The flip-flap technique to lengthen the urethra (Salle procedure) for treatment of neurogenic urinary incontinence.

We report the clinical results of a urethral lengthening procedure for neurogenic urinary incontinence. The urethra is lengthened by using a full thickness anterior bladder wall flap that is based at the urethra. This flap is approximated to a longitudinal strip of the trigonal mucosa and musculature. This neourethra is covered by urothelium creating a tunneled urethra, which creates a compressible flap valve mechanism that occludes with bladder filling. The ureters are reimplanted superior to the repair. Technical feasibility was first documented in the dog. Four myelomeningocele children with low urethral resistance and urinary incontinence refractory to medical management have undergone this procedure since July 1992. The 3 patients who have been followed for longer than 1 year are described. Two patients require concomitant bladder augmentation. Comparison of preoperative and postoperative urodynamics revealed increased urethral resistance. All 3 patients are clinically improved and dry on intermittent catheterization during the day. The patient without bladder augmentation has occasional nocturnal wetting. Since the posterior urethra and bladder wall remain intact without suture lines there have been no problems with catheterization. The upper tracts remain normal. We believe that this procedure is a helpful addition to the care of children with neuropathic incontinence. The technical aspects and results of this procedure are discussed in detail.