Indiana Pouch

A Continent Catherizable Urinary Pouch

What is urinary diversion?

When the bladder is removed due to cancer or trauma, the urinary track needs to be reconstructed in order to bring the urine from the abdomen to the outside of the body. This is called urinary diversion.

What are the options for urinary diversion after the bladder is removed?

After the bladder is removed, the options for controlling the urine are:

  • Ileal conduit – a piece of small bowel sewn to the skin where urine constantly comes out, and thus requires an ostomy appliance “glued” to the skin to collect the urine.
  • Neobladder – a new bladder pouch created out of small bowel, sewn to the urethra (where urine empties to the outside via the urethra).
  • Continent catherizable pouch – where a urine pouch is created out of bowel, stores urine and is regularly drained to the outside, by periodically passing a catheter through the skin, into the pouch. The most common surgically constructed pouch is the Indiana pouch.

What is an Indiana pouch?

The Indiana pouch is a continent catherizable urine pouch. The urine pouch is made out of bowel – specifically, the cecum and the ascending colon and a short segment of the small bowel, called the ileum.

The ileum is narrowed and then sewn to the skin at the level of the belly button or to the lower abdomen on the right side. The colon pouch stores the urine within the body, while the ileum acts as a catherizable channel from which the urine can be drained to the outside, by a catheter tube. To drain the urine, a catheter is pushed through the ileum at the level of the skin (the stoma) and down into the colon pouch. Then by gravity, the urine drains out of the pouch. Once the urine has drained, the catheter is removed. It is a continent reservoir. As the pouch has a set and limited capacity, the catheter has to be passed into the pouch several times a day.

Diagram of the Indiana Pouch

What are the key components of the urinary tract?

The urinary tract is made up of 2 kidneys, 2 ureters, a bladder, and urethra. The kidneys filter the blood and make urine. Each kidney has a ureter (tube) attached to it that carries urine down and into the bladder. The bladder stores urine. The urethra is the tube by which urine is passed to the outside of the body.

Diagram of the Indiana Pouch

What is a stoma?

The stoma is the end part of the bowel brought to the level of the skin at the outside of the abdomen. By passing a catheter into the stoma to drain the urine from the pouch. The stoma has little to no sensation. The stoma will often shrink in size during the first two months. The sutures at the skin level around the stoma will take a few weeks to fall out. The sutures are absorbable.

What temporary tubes will be coming out of the abdominal skin, directly after Indiana pouch surgery?

Typically, there will be 2 tubes inserted through the skin and into the pouch, two stents inserted up the ureter and into the kidneys, and a “JP” drain in the abdominal cavity. A tube is placed into the pouch in the portion of the colon known as the cecum. This tube is commonly called a “cecostomy tube” or pouch tube. It is usually a large bore catheter, so that blood and mucus will easily drain.

There will also be a smaller tube inserted through the stoma into the pouch. This will often be capped off and just be used to help flush the pouch. The stoma tube also acts as a scaffold to help the stoma heal to the skin.

Two ureteral stents will also be coming out of the skin. These stents help the ureter to heal to the side of the pouch. The stents are either removed prior to discharge home from the hospital, or removed in the office at the first post-surgery visit.

A small abdominal drain will also be in place to drain any blood or urine in the abdominal cavity. The drain is typically removed after the first bowel movement.

How many days will I stay in the hospital?

A typical hospital stay for Indiana Pouch surgery is 7- 10 days. In elderly or weak patients, the hospital stay can be more prolonged.

What are my pouch instructions when I am discharged home?

You will be given instructions when you are released from the hospital. Generally, you will be instructed to irrigate the pouch with saline 3 to 4 times a day in order to prevent mucus accumulation in the pouch and clogging of the tubes. Pouch irrigations usually begin 3 days after surgery.

When is the usual first post-operative visit in the office?

At around 3 weeks after surgery, a X-ray of the pouch is performed. This X-ray is usually called a ‘pouch-o-gram’. If this X-ray shows that the pouch is well healed, the cecostomy tube is capped and you will be taught how to catheterize the stoma. The cecostomy tube is left capped for a week or two, in order to act as a safety valve, in case there is any trouble catheterizing the pouch. The cecostomy tube is uncapped after each catheterization to confirm that the pouch is being properly drained. If you have no trouble passing the catheter for a week or two, then the cecostomy is removed in the office. Tube removal is usually quick and easy.

When can I drive after surgery?

You will usually be able to drive 3 weeks after your surgery – after the pouch X-ray and after most of the tubes are removed.

How long will it take to fully recover from surgery?

Recovery will take at least 6 weeks – but many do not feel 100% until 3 months after surgery.

What is the catheterization schedule after all the pouch tubes are removed?

In the beginning, it is important to keep the skin around your stoma healthy. The pouch capacity will initially be about 200 ml, so you will need to pass the catheter every 2 hours for the first month or so. After 3 to 6 months, the pouch will stretch in size to a much bigger capacity. Typically, the pouch will eventually stretch up to 500 ml or so, and most people can self-catheterize every 4 to 6 hours and at bedtime. Thus, having an Indiana pouch created is an investment of time – time till the pouch stretches.

Are there any side effects to an Indiana Pouch?

Side effects of the Indiana Pouch incude:

  • B 12 deficiency – usually takes years to manifest
  • High mucus production – may need frequent pouch irrigations
  • Urinary tract infections – can be prevented by frequent pouch irrigations and using clean techniques at catheterization
  • Incontinence – this can occur if the pouch over fills or if the Ileal cecal valve is not totally continent. Leakage of urine from the stoma occurs more frequently in the first few months after surgery, until the pouch stretches in size and a steady catheterization schedule is developed and adhered to. After the initial time period, leakage is very uncommon and if it does occur, it is usually minor and at night.
  • Scar tissue within the stoma. This can occur in up to 30% of cases long term. Correction of “stomal stenosis” is usually an easy and quick skin surgery.