exstrophy in Malaysia, and what challenges does it present for clinicians?

 Dr. Roger: Bladder exstrophy is exceedingly rare, with an estimated incidence of about 1 in 30,000 to 50,000 births, slightly less common in our region than in Western countries. Management is complex and long-term. Key challenges include ensuring proper initial reconstructive surgery, often requiring a highly specialized team, and providing lifelong follow-up for continence, kidney health, and psychosocial development. Access to pediatric urology centers and coordinated multidisciplinary support for families is also critical.

Q2. How is bladder exstrophy diagnosed and treated, and what sets the Kelly Procedure apart from conventional repair?

Dr. Roger: Antenatal diagnosis is possible through a detailed mid-trimester ultrasound, typically around 18-20 weeks. Clues include a persistently empty bladder and a lower abdominal wall defect. Traditionally, cases undergo staged repair: newborn bladder and abdominal wall closure, followed later by bladder neck and genital reconstruction. The Kelly Procedure is a variation of the second stage, using radical soft-tissue mobilization to reposition pelvic muscles, urethra, and surrounding tissues. This creates a tension-free closure, restores more natural anatomy, and strengthens the bladder outlet, potentially improving early continence and genital/abdominal wall aesthetics.

Q3. What outcomes and future directions should clinicians and patients know about?

Dr. Roger: Published data suggest that Kelly Procedure can achieve similar or better continence with fewer operations compared to conventional staged repair, while also improving long-term quality of life. However, it is technically demanding, carries risks like wound complications and fistula formation, and has a longer learning curve due to the small number of cases annually. As Malaysia gains experience and outcomes continue to improve, incorporating this procedure into local pediatric urology training could broaden expertise and enhance access to advanced reconstructive options.