Florida Pouch
The Florida Pouch is a detubularized right colonic continent cutaneous urinary reservoir with a doubly plicated distal ileal segment reinforced at the ileocecal valve as the continence mechanism, developed by Jorge L. Lockhart, Julio M. Pow-Sang, and Larry Persky at the University of South Florida, Tampa, beginning in 1986.[1][2][3][4] It is one of the most extensively documented right-colon-based continent diversions, with 179 patients in the original cohort and long-term follow-up exceeding 11 years, achieving a 97% continence rate with a 6% reoperation rate. A defining and historically controversial feature is its adoption of direct (nontunneled) mucosa-to-mucosa ureteral reimplantation — challenging the prevailing dogma that antireflux tunneled reimplantation was mandatory in continent reservoirs.
Historical Development
- 1986 — First Florida Pouch procedures performed at USF by Lockhart, Pow-Sang, and Persky.[1][3]
- 1989 — Bejany / Politano (University of Miami) published the first description of nontunneled, nonrefluxing ureterocolonic implantation in 32 patients (96% success in 76 anastomoses), establishing the foundation for the Florida Pouch's signature direct reimplantation approach.[5]
- 1990 — Lockhart's first major series: 92 patients (65 with adequate follow-up), mean follow-up 17 months, 97% continence. Three reimplantation techniques compared (modified Le Duc 75% / Goodwin transcolonic 88.6% / direct nontunneled 90.1%).[1]
- 1991 — Expanded 107-patient series in Surg Gynecol Obstet; 97.2% continence (105/108); reservoir capacity stable at 3–4 yr.[4]
- 1992 — Pow-Sang Florida Pouch I and II conversion series (n = 20). Florida Pouch II = conversion preserving an existing conduit (detubularized + patched onto a new right-colon reservoir) with original ureteral reimplantations left undisturbed when functioning.[6]
- 1993 — Helal 190-patient direct reimplantation analysis (326 ureters): obstruction 4.9% with direct vs 13.3% tunneled; reflux 7% — all followed conservatively without renal deterioration.[2]
- 1995 — Helal trans-reservoir technique for correction of ureterointestinal obstruction — approaching the obstructed anastomosis through the reservoir itself; all 5 ureters drained adequately at up to 45 months.[7]
- 1999 — Masel flap valve (FV) continence mechanism pilot study (n = 13) — alternative to the doubly plicated mechanism with less variable maximal outlet pressure.[8]
- 2003 — Webster definitive long-term series: 74 patients (of 179 originally operated 1986–1991), mean follow-up 133 months (11.1 yr).[3]
Design Principles
The Florida Pouch was designed around three principles.[1][2][4]
- Detubularized right colonic reservoir — cecum and ascending colon opened along the antimesenteric border and reconfigured into a spheroidal, low-pressure, high-capacity reservoir.
- Doubly plicated distal ileal continence mechanism — distal ileum tapered by double-row plication and reinforced at the ileocecal valve, creating a narrow high-resistance catheterizable channel.
- Direct (nontunneled) mucosa-to-mucosa ureteral reimplantation — a deliberate departure from antireflux tunneled techniques used in the Indiana Pouch and Mainz Pouch I.
Why nontunneled reimplantation?[1][2][5] The Florida group argued that in a large-volume low-pressure detubularized reservoir, intraluminal pressures are low enough that reflux, even when present, is clinically insignificant. Tunneled reimplantation carried a 13.3% obstruction rate vs 4.9% for direct, and obstruction was the more clinically consequential complication. This was validated by the finding that reflux occurred in 7% of directly reimplanted ureters with no renal deterioration in any refluxing unit on conservative follow-up.[2]
Surgical Technique
Florida Pouch I — Standard Construction
- Bowel isolation — right colon (cecum + ascending colon) and ~ 10–15 cm of distal ileum mobilized; ileocolic vascular pedicle preserved.[1][3][4]
- Bowel continuity — ileoascending or ileotransverse colonic anastomosis.
- Detubularization — colonic segment opened along the taenia (antimesenteric border), creating a wide bowel plate.
- Reservoir formation — opened plate folded and sutured into a spheroidal low-pressure reservoir; posterior wall closed first.
- Ureteral reimplantation — direct nontunneled mucosa-to-mucosa. A small colotomy is made on the posterior wall; the spatulated ureter is anastomosed directly to colonic mucosa with interrupted absorbable sutures. No submucosal tunnel. Stents placed.
- Continence mechanism — double-row plication of the distal ileum. Two rows of plication sutures along the antimesenteric border taper the ileum to ~ 14–16 Fr. Plication is reinforced at the ileocecal valve, which serves as a natural anchor and additional resistance point.
- Anterior-wall closure with running absorbable sutures.
- Stoma — distal end of plicated ileal segment brought through the abdominal wall as a flush catheterizable stoma (typically RLQ).
- Drainage — suprapubic tube or Malecot in the reservoir for 3–4 weeks.
Florida Pouch II — Conversion Technique
For conversion from an existing incontinent diversion (ileal conduit, sigmoid conduit, etc.).[6]
- The existing conduit is preserved and detubularized (opened along antimesenteric border).
- The detubularized conduit is patched onto a newly created right-colon reservoir to augment capacity.
- Original ureteral reimplantations are left undisturbed if functioning satisfactorily.
- New continence mechanism (doubly plicated distal ileum) constructed as in Florida Pouch I.
- In the 20-patient conversion series, 10 reimplantations left undisturbed in the detubularized conduit drained satisfactorily without obstruction; reflux was not demonstrated in 6 of these.[6]
Flap Valve Modification
In a pilot subset (n = 13), a flap valve replaced the doubly plicated ileum — the proximal continence channel runs along the inner wall of the reservoir, compressed as the reservoir fills (Mitrofanoff principle). Compared to the plicated version (n = 8), the flap valve (n = 5) showed less variable maximal outlet pressure (51.2 cm H₂O empty / 52.6 cm H₂O full vs 57.5 / 50.5) but significantly lower maximal enterocystometric capacity (515 vs 876.5 mL, p < 0.05).[8]
Functional Outcomes
| Series | n | Follow-up | Continence | Capacity | Pressure | Reoperation | Notes |
|---|---|---|---|---|---|---|---|
| Lockhart 1990[1] | 92 (65 evaluable) | Mean 17 mo | 97% | 550–1,200 mL (avg 747) | 10–58 cm H₂O (avg 35) | 6% (4 pts) | Three reimplantation techniques compared |
| Lockhart 1991[4] | 107 (108 evaluable) | 6–46 mo | 97.2% | 550–1,200 mL | 10–58 cm H₂O | 6.5% (7 pts) | Urodynamics stable at 3–4 yr |
| Pow-Sang 1992 (conversion)[6] | 20 | Variable | 100% | — | — | — | Florida Pouch I + II; all reported improved QoL |
| Helal 1993[2] | 190 (326 ureters) | Variable | — | — | — | — | Definitive direct-reimplantation analysis |
| Webster 2003[3] | 74 (of 179) | Mean 133 mo | 93.3% (69/74) | — | — | — | > 11-yr definitive long-term data |
Urodynamics
| Parameter | Doubly Plicated (PI) | Flap Valve (FV) |
|---|---|---|
| Maximum reservoir capacity | 550–1,200 mL (avg 747–876.5) | 515 mL |
| Maximal reservoir pressure | 10–58 cm H₂O (avg 25.9–35) | 24.6 cm H₂O |
| Pressure at first desire to empty | 19.5 cm H₂O | 19.2 cm H₂O |
| Maximal outlet pressure (empty) | 57.5 cm H₂O | 51.2 cm H₂O |
| Maximal outlet pressure (full) | 50.5 cm H₂O | 52.6 cm H₂O |
| Functional outlet length | 24.3 cm | 24.6 cm |
| Stability over time | Unchanged at 3–4 yr | — |
Reservoir capacity and pressure remained unchanged in patients restudied at 3–4 years postoperatively, confirming long-term stability.[4]
Ureteral Reimplantation — The Florida Pouch's Defining Contribution
The Florida group sequentially used three techniques.[1][2][4]
| Technique | Ureters | Success (no reflux/obstruction) | Obstruction | Reflux |
|---|---|---|---|---|
| Modified Le Duc (tunneled) | 4 | 75% | High | Low |
| Goodwin transcolonic (tunneled) | 26–30 | 84.7–88.6% | 13.3% | Low |
| Direct nontunneled mucosa-to-mucosa | 91–326 | 87.4–90.1% | 4.2–4.9% | 7% |
Key findings:[2] Obstruction with tunneled reimplantation 13.3%; with direct 4.9%. Reflux 7% with direct — all followed conservatively, no renal deterioration. Megaureters had a 50% obstruction rate (3/6) regardless of technique.
Management of Obstructed Reimplantations
Among 23 obstructed ureteral units:[2][7]
- 3 (13%) — autonephrectomy (unexpected)
- 20 (87%) — percutaneous balloon dilation + internal stent for 6–8 weeks:
- 12 (60%) recovered function
- 3 (15%) developed pyelonephritis requiring nephrectomy
- 5 (25%) stabilized following new reimplantation
The trans-reservoir technique (Helal 1995) was developed specifically for refractory obstruction, approaching the anastomosis through the reservoir itself and avoiding transabdominal adhesiolysis. All 5 treated ureters drained adequately at up to 45 months.[7]
Long-Term Ureteral Outcomes (>11 yr; Webster 2003)
| Reimplantation Category | Ureters | Obstruction Rate |
|---|---|---|
| Primary direct reimplantation | 108 | 6.3% (7) |
| Repeat reimplantation | 24 | 16.4% (4) |
| Radiated ureters | 14 | 28.4% (4) |
Radiated ureters had significantly higher obstruction (28.4% vs 6.3%, p = 0.02) — important for patient selection.[3]
Complications
Perioperative mortality 1.5% (1/65 — pulmonary embolism) in the original series.[1]
Long-Term Complications (Webster 2003, n = 74, mean 133 mo)
| Category | Complication | Incidence |
|---|---|---|
| Abdominal wall | Peristomal hernia | 4% (3/74) |
| External limb (continence mechanism) | Incontinence | 6.7% (5/74) |
| Stomal stenosis | 4% (3/74) | |
| Difficult catheterization | 1.4% (1/74) | |
| Reservoir | Reservoir stones | 5.4% (4/74) |
| Ureteral obstruction | Primary reimplantation | 6.3% (7/108) |
| Repeat reimplantation | 16.4% (4/24) | |
| Radiated ureters | 28.4% (4/14), p = 0.02 | |
| Metabolic | Persistent diarrhea | 2.7% (2/74) |
| Renal failure | 2.7% (2/74) | |
| Low vitamin B12 | 4% (3/74) | |
| Severe acidosis | 5.5% (4/74) | |
| Metabolic alterations (conversion patients) | 58% (7/12), p = 0.0001 |
Source: Webster 2003.[3]
Key long-term conclusions:
- The most common long-term problem was ureteral obstruction, especially in irradiated ureters (28.4%).
- Conversion patients (Florida Pouch II) had a dramatically higher rate of metabolic complications (58% vs 6.4%, p = 0.0001) — likely because of the greater total length of bowel excluded from the GI tract.
- Overall long-term complication profile is acceptable for a continent cutaneous diversion.
Metabolic Complications
- Hyperchloremia: 75% of conversion patients (mild).[6]
- Severe acidosis: 5.5% of long-term patients; 10% of conversion patients.[3][6]
- Low B12: 4% at > 11 yr.[3]
- Renal failure: 2.7% at > 11 yr.[3]
See Vitamin B12 Supplementation and Urinary Acidifiers & Alkalinizers.
Florida Pouch I vs Florida Pouch II
| Feature | Florida Pouch I | Florida Pouch II |
|---|---|---|
| Indication | Primary continent diversion | Conversion from existing incontinent diversion |
| Reservoir construction | New right-colon reservoir | Right-colon reservoir + detubularized existing conduit as patch |
| Ureteral reimplantation | New direct reimplantation into colonic reservoir | Existing reimplantations left undisturbed if functioning |
| Continence mechanism | Doubly plicated distal ileum | Doubly plicated distal ileum (new construction) |
| Metabolic complications | 6.4% | 58% (p = 0.0001) |
| Patient satisfaction | High | 100% reported improved QoL |
The Florida Pouch II concept — preserving the existing conduit and its ureteral anastomoses — reduces surgical morbidity in conversion cases by avoiding re-reimplantation, but the significantly higher metabolic-complication rate (greater total bowel exclusion) remains a concern.[3][6]
Comparison with Other Continent Cutaneous Diversions
| Feature | Florida | Indiana | Mainz I | Kock |
|---|---|---|---|---|
| Reservoir | Detubularized right colon | Detubularized right colon + terminal ileum | Detubularized cecum + 2 ileal loops | Detubularized ileum only |
| Continence mechanism | Doubly plicated distal ileum at ileocecal valve | Plicated/tapered terminal ileum through ileocecal valve | Appendix or intussuscepted nipple | Intussuscepted efferent nipple |
| Ureteral reimplantation | Direct nontunneled | Tunneled or direct | Submucosal tunnel or SLET | Intussuscepted afferent nipple |
| Continence rate | 93.3–97.2% | 89–100% | 82–92.8% | 84–95% |
| Ureteral obstruction | 4.9–6.3% (primary); 28.4% irradiated | 6–22% | 4.1–7.3% | 4.3–9.8% |
| Reflux rate | 7% (clinically insignificant) | Variable | Low | Low |
| Stone formation | 5.4% | 5.4–19% | 5.6–10.8% | 16.7–44% |
| Reoperation rate | 6–6.5% | 10.8–22% | 11–36% | 22–53% |
| Capacity | 550–1,200 mL (avg 747) | 400–800 mL | Large | Up to 1,400 mL |
| Technical complexity | Simplest | Simple | Moderate | Complex |
Distinguishing features of the Florida Pouch:
- Lowest reoperation rate among major continent cutaneous diversions, attributed to simplicity of the doubly plicated mechanism and avoidance of intussusception, staples, or nonabsorbable materials.[1][4]
- Direct nontunneled ureteral reimplantation — lowest obstruction rate, at the cost of clinically insignificant reflux.[2]
- Largest reservoir capacity among right-colon-based pouches.[1]
- Simplest construction — no intussusception, no staples, no nonabsorbable materials, no submucosal tunneling.[1][4]
Relationship to the Miami Pouch
The Miami Pouch is a closely related ileocolic continent cutaneous diversion developed at the University of Miami. The Miami Pouch uses the terminal 15 cm of ileum + right colon to build a heterotopic pouch with the efferent catheterizable tube connected to skin. In a contemporary French series (2016–2017), the Miami Pouch achieved 100% continence at 39 months with no stomal stenosis.[9] A comparative study of Miami Pouch vs ileal pouch with Mitrofanoff principle showed 79% continence for the Miami Pouch with significantly lower cutaneous-tube stenosis (7% vs 47%, p = 0.02).[10]
The Florida and Miami pouches share the same fundamental design (detubularized right colon reservoir with plicated ileal continence mechanism through the ileocecal valve) but differ in technical detail; both are sometimes grouped as "right colon pouches."[11]
Strengths and Limitations
Strengths
- Technical simplicity — the doubly plicated ileal mechanism is straightforward, reproducible, and avoids intussusception, staples, and nonabsorbable materials.[1][4]
- Lowest reoperation rate (6–6.5%) among major continent cutaneous diversions.[1][4]
- Excellent continence (93.3–97.2%).[1][3]
- Large stable reservoir capacity (avg 747 mL, up to 1,200 mL).[1][4]
- Low stone formation (5.4%) — no exposed staples or foreign material.[3]
- Direct nontunneled reimplantation — technically simpler with lower obstruction rates than tunneled techniques.[2]
- Florida Pouch II versatility — allows conversion from existing incontinent diversions while preserving functioning ureteral anastomoses.[6]
- Long-term durability — acceptable complication rates at > 11 yr.[3]
Limitations
- Reflux 7% with direct reimplantation — clinically insignificant in the low-pressure reservoir but a theoretical concern for very long-term upper-tract protection.[2]
- High ureteral obstruction in irradiated ureters (28.4%) — significant limitation in postradiation patients.[3]
- High metabolic complication rate in conversion patients (58%) — greater total bowel exclusion.[3]
- Severe acidosis 5.5% — requires monitoring and alkali supplementation.[3]
- Limited modern series — not as widely adopted as Indiana / Mainz I; contemporary comparative data are limited.[11]
Current Status and Legacy
The Florida Pouch occupies an important place in the history of continent urinary diversion:
- Demonstrated that direct nontunneled ureteral reimplantation is safe in low-pressure continent reservoirs — influencing the broader trend toward questioning the necessity of antireflux mechanisms in all continent diversions.[2][12]
- Achieved the lowest reoperation rate among major continent cutaneous diversions through a simple, reproducible continence mechanism without intussusception or foreign materials.[1][4]
- The Florida Pouch II concept (preserving existing conduit and ureteral anastomoses during conversion) was an innovative approach to reducing surgical morbidity in revision cases.[6]
- Contributed to the understanding that metabolic complications are amplified when greater total bowel length is excluded from the GI tract, particularly in conversion cases.[3]
In current practice, the Florida Pouch is less commonly performed as a standalone technique; most centers favor the Indiana Pouch or modified right colon pouch. However, its principles — particularly direct reimplantation and simple plication-based continence — have been incorporated into many contemporary continent diversion techniques.[11][13]
Key Takeaways
- The Florida Pouch is a detubularized right colonic continent cutaneous reservoir with a doubly plicated distal ileal segment reinforced at the ileocecal valve — Lockhart / Pow-Sang / Persky, USF, 1986.[1][3][4]
- Long-term (> 11 yr) continence is 93.3% and reoperation rate 6–6.5% — the lowest among major continent cutaneous diversions.[1][3][4]
- Direct nontunneled ureteral reimplantation has lower obstruction (4.9% vs 13.3%) than tunneled techniques; the 7% reflux rate is clinically insignificant in the low-pressure reservoir.[2]
- Irradiated ureters have a 28.4% long-term obstruction rate (vs 6.3% primary) — a key patient-selection consideration.[3]
- The Florida Pouch II (conversion from incontinent diversion) preserves existing reimplantations but carries a 58% metabolic-complication rate due to greater total bowel exclusion.[3][6]
- The Florida Pouch's principal legacy is establishing that simple, plication-based continence and direct nontunneled reimplantation can deliver excellent long-term outcomes without the complications of intussuscepted nipple valves or foreign-material anchoring.[1][2][4]
See Also
- Urinary Diversion Principles
- Indiana Pouch
- Right Colon Pouch
- Mainz Pouch I
- Kock Pouch
- Vitamin B12 Supplementation
- Urinary Acidifiers & Alkalinizers
References
1. Lockhart JL, Pow-Sang JM, Persky L, et al. "A Continent Colonic Urinary Reservoir: The Florida Pouch." J Urol. 1990;144(4):864–7. doi:10.1016/s0022-5347(17)39610-6
2. Helal M, Pow-Sang J, Sanford E, Figueroa E, Lockhart J. "Direct (Nontunneled) Ureterocolonic Reimplantation in Association With Continent Reservoirs." J Urol. 1993;150(3):835–7. doi:10.1016/s0022-5347(17)35626-4
3. Webster C, Bukkapatnam R, Seigne JD, et al. "Continent Colonic Urinary Reservoir (Florida Pouch): Long-Term Surgical Complications (Greater Than 11 Years)." J Urol. 2003;169(1):174–6. doi:10.1016/S0022-5347(05)64061-X
4. Lockhart JL, Pow-Sang JM, Persky L, Sanford E, Helal M. "Results, Complications and Surgical Indications of the Florida Pouch." Surg Gynecol Obstet. 1991;173(4):289–96. PMID: 1925898
5. Bejany D, Suarez G, Penalver M, Politano V. "Nontunneled Ureterocolonic Anastomosis: An Alternate to the Tunneled Implantation." J Urol. 1989;142(4):961–3. doi:10.1016/s0022-5347(17)38953-x
6. Pow-Sang JM, Helal M, Figueroa E, et al. "Conversion From External Appliance Wearing or Internal Urinary Diversion to a Continent Urinary Reservoir (Florida Pouch I and II): Surgical Technique, Indications and Complications." J Urol. 1992;147(2):356–60. doi:10.1016/s0022-5347(17)37236-1
7. Helal MA, Figueroa TE, Pow-Sang J, Sanford E, Lockhart JL. "A Trans-Reservoir Technique for Correction of Ureterointestinal Obstruction in Continent Urinary Diversion." J Urol. 1995;153(4):1108–9. PMID: 7869473
8. Masel JL, Austin PF, Spyropoulos E, et al. "Evaluation of Flap Valve as an Alternative Continence Mechanism in the Florida Pouch." Urology. 1999;53(3):506–9. doi:10.1016/s0090-4295(98)00566-4
9. Baboudjian M, Gondran-Tellier B, Michel F, et al. "Miami Pouch: A Simple Technique for Efficient Continent Cutaneous Urinary Diversion." Urology. 2021;152:178–83. doi:10.1016/j.urology.2021.02.004
10. Pattou M, Baboudjian M, Pinar U, et al. "Continent Cutaneous Urinary Diversion With an Ileal Pouch With the Mitrofanoff Principle Versus a Miami Pouch in Patients Undergoing Cystectomy for Bladder Cancer: Results of a Comparative Study." World J Urol. 2022;40(5):1159–65. doi:10.1007/s00345-022-03954-z
11. Farnham SB, Cookson MS. "Surgical Complications of Urinary Diversion." World J Urol. 2004;22(3):157–67. doi:10.1007/s00345-004-0429-5
12. Fisch M, Thüroff JW. "Continent Cutaneous Diversion." BJU Int. 2008;102(9 Pt B):1314–9. doi:10.1111/j.1464-410X.2008.07976.x
13. Al Hussein Al Awamlh B, Wang LC, Nguyen DP, et al. "Is Continent Cutaneous Urinary Diversion a Suitable Alternative to Orthotopic Bladder Substitute and Ileal Conduit After Cystectomy?" BJU Int. 2015;116(5):805–14. doi:10.1111/bju.12919