UNIVERSITAS INDONESIA

BLADDER NECK RECONSTRUCTION USING PIPPI SALLE

PROCEDURE WITH MITROFANOFF AND
ILEOCYSTOPLASTY IN AN INCONTINENCE
PEDIATRIC PATIENT AFTER EPISPADIA REPAIR

PENULIS
dr. Eko Arianto
(1506816935)

PEMBIMBING
Dr. dr. Irfan Wahyudi, SpU(K)

Departemen Urologi
Fakultas Kedokteran Universitas Indonesia
RSUPN Dr. Cipto Mangunkusumo
Jakarta
2017
 LEMBAR PERSETUJUAN

Paper dengan judul :

Bladder Neck Reconstruction Using Pippi Salle Procedure with

Mitrofanoff and Ileocystoplasty in an Incontinence
Pediatric Patient after Epispadia Repair
Penelitian ini disusun sebagai salah satu syarat menempuh Program Pendidikan Dokter
Spesialis Urologi Fakultas Kedokteran Universitas Indonesia

Oleh :
dr. Eko Arianto

Disetujui oleh Pembimbing :

1. Dr. dr. Irfan Wahyudi, SpU(K) ( ttd )

Nilai,

( nilai )

Departemen Urologi
Fakultas Kedokteran Universitas Indonesia
RSUPN Dr. Cipto Mangunkusumo
Jakarta
2017
Bladder Neck Reconstruction Using Pippi Salle Procedure with Mitrofanoff and
Ileocystoplasty in an Incontinence Pediatric Patient after Epispadia Repair
*Eko Arianto, **Irfan Wahyudi
*Registrar in Department of Urology Cipto Mangunkusumo Hospital, Jakarta
**Staff of Department of Urology Cipto Mangunkusumo Hospital, Jakarta

Background
The main technical challenge for urologists in pediatrics bladder neck reconstruction
is to provide adequate outflow resistance and thereby achieving continence.(1) The problems
exist could be neurogenic cause or due to anatomical anomalies. Each underlying problem
may cause difficulties in managing the patient. Hence, many different techniques have been
reported and modified by surgeons. (2)
In general, there are two options to achieve continence, first by keeping lower urinary
tract intact for transurethral bladder emptying and secondly by continent urinary diversion
system.(1,2) Since Lapides et al presented the use of clean intermittent catheterization (CIC)
back in 1972, it has been the safest methods allowing complete and regular bladder emptying
while keeping lower urinary tract intact. (3) However, it might affect patients’ quality of life
especially in school age. Therefore, other surgical procedures for improving bladder outlet
resistance, capacity, and compliance are deemed necessary. (4)
In 1986 Kropp et al reported a novel urethral lengthening procedure for managing
urinary incontinence, initially used for children with meningomyelocele. This technique
lengthened the urethra by creating a tabularized anterior detrusor wall continuously with the
urethra and implants it into a submucosal tunnel within the trigonum. Using this tube, this
technique can provide a flap-valve allowing catheter introduction and preventing urinary
leakage. Many series reported an impressive continence rate with this technique, ranging
from 80% to 100%. However, the bulky neourethra made was shown to be a significant
drawback of this procedure. Urinary retentions were commonly reported and mucosal
discontinuity resulted in difficult urinary catheter insertion.(3–5)
Later, Mollard et al in 1990 and Pippi Salle et al in 1993 reported a modified Kropp
onlay procedure to achieve better outcome. Pippi Salle recommended the usage of anterior
bladder wall onlay flap, aiming to avoid any mucosal discontinuity and thereby providing
easier catheterization. In 1997 Salle et al reported a modified version of their technique
resulted in improved flap viability, minimal fistula formation, and extended indications for
this operation. (3,4).

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Patient and Method
Patient
Our patient is a 13 years old male student who was diagnosed with urinary
incontinence after epispadia repair. He was first undergoing an epispadia repair operation in
2010. Patient is complaining frequency and incontinence after the operation. In 2015 patient
had a VCUG procedure and found out to have problem in bladder neck structure and small
bladder capacity. It was decided to use Pippi Salle technique for bladder neck reconstruction
and urethral lengthening. Bladder augmentation and Mitrofanoff urinary diversion technique
are also deemed necessary in our patient. He was scheduled for a 10-hour operation in 12th
April 2016.

Results and Discussion

Operation
Patient was placed in supine position under general anesthesia. We did aseptic and
antiseptic in operation site. An 8 Fr silicone catheter was placed. Midline incision cut through
cutis, sub cutis, muscle and peritoneum. Bladder identification found out a small bladder, and
then bladder was freed laterally and posteriorly (fig 1). We opened the bladder and found
neither mass nor stone (fig 2). We identified both ureteral orifices and inserted 5 Fr
nasogastric tubes. Ureters were then freed from surrounding tissue and preserved. (fig 3)

(1) (2)

Figure 1. Small bladder was

identified

Figure 2. No mass nor stone

found inside the bladder

Figure 3. 5 Fr NGTs were

(3) inserted to both ureters

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 We did a bladder neck reconstruction, anterior bladder flap, and urethral lengthening
with Pippi Salle technique. Incision was done in trigonum area according to design (fiq 4-5).
Mucosa was separated from seromuscular. Guided with Folley Catheter (fig 6), we did
neourethra tubularisation with continuous Vicryl 4.0, and then seromuscular layer was sewed
with Vicryl 4.0 (fig 7). Bilateral ureter reimplantations were done with submucosal tunneling
technique (fig 8). Ureters and bladder mucosa were sewed with interrupted Vicryl 4.0 (fig 9).

(4) (5)

(6) (7)

(8) (9)

Figure 4. Design; Figure 5. Incision according to design; Figure 6. Folley catheter

guidance; Figure 7. Neourethra tubularisation; Figure 8. Bilateral ureters
reimplantation; Figure 9. Ureters and bladder mucosa were sewed

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 Ileocaecal junction and vermiformis appendix was identified. We freed the base of
appendix with appendicularis artery preservation. Appendectomy was done along with some
caecal mucosa. Caecum was then sewed with silk 3.0. Ileal segment was prepared, we took
20 cm of its segment, starting at 15 cm from valvula Bouhini. We did ileoileal end to end
anastomosis with 3.0 continuous silk and overhecting it with interrupted 3.0 silk.
Mesenterium was then resewed. (Fig 10)

Figure 10. Appendix

preservation.
(10)
We made a submucosal tunnel in posterior bladder. Next, we inserted the tail of
appendix to bladder tunneling, along with insertion of 14 Fr nasogastric tube. The end of
appendix tail was then sewed to bladder mucosa with 4.0 Vicryl. Base of appendix was
brought out to cutis at the umbilical position and fixated.
After that we continue the operation with bladder augmentation using the ileal
segment we took. Resected ileal was incised at anteromesenterium and shaped to “U” form.
The ileal segment was then sewed to posterior bladder and reached bladder dome, a 10 Fr
silicone Folley Catheter was leaved. Both nasogastric tube from ureters were then pierced
through skin (ureterovesicocutaneostomy). (fiq 11-13)
Peritoneal was then washed and closed. Retzii drain was placed using 14 Fr
nasogastric tube. Abdominal wall was closed per layers. Total blood loss was 100 cc. There
was no intraoperative complication. The duration of the whole procedures was 8 hours.

(11) (12)

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 Figure 11. “U” formed
resected ileal.

Figure 12. Neobladder

augmentation.

Figure 13. UVCS

pierced through
(13)

1-Year Follow Up
Patient came in outpatient clinic with complaints of persistent incontinence problem.
He learned to use CIC through Mitrofanoff himself but admitted minimal usage due to
comfortability issue (fig 14). Urine leaks through OUE all day, without feeling any sensation
of full bladder.

Figure 14. CIC through

Mitrofanoff channel
(14)
We did Pouch-o-Gram in February 2017, and found left vesicoureteral reflux grade I,
and confirmed urinary leakage from OUE during bladder filling at 100 cc. He felt no
sensation of urinating during procedure. No contrast extravasation from the bladder. We
decided to maintain Mitrofanoff for our patient. (fig 15-16)

(15) (16)

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Discussion

The Pippi Salle procedure was a modification of Kropp procedure primarily meant to
increase bladder outlet resistance for patients previously using CIC. Other techniques also
aiming the same target of achievement, such as the original Kropp procedure, bladder neck
suspension, artificial urinary sphincter, or the Young-Dees Leadbetter procedure.(1,3) We
report a case in which we decided to choose Pippi Salle Procedure.
The original Kropp procedure is generally more difficult and has more technical
challenge. Pippi Salle technique permits us to avoid three main pitfalls commonly
encountered in original Kropp: the creation of a tube, the submucosal insertion of the
lengthened urethra, and the mobilization of the ureters.(3) Difficulty in inserting a catheter is
due to a mucosal discontinuity happened in the original Kropp procedure. This could be
avoided in the Pippi Salle procedure as it provides mucosal continuity.(4)
Other significant advantage for chosing Pippi Salle over Kropp is the complication
after operation. Urinary retention is not uncommon in Kropp, while it is not possible in Pippi
Salle which acted as a safety valve. This is essential especially for those patients who often
forget to catheterize themselves. (1,2)
However, previous studies mainly reported case series or post-operative analysis in
female patients. Mouriquand et al reported 8 female patients with satisfactory outcomes but
states no previous experience for male patients.(3) A study by Hayes et al stated that although
final continence rate was considered good in females, the outcome was disappointing in male
patient with only 5 out of 12 patients achieved continence. (4)
The explanation for sex-related outcome differences is not yet understood. However,
it might be related to difference in anatomy and physiology. Worse outcome is expected in
males considering the focus of this procedure is to achieve longer urethra (urethral
lengthening procedure). Even though hormonal factors and physiologic difference in bladder
emptying are suspected to affect continence outcomes, this theory is not clearly explained
yet.(4)
Urethral lengthening operation can be combined with urinary diversion when
considered necessary.(6) In patients with severe orthopedics handicap or patients with poor
access to their urethral meatus could be benefitted with continent diversion.(7) Continent
urinary diversion, such as ileal conduit or Mitrofanoff, can provide two access to the bladder.
The urethral lengthening can then be used to empty the bladder if the patient experiences

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difficulties with the diversion. This could avoid closure of the bladder neck, which may itself
fail and requires further operation.(3)
Bladder augmentation itself can give satisfactory result in most patients.(8–10) A
study by Hayes et al reports that 82% patients that underwent Pippi Salle reconstruction also
had bladder augmentation. It brought up arguments, whether bladder augmentation alone
might give a considerably acceptable result, and whether the need of bladder outlet resistance
is mandatory. However, they proved no correlation between augmentation and surgical
outcome.(4)

Conclusion

As conclusion, management of pediatric incontinence should be tailored individually.

Based on current studies and reports, Pippi Salle urethral lengthening procedure is
considerably better than other procedures. It offers technical easiness and theoretical
advantages. We consider our patient is particularly best suited with this procedure. Longer
follow up data is enticing whether complications might be perceived if any.

References

1. Adams MC, Joseph DB, Thomas JC. Urinary Tract Reconstruction in Children. In:
Wein AJ, Kavoussi LR, Partin AW, Peters C, editors. Campbell Walsh Urology. 11th
ed. Philadelphia, Pennsylvania: Elsevier Inc.; 2016.
2. Lopes RI, Lorenzo A. Recent Advances in Urinary Tract Reconstruction for
Neuropathic Bladder in Children [ version 1 ; referees : 2 approved ] Referee Status :
F1000 Res. 2016;5(0):1–10.
3. Mouriquand PDE, Sheard R, Phillips N, White J, Sharma S, Vandeberg C. The Kropp-
onlay procedure ( Pippi Salle procedure ): a simplification of the technique of urethral
lengthening . Preliminary results in eight patients. Br J Urol. 1995;75:656–62.
4. Hayes MC, Bulusu A, Terry T, Mouriquand PDE, Maloni P. The Pippi Salle urethral
lengthening procedure ; experience and outcome from three United Kingdom centres.
BJU Int. 1999;28:701–5.
5. Pippi JL, Mclorie GA, Khoury AE, Ba DJ. Modifications of and extended indications
for the Pippi Salle procedure. World J Urol. 1998;16:279–84.
6. Jouwena D, Pramod S. Laparoscopic Radical Cystectomy with Ileal Conduit Urinary
Diversion, First Experience in Bandung. Indones J Urol. 2015;22(2):95–100.

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7. Koraitim MM. Bladder neck incompetence at posterior urethroplasty. Arab J Urol
[Internet]. Arab Association of Urology; 2015;13(1):64–7. Available from:
http://dx.doi.org/10.1016/j.aju.2015.02.004
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Term Outcomes of Bladder Neck Reconstruction without Augmentation Cystoplasty in
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http://dx.doi.org/10.1016/j.juro.2015.06.103
10. Merriman LS, Arlen AM, Kirsch AJ, Leong T, Smith EA. Does augmentation
cystoplasty with continent reconstruction at a young age increase the risk of
complications or secondary surgeries ? J Pediatr Urol [Internet]. Elsevier Ltd;
2015;11(1):41.e1–41.e5. Available from:
http://dx.doi.org/10.1016/j.jpurol.2014.08.016