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Indiana Pouch

The Indiana pouch is a continent cutaneous urinary diversion (CCUD) using the right colon (cecum / ascending colon) and terminal ileum to create an internal reservoir with a catheterizable, continent stoma — eliminating the need for an external collection bag.[1][2][3] It is the most commonly performed continent cutaneous diversion but accounts for only 8–10.4% of US radical cystectomies, largely because of disparities in surgeon training, hospital volume, and patient selection.[4]

The procedure evolved from the Gilchrist 1950 ileocecal-reservoir concept and was refined at Indiana University in 1984.[3][5]

Anatomy​

Indiana pouch: a detubularized right-colon reservoir with ureters reimplanted, a tapered ileal efferent limb, and ileocecal-valve continence to a catheterizable stoma

The Indiana configuration. A low-pressure reservoir is built from detubularized right colon; the terminal ileum is tapered (~14 Fr) and brought to a catheterizable umbilical stoma, with continence supplied by the ileocecal valve + ileal-limb plication + low pouch pressure. The ureters are reimplanted into the pouch. Unlike an orthotopic neobladder (voided per urethra), the patient self-catheterizes the stoma every 4–6 h and wears no external bag. (Original WARWIKI schematic)

ComponentDetail
ReservoirRight colon (cecum + ascending colon), ~ 26–30 cm, detubularized along the antimesenteric border and reconfigured into a low-pressure high-capacity pouch[6]
Efferent (continence) limbTerminal 8–12 cm of ileum, including the ileocecal valve, tapered / plicated and brought through the abdominal wall — often into the umbilicus for cosmetic concealment[1][2][6]
Continence mechanismSynergy of natural ileocecal valve + stapled ileal-limb plication + low intraluminal reservoir pressure[2][7]

Surgical Technique​

  1. Isolation of ileocecal segment — terminal 8–12 cm ileum + 26–30 cm right colon on mesenteric pedicle; appendectomy
  2. Bowel continuity — ileoascending colonic anastomosis
  3. Detubularization — cecum / ascending colon opened along antimesenteric tenia and reconfigured (folded transverse, or U-shaped ileal patch augmentation)[3][5]
  4. Efferent-limb construction (continence mechanism):
    • Terminal ileum tapered with GIA staples to ~ 14 Fr
    • Ileocecal valve plicated with reinforcing sutures
    • Creates a one-way valve permitting easy catheter passage but preventing leakage[2][3]
  5. Ureteral reimplantation — typically tunneled tenial (submucosal) for antireflux; some surgeons use simpler transcolonic reimplantation[2][6]
  6. Stoma creation — efferent limb through abdominal wall, commonly umbilical, flush and continent[1]
  7. Closure — watertight reservoir; ureteral stents and pouch catheter postoperatively

Open vs robotic[4][9][8]​

ApproachOperative timeContinence
Open (traditional)~ 422 minHigh
Robotic + extracorporeal pouch (Torrey 2012, n=34)—97% at 20 mo
Totally intracorporeal robotic (Desai 2017, n=10)6 h median100% at 14 mo
16-yr robotic series (Kim 2024, n=97)8 h median99%; median OS 108 mo

Indications​

  • Patients desiring continent diversion who are not orthotopic-neobladder candidates (positive urethral margin, damaged sphincter, prior pelvic radiation)[1][2][3][11]
  • Women — particularly those requiring urethrectomy; QoL outcomes comparable between Indiana pouch and neobladder in women[12]
  • Patients with adequate manual dexterity and motivation for CIC every 4–6 hr
  • Patients who strongly prefer avoidance of an external bag
  • Neurogenic bladder requiring continent catheterizable stoma (Khavari 2012 IAC modification)[13]

Contraindications​

  • IBD (especially Crohn's involving ileocecal region)
  • Short-bowel syndrome
  • Cr > 2 mg/dL
  • Severe hepatic dysfunction
  • Inability or unwillingness to perform CIC
  • Prior right hemicolectomy

Functional Outcomes — Continence​

SeriesnFUDaytimeNighttime
Rowland (Indiana University, original)69≥ 2 yr97%97%
Bihrle (Indiana University)LargeLong-term94%94%
Ahlering (modified Indiana)703–24 mo100%100%
Kim (USC robotic, 16 yr)9793 mo99%99%
Torrey (robotic extracorporeal)3420 mo97%97%
Desai (robotic intracorporeal)1014 mo100%100%
Nieuwenhuijzen (multi-diversion)51Variable96%73%
Ferriero (simplified IP)3248 mo94% appendicostomy / 90% ileostomy88% / 85%

Patients catheterize every 4–6 hr; 88% catheterize every 4–8 hr and 7% every 8–10 hr. Continence at median 36 mo: 89% in multi-institutional series.[11]

Urodynamic properties[7][6][15]​

  • Capacity 400–800 mL (modified IP); median 628 mL at 12 mo, stable 608 mL at 48 mo
  • End-filling pressure decreases over time — median 28 cmH₂O at 12 mo → 18 cmH₂O at 48 mo (p < 0.05)
  • Appendicostomy efferent: closing pressure increases over time (75 → 91 cmH₂O); ileostomy efferent: closing pressure decreases (73 → 63 cmH₂O)

Complications​

Early (within 90 days)[4][10][14][9]​

  • Overall early complication rate: 39–73%
  • Major (Clavien III–V): 17.5% at 30 days
  • Most common major: abdominal infection, ureterocolonic stricture
  • Early readmission 18–21%, reoperation 7.3%, mortality 1.5%

Late (> 90 days) — Holmes long-term single-surgeon series (n=125, mean FU 41 mo)[16]​

ComplicationIncidence
Any complication89.6%
Efferent-limb complications (total)58.4%
— Incontinence (any leakage)28.0%
— Stomal stenosis15.2%
— Difficult catheterization9.6%
Gallstones25.6%
Pouch stones10.4%
Ureteral anastomotic stricture7.2%
Kidney stones6.4%
Small-bowel obstruction4.8%
Pouch perforation3.2%
Reoperation (any)52.0% (open 20.8%, MIS 31.2%)

In contrast, the Indiana University 7-yr series (Burns 2022, n=137) reported 39% first-year complication rate and 7.3% early / 8% midterm reoperation rates.[10]

Very long-term — Polm 2024 Dutch series (median FU 258 mo / 21.5 yr)[17]​

  • 67% required at least one surgical revision
  • 45 revision procedures total
  • Mean revision-free survival 198 mo (16.5 yr) — establishes the Indiana pouch as a durable option

Irradiated patients​

Wilkin 2005 — high-dose pelvic radiation increases complications 83% vs 57%, with more ureteral strictures, renal insufficiency, and secondary operative procedures.[18]

Metabolic Consequences[14][19][20][21]​

  • Hyperchloremic metabolic acidosis — alkali (Na⁺ / K⁺ citrate) required in 37% of ileocecal-pouch patients at > 5 yr[21]
  • Vitamin B12 deficiency — low B12 in 15% of IP patients (vs 23% IC); supplementation recommended in 32% of ileocecal-pouch patients[14][21]
  • Metabolic changes overall in 26% of IP patients (vs 21% IC, 28% neobladder)[14]
  • Urolithiasis risk — increased calcium / phosphate / magnesium excretion; hypocitraturia < 320 mg/day in > 33% of all diversion types[20]
  • Bone health — no clinical osteoporosis at long-term FU when systematic alkali is used[21]

For pharmacologic management see Vitamin B12 supplementation, Urinary acidifiers & alkalinizers, and Mucus management.

Renal function[11][22][23][24]​

  • Multi-institutional 322-pt series — diversion type not associated with renal-function decline on multivariate analysis. Independent predictors: age, diabetes, baseline eGFR, hydronephrosis, pyelonephritis, ureteroenteric stricture
  • Zabell SEER-Medicare (n=4,015) — no increased ESKD risk with continent diversion vs IC (HR 1.06, p = 0.71); ESKD at 5 / 10 / 15 yr was 8.3% / 16.9% / 24.4%
  • Mayo (Eisenberg, n=1,631, median 10.5 yr FU) — by 10 yr the risk of renal-function decrease was similar for incontinent (71%) and continent (74%) diversions (p = 0.13)

Quality of Life[25][26][12][27]​

  • Kern 2021 longitudinal QoL across all three diversions (n=146) — no significant differences in overall FACT-VCI scores. Physical well-being favored neobladder over IC and IP
  • Gellhaus 2017 > 5 yr — IC and IP had significantly better urinary function than neobladder (p = 0.02); sexual bother lower with neobladder than IP
  • Women (Large 2010) — no significant QoL differences between IP and orthotopic neobladder
  • Cheng 2021 — IP had higher continence and fewer high-grade diversion-related complications than appendico-umbilicostomy variants; majority rated overall QoL good–excellent

Indiana Pouch vs Other Diversions​

FeatureIndiana PouchIleal ConduitOrthotopic Neobladder
ContinenceContinent (CIC via stoma)Incontinent (external bag)Continent (voids per urethra)
Bowel segmentsRight colon + terminal ileumDistal ileum 15–20 cmDistal ileum 55–65 cm
External applianceNone (flush stoma)Yes (ostomy bag)None
Stoma visibilityMinimal (umbilicus possible)Visible (RLQ)None
Daytime continence94–100%N/A86–99%
Nighttime continence73–97%N/A66–83%
CIC requiredAlways (q4–6 h)Never5–28%
Early complication rate39–73%48%58%
Late complication rate63%39%59–60%
Long-term reoperation52% (very long-term: 67%)LowestHigher
Long-term urinary functionBetter than neobladderBetter than neobladderWorse
Renal function declineComparableComparableComparable
Ideal candidateNeeds urethrectomy, desires continence, good dexterityElderly, comorbid, poor dexterityYounger, motivated, intact urethra

Indiana Pouch vs Kock Pouch​

The Indiana pouch largely replaced the Kock pouch due to simpler construction and lower complication rates:[28][29]

  • Reoperation: IP 10.8% vs Kock 22.1%
  • Stone formation: IP 5.4% vs Kock 26.5% (Kock stones often formed on exposed staples / nonabsorbable collars)
  • Continence equivalent
  • IP has technical demands similar to ileal conduit, whereas Kock is significantly more complex

Special Populations​

  • Neurogenic bladder — Khavari 2012 Indiana augmentation cystoplasty (IAC) modification adds catheterizable continent stoma to ileocecal-augmented native bladder; 100% continence with 44% long-term complication rate (mostly minor) in MS / spina bifida / SCI[13]
  • Young patients — given 67% revision rate at median 21.5 yr, lifelong-follow-up and revision counseling is essential[17]

Long-Term Surveillance[10][17][16][19][21]​

  • Pouch imaging — pouchography or CT for stones, hydronephrosis, pouch integrity
  • Renal function — eGFR; nuclear GFR if creatinine unreliable
  • Metabolic — bicarbonate, chloride, vitamin B12 annually; bone density if indicated
  • Stoma — assessment for stenosis, difficult catheterization, leakage
  • Urine cultures — continent reservoirs are almost always colonized[2]
  • Stone surveillance — pouch and renal stones
  • Cancer surveillance — per primary-disease protocol
  • Gallstone screening — notably elevated 25.6% incidence in long-term series[16]

See Also​

References​

1. Khosla AA, Mendhiratta N, Jatwani K. "Urinary diversion after cystectomy for bladder cancer." JAMA Oncol. 2025. doi:10.1001/jamaoncol.2025.3644

2. 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

3. 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

4. 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

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

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

7. 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

8. 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

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. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Terai A, Arai Y, Kawakita M, Okada Y, Yoshida O. "Effect of urinary intestinal diversion on urinary risk factors for urolithiasis." J Urol. 1995;153(1):37–41. doi:10.1097/00005392-199501000-00016

21. 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

22. Pyrgidis N, Sokolakis I, Haltmair G, Hatzichristodoulou G. "The effect of urinary diversion on renal function after cystectomy for bladder cancer: comparison between ileal conduit, orthotopic ileal neobladder, and heterotopic ileocecal pouch." World J Urol. 2022;40(12):3091–3097. doi:10.1007/s00345-022-04211-z

23. 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

24. 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

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. 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

27. 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

28. Ahlering TE, Weinberg AC, Razor B. "A comparative study of the ileal conduit, Kock pouch and modified Indiana pouch." J Urol. 1989;142(5):1193–1196. doi:10.1016/s0022-5347(17)39026-2

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