Kelly Procedure (Radical Soft-tissue Mobilization)

Radical soft-tissue mobilization, also known as the Kelly procedure, is a surgical option used to repair bladder exstrophy — a rare condition present at birth where the bladder develops outside the body. In this condition, the external genitalia are also not fully formed and appear on the front (anterior) surface of the body. Surgical reconstruction is needed to close the bladder and move it inside the body, and to bring the external genitalia together in the correct position.

The Kelly procedure differs from other repair techniques such as modern staged repair of bladder exstrophy (MSRE) and complete primary repair of bladder exstrophy (CPRE). In the Kelly procedure, the corporal bodies (the tissue that forms the penis) are separated from the pubic bones, which may help maximize boys’ penile length after reconstruction.

Some centers perform the Kelly procedure in stages: The bladder is closed during the newborn period, and the Kelly repair is performed later. However, our center performs the Kelly procedure as a single-stage repair. We combine the Kelly procedure with CPRE. This means the bladder closure, pelvic bone approximation, and genital reconstruction are all done in one operation.

During the Kelly procedure, a team of surgeons works carefully to repair the parts of the body affected by bladder exstrophy.

To complete the repair, surgeons will:

• Move the bladder inside the body. In bladder exstrophy, the bladder is open and exposed to the outside world. Surgeons place it back inside the body to protect it and help it hold urine.
• Bring the pelvic bones closer together. Children with bladder exstrophy often have pelvic bones that are too far apart. Surgeons cut and move these bones together to support the bladder and lower belly.
• Repair the affected muscles and soft tissues. These tissues help hold everything in place and protect the bladder. Fixing them also helps the body function more normally.
• Reshape the genitals. Surgeons work to improve how the genitals look and function, helping with urination and overall development. We believe the Kelly procedure offers boys the best opportunity to maximize penile length visible outside the body. After the surgery, the opening where your child voids from may not be located at the tip of the penis.

The Kelly procedure is a complex surgery that can take several hours, and your child will be admitted to the hospital afterward to heal and recover. The care team will give you detailed instructions and support during this time.

After the combined Kelly and CPRE procedure, your child will stay in the hospital for seven to 10 days. During this time, they’ll have IV fluids, pain medicine (often through an epidural catheter), and several small tubes to help with healing. These include:

• A catheter to drain urine from the bladder
• Small stents to keep the ureters and urethra open during healing
• Spica cast to minimize mobility of the abdomen and lower extremities

Your child may also experience uncomfortable bladder spasms after the procedure. Their care team will provide medications to help. Gentle movement will be encouraged as your child starts to recover.

Your child will come home with their spica cast in place. They’ll still need time to heal, and they may need help with postoperative care. The care team will stay in close contact and guide you through recovery, helping your child gradually return to their normal routine.

Boston Children’s is one of the only centers in the country that regularly performs the Kelly procedure. The surgery is performed by experts in our Bladder Exstrophy Program, which brings together specialists with deep experience in this complex, single-stage repair. Our team has helped refine the technique to improve both bladder function and appearance.

As part of this approach, our surgeons carefully separate structures in the penis from the pubic bone while preserving blood supply and nerves — a step that we believe helps maximize penile length. Ongoing research aims to better understand how this technique affects long-term length, appearance, and continence.

The surgery is performed by a highly specialized team that includes pediatric urologists, orthopedic surgeons, and anesthesiologists who work together before, during, and after the operation. We take a personalized, family-centered approach to care, making sure your child is ready for surgery and that you feel informed and supported every step of the way.

In select patients, we perform the redo Kelly procedure in patients who have had prior reconstructions performed elsewhere. The redo Kelly may be used to improve penile appearance and length in combination with bladder neck reconstruction for urinary continence.