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Indiana Augmentation Cystoplasty (IAC)

Indiana augmentation cystoplasty, also described within the continent cutaneous ileocecocystoplasty (CCIC) family, uses a colonic augment joined to the native bladder and a tapered terminal-ileal channel with a reinforced ileocecal continence mechanism. It offers reservoir enlargement and an abdominal catheterizable route in one reconstruction.[1][2]

This differs from the Indiana Pouch, a separate urinary reservoir commonly constructed after cystectomy. Post-cystectomy survival, ureteroenteric stricture rates, and diversion-specific continence cannot be treated as direct IAC outcomes.

Selection​

Consider IAC when both a low-pressure reservoir and a catheterizable abdominal channel are needed, with suitable bowel anatomy and the ability of the patient or caregiver to manage lifelong catheterization. Assess renal/metabolic reserve, bowel function, prior ileocecal resection, abdominal access, and stoma reach. A channel alone may be sufficient when storage capacity and pressures are already safe.[1][3][4]

The ureters may remain implanted in the native bladder when no separate ureteral reconstruction is indicated. IAC does not automatically correct obstruction, reflux independent of storage pressure, or an unsafe outlet. Bladder-neck closure, a sling, or an AUS may be selected for outlet dysfunction, but none is an obligatory step.[1]

Operative Principles​

  1. Plan the whole urinary and bowel reconstruction. Determine reservoir size, outlet management, stoma site, and catheterization access. Mark the site with the patient's usual posture and mobility aids in mind.
  2. Harvest a well-vascularized ileocecal segment. Length and extent of colonic mobilization depend on the chosen configuration and anatomy. Preserve perfusion and restore bowel continuity without tension.
  3. Detubularize the reservoir component. Open and reconfigure the colonic augment; leave the intended ileal channel tubular. Avoid narrowing the junction with the native bladder.
  4. Construct the continence mechanism. Taper the terminal ileum and reinforce the ileocecal junction according to the selected technique. Confirm easy catheter passage; excessive narrowing risks obstruction.
  5. Join the augment to the widely opened bladder. Tailor accompanying ureteral or outlet procedures to documented anatomy and function.
  6. Route and mature the stoma. Avoid tension, mesenteric twist, and angulation. Establish dependable early drainage and a plan for later catheterization or stoma failure.[1][3]

Historical Indiana-pouch descriptions used different bowel lengths, sutures, and stapling modifications. A named stapler does not imply that its staples are absorbable, and historical dimensions should not be presented as mandatory for native-bladder augmentation.[5][6][7]

The continence mechanism depends on the valve/channel construction and low reservoir pressure. A 21-reservoir urodynamic comparison of plicated versus stapled ileum found only a nonsignificant trend toward higher mean contraction pressure with stapling (p=0.054); it does not prove one method is more durable or safer.[8][9]

Direct Outcomes and Maintenance Burden​

StudyFindingsLimits
Khavari 2012, 34 neurogenic patients, median 31 monthsAll were continent at last follow-up; 15/34 (44.1%) had long-term complications, including four stomal revisionsRetrospective, selected single-center cohort; additional outlet procedures in some patients; 1993–2010 was the treatment period, not each patient's follow-up[1]
Cheng 2020, 114 adults, median 40 monthsMajor complications by three months in 18/114 (15.8%); 24/114 (21.1%) readmitted; 48/114 (42.1%) had additional related surgery; 23/114 (20.2%) had channel revision; 11/114 (9.6%) abandoned the channelMulticenter retrospective CCIC experience; not a randomized comparison with other channels[2]
Redshaw 2014, 61 adults, median 16 monthsChannel intervention in 4/31 CCIC versus 15/30 tunneled-channel patients (OR 6.4, 95% CI 1.8–28 for tunneled channels); reported stomal leakage 29% versus 43% was not significantly differentShort, nonrandomized comparison; does not establish lifelong superiority of the ileocecal valve[10]

A dry stoma does not mean freedom from reoperation, catheterization difficulty, symptomatic infection, or metabolic effects. Patients need to understand both functional benefit and the long-term care burden.

Complications​

  • Stomal or channel obstruction: stenosis, angulation, redundancy, or a tight continence mechanism can impair catheterization. Repeated forceful catheter attempts risk false passage; an acutely undrainable reservoir needs prompt urologic care.
  • Leakage: evaluate reservoir pressure, emptying, and the outlet/channel rather than assuming a single mechanical cause.
  • Stones, mucus, and symptomatic infection: common reasons for ongoing treatment or intervention. Bacteriuria alone is not an indication for antibiotics in a stable NLUTD patient.
  • Bowel and abdominal complications: ileus, obstruction, bowel anastomotic problems, and hernia remain relevant after bowel harvest.
  • Metabolic and nutritional effects: intestinal urine contact may cause hyperchloremic acidosis. Terminal ileal/ileocecal harvest may contribute to B12 or bile-salt malabsorption and altered bowel function; these are risks, not inevitable outcomes in every patient.
  • Perforation and malignancy: long-term augmentation risks persist and require symptom awareness and follow-up.[1][11][12][3][2][4]

Historical Schilling-test malabsorption percentages from continent diversion cohorts should not be used as an IAC-specific B12 deficiency rate. Record the actual bowel segment used and monitor nutritional status over time.[12][4]

Follow-Up​

AUA/SUFU recommends annual history/examination and symptom assessment, basic metabolic panel, and urinary tract imaging after adult NLUTD reconstruction incorporating bowel. Review catheterization, stoma function, irrigation needs, and B12 risk. New gross hematuria, recurrent unexplained symptomatic UTI, or suprapubic pain requires cystoscopy and appropriate additional evaluation. Sudden abdominal pain or sepsis may indicate reservoir perforation.[4]

References​

1. Khavari R, Fletcher SG, Liu J, Boone TB. A modification to augmentation cystoplasty with catheterizable stoma for neurogenic patients: technique and long-term results. Urology. 2012;80(2):460–464. doi:10.1016/j.urology.2012.03.038

2. Cheng PJ, Keihani S, Roth JD, et al. Contemporary multicenter outcomes of continent cutaneous ileocecocystoplasty in the adult population over a 10-year period: A Neurogenic Bladder Research Group study. Neurourol Urodyn. 2020;39:1771–1780. doi:10.1002/nau.24420.

3. Cheng PJ, Myers JB. Augmentation cystoplasty in the patient with neurogenic bladder. World J Urol. 2020;38(12):3035–3046. doi:10.1007/s00345-019-02919-z

4. Ginsberg DA, et al. The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-Up. J Urol. 2021. doi:10.1097/JU.0000000000002239.

5. Rowland RG. Present experience with the Indiana pouch. World J Urol. 1996;14(2):92–98. doi:10.1007/BF00182564

6. Rowland RG, Kropp BP. Evolution of the Indiana continent urinary reservoir. J Urol. 1994;152(6 Pt 2):2247–2251. doi:10.1016/s0022-5347(17)31651-8

7. Ahlering TE, Weinberg AC, Razor B. Modified Indiana pouch. J Urol. 1991;145(6):1156–1158. doi:10.1016/s0022-5347(17)38561-0

8. Juma S, Morales A, Emerson L. The mechanisms of continence in the Indiana pouch: a video-urodynamic study. J Urol. 1990;143(5):973–974. doi:10.1016/s0022-5347(17)40154-6

9. Carroll PR, Presti JC. Comparison of plicated and stapled continent ileocecal stoma. Urology. 1992;40(2):107–109. doi:10.1016/0090-4295(92)90504-p

10. Redshaw JD, Elliott SP, Rosenstein DI, et al. Procedures needed to maintain functionality of adult continent catheterizable channels: a comparison of continent cutaneous ileal cecocystoplasty with tunneled catheterizable channels. J Urol. 2014;192(3):821–826. doi:10.1016/j.juro.2014.03.088

11. Fisch M, Wammack R, Spies F, et al. Ileocecal valve reconstruction during continent urinary diversion. J Urol. 1994;151(4):861–865. doi:10.1016/s0022-5347(17)35107-8

12. Terai A, Okada Y, Shichiri Y, et al. Vitamin B12 deficiency in patients with urinary intestinal diversion. Int J Urol. 1997;4(1):21–25. doi:10.1111/j.1442-2042.1997.tb00133.x