Indiana Pouch
The Indiana pouch is a continent cutaneous urinary diversion: a detubularized right-colon reservoir is emptied through a catheterizable ileal outlet, with the ileocecal valve and outlet plication contributing to continence. It offers an option for patients who prefer an internal reservoir and can maintain catheterization and lifelong follow-up.[1][2] The often-quoted 8–10.4% US utilization figure concerns continent diversions collectively, not the Indiana pouch alone.[3]
Developed at Indiana University in 1984 from the earlier Gilchrist ileocecal-reservoir concept, the procedure evolved through modifications of reservoir detubularization, the outlet and ureteral implantation.[2][4]
Anatomy and Construction
Indiana continent reservoirOriginal schematic · v2026-09-11 · Clinical review pendingDetubularized right colon forms the reservoir; a tapered ileal outlet and reinforced ileocecal valve provide the catheterizable continence mechanism.View: Ileocecal reservoir, simplified anterior view. Scale: Conceptual schematic; not to scale. Units: No measured geometry; any dimensions are illustrative.Limits: Detailed construction and geometry need technical review; catheterization frequency depends on capacity, output and clinical plan.Source check: 2026-09-11. This is an editorial check with the access limits below. No named clinician has signed off.Rowland and Kropp: evolution of the Indiana continent reservoir — 1994 original technical article. Access: abstract checked. Detubularized reservoir, tapered efferent limb and ileocecal-valve plication; exact operative geometry still needs review.WARWIKI original vector schematic; individual illustrator not recorded. No separate figure reuse license recorded; linked sources are concept references, not artwork licenses.Open original SVG with embedded source record ↗
Detubularized right colon forms the reservoir; a tapered ileal outlet and reinforced ileocecal valve provide the catheterizable continence mechanism. Detailed construction and geometry need technical review; catheterization frequency depends on capacity, output and clinical plan. (Original WARWIKI schematic; see the figure source record and review limits.)
| Component | Operative role |
|---|---|
| Reservoir | Detubularized cecum and ascending colon reconfigured for storage. Ahlering's modified technique used 26–30 cm of right colon; dimensions vary with the reconstruction.[5] |
| Efferent limb | Terminal ileum, tapered and/or plicated with reinforcement at the ileocecal junction. Ahlering used 8–12 cm; this is a described technique, not a universal required length.[5] |
| Continence | Depends on the outlet, ileocecal valve and reservoir pressure together. Detubularization does not eliminate all bowel contractions, and a technically competent outlet does not guarantee freedom from leakage.[1][6] |
Operative framework
- Plan the outlet and stoma with the patient; accessibility, clothing, body habitus and reliable catheter passage govern the site. An umbilical stoma is one option.
- Isolate vascularized ileocecal bowel and restore gastrointestinal continuity with an ileocolic anastomosis to the remaining colon.
- Detubularize and reconfigure the colonic reservoir, preserving its blood supply.
- Construct the tapered ileal outlet and reinforce the ileocecal valve. Check easy catheter passage repeatedly while narrowing it; excessive resistance creates catheterization problems. Pearce's institutional technique tapered over an 18-Fr catheter; channel construction and calibration vary by technique.
- Implant the ureters with a tension-free, well-perfused anastomosis; tunneled and direct approaches have been described.
- Complete and test the reservoir, mature the outlet without kinking, and provide secure initial catheter drainage.[7]
Historical ileal-patch augmentation of the cecal reservoir is a separate modification; it is not an additional mandatory step in every Indiana pouch.[4] Ureteral implantation is also variable: the early Indiana series used tenial tunnels, whereas Ahlering described transcolonic implantation. Evidence does not establish that every continent reservoir requires an antireflux tunnel.[1][5]
Open and robotic approaches
These cohorts differ in selection, reconstruction and outcome measurement; they do not establish an approach ranking.
| Series | Patients and observation | Findings |
|---|---|---|
| Burns 2022, open | 137; complications assessed during the first postoperative year | Mean operation 422 minutes; 53/137 had a Clavien II–V complication.[8] |
| Torrey 2012, robotic cystectomy with extracorporeal pouch | 34 operated; continence data in 31, mean 20.1 months | 30/31 had daytime and nighttime continence. Continence was assessed in the 31 patients with available data.[9] |
| Desai 2017, fully intracorporeal | 10; median 13.7 months | One patient requested conversion to a conduit; the remaining nine catheterized and were continent. Median total operating time was six hours.[10] |
| Kim 2024, robotic-assisted cystectomy with CCUD | 97 accrued during 2004–2020; median follow-up 93 months | Reported urinary continence 99%; median operation eight hours. “16-year experience” describes the accrual period, not each patient's follow-up.[3] |
Patient Selection
Discuss conduit, continent cutaneous and orthotopic options when appropriate. An Indiana pouch can be useful when the patient wants continent diversion but an orthotopic reservoir is unsuitable, for example because a negative urethral margin cannot be obtained or the urethral outlet is nonfunctional. Assess renal and hepatic function, usable bowel, cognition, dexterity and the ability to sustain catheterization. Age alone does not determine the diversion.[11][12]
Severe renal or hepatic impairment, insufficient usable bowel, significant disease of the proposed bowel segment, or inability to maintain catheterization may preclude a continent reservoir. The AUA discussion gives eGFR below 45 mL/min/1.73 m² as an example of inadequate renal function for continent diversion; a serum creatinine cutoff of 2 mg/dL is not an adequate substitute for individualized assessment.[12] Prior right hemicolectomy may remove the required segment. Prior radiation requires assessment of tissue and ureteral quality and does not automatically make a bowel reservoir preferable.[7][13]
For neurogenic disease, distinguish total diversion from Indiana augmentation cystoplasty, which retains and augments the native bladder. Khavari's retrospective augmentation series included 34 patients, all continent at latest follow-up, but 15 had long-term complications at a median 31 months. These results do not describe isolated Indiana pouch diversion or guarantee the same outcome in other neurologic populations.[14]
Catheterization and Functional Outcomes
Catheterization is lifelong. The early postoperative schedule is usually more frequent than the eventual stable schedule. After healing, timing must account for urine output, storage pressure, capacity, leakage and complete drainage; overnight catheterization may remain necessary. Published 8–10-hour intervals in a few selected patients are not a general instruction to allow such prolonged filling.[7][15]
| Study | Scope | Reported continence |
|---|---|---|
| Rowland 1994 | First 69 patients; minimum two-year follow-up | 97% day and night by one year.[2] |
| Ahlering 1991 | 70 modified pouches; 3–24 months | All reported continent day and night; short and variable follow-up limits durability inference.[5] |
| Nieuwenhuijzen 2008 | Indiana subgroup 51 within a 281-patient diversion cohort | Complete daytime continence 96%, nighttime 73%.[16] |
| Al Hussein Al Awamlh 2015 | 73 CCUD patients within 322 diversions; Indiana or appendiceal-stoma constructions | 89% continent at median 36 months; a mixed CCUD outcome, not an Indiana-only estimate.[15] |
Urodynamic studies and variants
Ahlering reported catheterized volumes of 400–800 mL, but these are observed volumes, not a prescribed filling target.[5] Ferriero's simplified Indiana pouch with multiple taeniamyotomies is a distinct variant: 32 of 62 operated patients underwent both 12- and 48-month studies, with an appendiceal outlet in 62.5% and an invaginated ileal nipple in 37.5%. Median capacity was 627.5 versus 607.5 mL and end-filling pressure 28 versus 18 cm H₂O. The measurements should not be presented as the expected trajectory of the conventional tapered ileal outlet.[17]
Complications and Revision Burden
Early morbidity
Kim's 97-patient cohort reported any complication in 73.2% at 30 days and 76.5% at 90 days; major complications were 17.5% and 22.7%, respectively. Abdominal infection and ureterocolonic stricture were important major events.[3] Burns' 39% figure covers Clavien II–V complications over the first year, not a directly comparable 90-day all-grade rate; early and 90–365-day reoperations were 7.3% and 8%.[8]
Longer-term problems
Holmes reviewed 125 of 129 modified pouches with complete records, mean follow-up 41.1 months. The reported complications include both perioperative and later events; several patients had multiple problems.[18]
| Outcome | Patients / proportion reported |
|---|---|
| Any complication | 112/125 (89.6%) |
| Leakage, defined as any leakage | 35/125 (28%) |
| Stomal stenosis | 19/125 (15.2%) |
| Difficult catheterization | 12/125 (9.6%) |
| Pouch stones | 13/125 (10.4%) |
| Ureteroenteric stricture | 9/125 (7.2%) |
| Pouch perforation | 4/125 (3.2%) |
| Any reoperation | 65/125 (52%): 26 had open procedures and 39 minimally invasive procedures |
In Polm's 2024 benign-disease follow-up cohort, 22 of 33 patients underwent at least one revision over a median 258 months; 45 revisions were performed. Estimated mean revision-free survival was 198 months. A reservoir can remain usable for decades while requiring substantial maintenance and revision.[19]
Radiation
Wilkin compared 12 heavily irradiated women with recurrent gynecologic cancer against 14 nonirradiated patients. Any complications occurred in 83% versus 57%, but this small comparison was not statistically significant (p = 0.2). Nephrostomy and ureteral reimplantation were more frequent in the irradiated group. The study supports careful drainage surveillance and counseling, rather than a precise universal radiation risk multiplier.[13]
Stones and access
Assess emptying, mucus, foreign material, infection and metabolic contributors. Passage of large instruments through a continent channel can damage its continence mechanism; percutaneous or open pouch-stone access is often preferred. Regular saline irrigation can reduce stone recurrence, with the volume and schedule adapted to the reservoir and patient; the EAU recommendation applies to patients without a history of autonomic dysreflexia.[20]
Metabolic and Renal Follow-up
Ileal and colonic urinary segments can produce hyperchloremic metabolic acidosis, vitamin B12 problems, altered bowel function and stones. These risks persist after an uncomplicated operation.[21] Nieuwenhuijzen reported metabolic changes in 26% and low B12 in 15% of the Indiana subgroup; these historical observations are not universal prevalence estimates.[16]
The frequently cited 37% alkali use and 32% B12 supplementation recommendation came from Pfitzenmaier's 94-patient Mainz I cohort, not Indiana pouches. Supplementation included low-normal B12 results, and the observational study did not prove that prophylactic alkali prevents osteoporosis.[22]
Renal comparisons need similar care. Al Hussein Al Awamlh's 322-patient study included 73 mixed CCUDs and found no independent association between diversion type and renal decline; postoperative obstruction and baseline patient factors mattered.[15] In the 4,015-patient SEER–Medicare analysis, the continent-versus-conduit ESKD hazard ratio was 1.06 (95% CI 0.78–1.44), not proof of equal renal risk. Patients with pre-existing renal disease or significant hydronephrosis were excluded.[23] Eisenberg's 1,631-patient retrospective cohort also associated renal decline with hydronephrosis, pyelonephritis and ureteroenteric stricture.[24]
For drug selection and dosing, see Vitamin B12 supplementation, Urinary acidifiers and alkalinizers, and Mucus management.
Quality of Life and Alternatives
Quality-of-life studies are observational and affected by selection and response rates. Kern's longitudinal study included 146 patients, of whom 31 had an Indiana pouch; overall scores did not differ significantly between diversion groups.[25] Large's comparison of women obtained questionnaires from 21 neobladder and 19 Indiana-pouch survivors and also found no significant domain differences. Neither study establishes equivalence for every patient.[26]
Gellhaus received responses from 128 of 300 contacted long-term survivors; urinary function favored conduit and Indiana groups, whereas urinary bother did not. Results depend on the quality-of-life domain and the selected population.[27] Cheng's 58-patient study compared Indiana with appendiceal and neo-appendiceal right-colon outlets; differences in age, comorbidity and operating surgeon limit causal comparisons.[28]
| Diversion | Daily requirements and selection considerations |
|---|---|
| Indiana pouch | Catheterization through a stoma, mucus management and surveillance; useful when an internal reservoir is preferred and reliable catheterization is feasible. |
| Ileal conduit | External appliance and stoma care; avoids scheduled emptying of a large continent reservoir. |
| Orthotopic neobladder | Urethral emptying and continence training; requires an appropriate urethral outlet and willingness to catheterize if emptying is inadequate. |
All options carry operative and long-term risks; choose through shared decision-making rather than age labels or unadjusted percentages from different series.[11][12]
Historically, Arai compared 68 Kock and 37 Indiana pouches with at least one-year follow-up (means 53 and 34 months). Revisions occurred in 22.1% versus 10.8% and stones in 26.5% versus 5.4%. Many Kock complications involved older collars or exposed staples, limiting extrapolation to other designs or current techniques.[29]
Long-Term Surveillance
- Reservoir and outlet: review catheterization, leakage, mucus, pain, infections and changes in drainage. New inability to catheterize or suspected perforation warrants prompt assessment.
- Kidneys and drainage: monitor renal function and upper-tract imaging; investigate new hydronephrosis or functional decline. A pouchogram evaluates reservoir integrity and selected anastomotic questions; it does not replace upper-tract assessment.
- Laboratory monitoring: after cancer cystectomy, AUA advises testing every 3–6 months for 2–3 years and then annually; tailor renal and electrolyte monitoring to abnormalities and risk. EAU recommends annual B12 measurement after bowel diversion.[12][30]
- Infection: obtain cultures when clinically indicated. Do not routinely screen or treat asymptomatic bacteriuria solely because a bowel reservoir is colonized; exceptions include preparation for urological procedures breaching mucosa and other established indications.[31]
- Cancer and other late complications: follow the original disease protocol and investigate concerning symptoms. Lifelong functional follow-up remains necessary for benign as well as oncologic diversions.[19][30]
See Also
- Urinary Diversion Principles
- Right Colon Pouch
- Ileal Conduit
- Studer Neobladder
- Cutaneous Ureterostomy
References
1. Bihrle R. "The Indiana pouch continent urinary reservoir." Urol Clin North Am. 1997;24(4):773–779. doi:10.1016/s0094-0143(05)70419-5
2. 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
3. Kim AH, Ruel NH, Yamzon J, et al. "Indiana pouch continent cutaneous urinary diversion after robotic-assisted radical cystectomy: a 16-year experience." Urology. 2024;183:e325–e327. doi:10.1016/j.urology.2023.10.023
4. Rowland RG. "Present experience with the Indiana pouch." World J Urol. 1996;14(2):92–98. doi:10.1007/BF00182564
5. Ahlering TE, Weinberg AC, Razor B. "Modified Indiana pouch." J Urol. 1991;145(6):1156–1158. doi:10.1016/s0022-5347(17)38561-0
6. 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
7. Pearce SM, Cohn JA, Steinberg Z, Steinberg GD. Patient selection, operative technique, and contemporary outcomes of continent catheterizable diversion: the Indiana pouch. Curr Bladder Dysfunct Rep. 2014;9:293–301. doi:10.1007/s11884-014-0265-4.
8. Burns R, Speir R, Kern SQ, et al. "Early and midterm complications of the continent catheterizable Indiana pouch urinary diversion: a 7-year experience." Urology. 2022;167:229–233. doi:10.1016/j.urology.2022.04.016
9. Torrey RR, Chan KG, Yip W, et al. "Functional outcomes and complications in patients with bladder cancer undergoing robotic-assisted radical cystectomy with extracorporeal Indiana pouch continent cutaneous urinary diversion." Urology. 2012;79(5):1073–1078. doi:10.1016/j.urology.2011.12.050
10. Desai MM, Simone G, de Castro Abreu AL, et al. "Robotic intracorporeal continent cutaneous diversion." J Urol. 2017;198(2):436–444. doi:10.1016/j.juro.2017.01.091
11. European Association of Urology. EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. 2026. Urinary diversion, section 6.7.5. Guideline.
12. American Urological Association / ASCO / ASTRO / SUO. Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer. 2024 amendment. Statements 13–14 and 31–32 and discussions. Guideline.
13. Wilkin M, Horwitz G, Seetharam A, et al. "Long-term complications associated with the Indiana pouch urinary diversion in patients with recurrent gynecologic cancers after high-dose radiation." Urol Oncol. 2005;23(1):12–15. doi:10.1016/j.urolonc.2004.07.018
14. 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
15. 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):805–814. doi:10.1111/bju.12919
16. Nieuwenhuijzen JA, de Vries RR, Bex A, et al. "Urinary diversions after cystectomy: the association of clinical factors, complications and functional results of four different diversions." Eur Urol. 2008;53(4):834–842. doi:10.1016/j.eururo.2007.09.008
17. Ferriero M, Simone G, Papalia R, et al. "Early and late urodynamic assessment of simplified Indiana pouch with multiple taeniamyotomies." BJU Int. 2011;107(1):112–116. doi:10.1111/j.1464-410X.2010.09432.x
18. Holmes DG, Thrasher JB, Park GY, Kueker DC, Weigel JW. "Long-term complications related to the modified Indiana pouch." Urology. 2002;60(4):603–606. doi:10.1016/s0090-4295(02)01945-3
19. Polm PD, Wyndaele MIA, de Kort LMO. "Very long-term follow-up of Indiana pouches proves durability." Neurourol Urodyn. 2024;43(5):1090–1096. doi:10.1002/nau.25344
20. European Association of Urology. EAU Guidelines on Urolithiasis. 2026. Bladder stones after augmentation or urinary diversion, sections 6.4.5–6.6. Guideline.
21. Roth JD, Koch MO. "Metabolic and nutritional consequences of urinary diversion using intestinal segments to reconstruct the urinary tract." Urol Clin North Am. 2018;45(1):19–24. doi:10.1016/j.ucl.2017.09.007
22. Pfitzenmaier J, Lotz J, Faldum A, et al. "Metabolic evaluation of 94 patients 5 to 16 years after ileocecal pouch (Mainz pouch 1) continent urinary diversion." J Urol. 2003;170(5):1884–1887. doi:10.1097/01.ju.0000091900.57347.ee
23. Zabell JR, Adejoro O, Konety BR, Weight CJ. "Risk of end-stage kidney disease after radical cystectomy according to urinary diversion type." J Urol. 2015;193(4):1283–1287. doi:10.1016/j.juro.2014.10.103
24. Eisenberg MS, Thompson RH, Frank I, et al. "Long-term renal function outcomes after radical cystectomy." J Urol. 2014;191(3):619–625. doi:10.1016/j.juro.2013.09.011
25. Kern SQ, Speir RW, Tong Y, et al. "Longitudinal HRQoL after open radical cystectomy: comparison of ileal conduit, Indiana pouch, and orthotopic neobladder." Urology. 2021;152:184–189. doi:10.1016/j.urology.2020.12.036
26. Large MC, Katz MH, Shikanov S, Eggener SE, Steinberg GD. "Orthotopic neobladder versus Indiana pouch in women: a comparison of HRQoL outcomes." J Urol. 2010;183(1):201–206. doi:10.1016/j.juro.2009.08.148
27. Gellhaus PT, Cary C, Kaimakliotis HZ, et al. "Long-term HRQoL outcomes following radical cystectomy." Urology. 2017;106:82–86. doi:10.1016/j.urology.2017.03.053
28. Cheng KW, Yip W, Shah A, et al. "Stoma complications and quality of life in patients with Indiana pouch versus appendico/neo-appendico-umbilicostomy urinary diversions." World J Urol. 2021;39(5):1521–1529. doi:10.1007/s00345-020-03348-z
29. Arai Y, Kawakita M, Terachi T, et al. "Long-term followup of the Kock and Indiana pouch procedures." J Urol. 1993;150(1):51–55. doi:10.1016/s0022-5347(17)35394-6
30. European Association of Urology. EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. 2026. Functional follow-up, section 7.4. Guideline.
31. European Association of Urology. EAU Guidelines on Urological Infections. 2026. Asymptomatic bacteriuria in reconstructed lower urinary tracts and before urological surgery, sections 3.3.5.d.5, 3.3.5.e and 3.3.7. Guideline.