title: Urethral lengthening with anterior bladder wall flap (Pippi Salle procedure): modifications and extended indications of the technique.
abstract: OBJECTIVE
  We report a clinical case series of an innovative method of urethral reconstruction for the treatment of urinary incontinence. Modifications of our original technique are presented.
  
  
  METHODS
  Bladder neck repair was done in 17 patients, mean age 9.3, with neurogenic incontinence (13) or exstrophy (4). Average followup is 25.6 months. Of the patients 9 with neurogenic bladder underwent the original procedure using a midline anterior bladder wall flap. In the 4 patients with exstrophy a modified procedure was done using an anterolateral bladder wall flap. In another 4 patients an extended flap of distal mucosa was used to avoid ureteral reimplantation. Augmentation was performed in 13 of the 17 cases (10 detubularized ileum and 3 detubularized colon).
  
  
  RESULTS
  Continence (greater than 4 hours) was obtained in 12 of the 17 patients (70%), 2 are dry for 1 to 2 hours and 3 are incontinent. A urethrovesical fistula developed in 2 patients (1 closed successfully), and 3 patients have problems with catheterization.
  
  
  CONCLUSIONS
  Urethral lengthening with anterior bladder wall flap is a versatile alternative in the surgical treatment of urinary incontinence. Variations of the original technique resulted in an improved vascular supply and decreased the formation of fistula at the base of the flap. The modified technique was successful in patients with exstrophy, including those who had failed bladder neck surgery.
authors.affiliation: Division of Pediatric Urology, Hospital de Clinicas de Porto Alegre, Brazil.
authors.forename: J L
authors.initials: JL
authors.lastname: Salle
authors.forename: G A
authors.initials: GA
authors.lastname: McLorie
authors.forename: D J
authors.initials: DJ
authors.lastname: Bägli
authors.forename: A E
authors.initials: AE
authors.lastname: Khoury
mesh_terms: D001746:Bladder Exstrophy / Q000150:complications / Q000601:surgery*; D002648:Child; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D013524:Surgical Flaps / Q000009:adverse effects / Q000379:methods*; D014521:Urethra / Q000601:surgery*; D001743:Urinary Bladder / Q000637:transplantation; D001750:Urinary Bladder, Neurogenic / Q000150:complications / Q000601:surgery*; D014549:Urinary Incontinence / Q000209:etiology / Q000601:surgery*