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Mainz Pouch I

The Mainz Pouch I (an acronym for Mixed Augmentation Ileum 'N Zecum) is a detubularized ileocecal reservoir developed by Joachim W. Thüroff, Peter Alken, Herbert Riedmiller, Günter H. Jacobi, and Rudolf Hohenfellner at Johannes Gutenberg University, Mainz, Germany, beginning in 1983.[1][2][3][4] It is one of the most versatile and extensively documented continent urinary diversions in the world, with applications spanning continent cutaneous diversion, orthotopic bladder substitution, and bladder augmentation — accumulating over 800 patients in the two primary German centers (Mainz and Wuppertal) with a mean follow-up of 7.6 years.

Historical Development​

  • 1983 — First Mainz pouch procedures performed at the University of Mainz for bladder augmentation and continent cutaneous diversion.[2][5]
  • 1985 — Thüroff, Alken, Engelmann, et al. published the first description in Eur Urol — 10 patients (4 augmentation, 6 diversion). Three functional pillars established: low-pressure reservoir from detubularized cecum + two ileal loops, antirefluxing submucosal tunnel into cecum, and continent closure via isoperistaltic ileoileal intussusception.[5]
  • 1986 — Expanded J Urol description (n = 23) confirming the three functional features.[1]
  • 1988 — 100-patient milestone (34 augmentation, 15 orthotopic substitution, 51 cutaneous diversion). Staple fixation of the continence nipple to the ileocecal valve solved nipple prolapse; the umbilicus was adopted as the stomal site for cosmetic reasons.[2]
  • ~1990 — Introduction of the in situ submucosally embedded appendix as the continence mechanism — a landmark simplification.[6]
  • 1994 — 561 patients across Mainz and Wuppertal (60 augmentation, 61 orthotopic, 440 cutaneous diversion).[4]
  • 1995 — Lampel introduced seromuscular and full-thickness bowel flap tubes as alternative continence mechanisms when the appendix was unavailable.[7]
  • 1997 — Gerharz: 193-patient direct comparison of intussuscepted ileal nipple vs in situ appendix.[8]
  • 1999 — Leissner / Hohenfellner: 108-patient orthotopic bladder substitution series.[9]
  • 2005 — Stein: 70-patient pediatric/adolescent neurogenic bladder series, median follow-up 8.7 years.[10]
  • 2006 — Wiesner: long-term comparison of intussuscepted ileal nipple vs in situ appendix (n = 401)[6] and the 800+ patient series from two tertiary centers — the largest CCUD experience in the world.[3]
  • 2007 — Wiesner: definitive comparison of submucosal tunnel (ST) vs serous-lined extramural tunnel (ET) for ureteral reimplantation in 458 patients (median follow-up 89 months).[11]

Design Principles​

The Mainz Pouch I was designed around three functional pillars.[1][5]

  1. Low-pressure, high-capacity reservoir — combining cecum / ascending colon with two ileal loops, all detubularized and reconfigured into a spheroidal pouch. The combination of two different intestinal segments (ileum + colon) disrupts coordinated peristalsis more effectively than ileum alone.
  2. Antirefluxing ureteral implantation — submucosal tunnel into cecum (exploiting the thick colonic wall) or, later, the serous-lined extramural tunnel (SLET) for dilated ureters.[1][11]
  3. Continent outlet — initially intussuscepted ileal nipple anchored to the ileocecal valve; later the in situ submucosally embedded appendix; bowel-flap tubes when the appendix was unavailable.[1][6][7]

Advantages over the Kock pouch:

  • The ileocecal valve anchors the intussuscepted nipple, reducing dessusception risk.
  • The thick colonic wall of the cecum provides a reliable substrate for submucosal-tunnel ureteral reimplantation — a well-established native-bladder technique.
  • Combining ileum and cecum disrupts peristalsis more effectively than ileum alone.
  • Less ileum is used (~20–30 cm vs 60–80 cm for Kock), reducing B12-deficiency and bile-salt-malabsorption risk.[1][2]

Surgical Technique​

Reservoir Construction​

  1. Bowel isolation — approximately 10–15 cm of cecum and ascending colon and two ileal loops of the same length are isolated, preserving the ileocecal junction and ileocolic vascular pedicle.[1][2][5]
  2. Ileoascending colonic anastomosis restores GI continuity.
  3. Detubularization — all three segments are opened along the antimesenteric border (ileum) and along the taenia (cecum / ascending colon).
  4. Pouch formation — the opened plates are folded and sutured into a spheroidal low-pressure reservoir.
  5. Optional teniamyotomies — Alcini et al. demonstrated that multiple transverse cecal teniamyotomies further increase compliance, achieving a mean capacity of 396 mL with full-filling pressure of only 28 cm H₂O in 30 patients.[12]

Antireflux Ureteral Reimplantation​

Two techniques have been used.[1][11]

1. Submucosal tunnel (ST) — original technique. Standard submucosal tunnel into cecum or ascending colon (analogous to Leadbetter-Politano or Cohen). In 809 RUs (median follow-up 89 mo): obstruction 7.3%; obstruction-free at 1/5/10 yr = 97%/93%/91%; serum creatinine ≤ 1.6 mg/dL in 97%. Higher obstruction rates with previously dilated upper tracts (13.9%) and neurogenic bladder (17.1%).[11]

2. Serous-lined extramural tunnel (ET) — adopted later (Abol-Enein/Ghoneim technique). In 74 RUs: obstruction 4.1%; obstruction-free at 1/5/10 yr = 100%/96%/96%; serum creatinine ≤ 1.6 mg/dL in 98%. Significantly lower obstruction rates in dilated upper tracts (3.1% vs 13.9%) and neurogenic bladder (7.1% vs 17.1%).[10][11] ET is now preferred for dilated ureters and neurogenic bladder.

Continence Mechanisms​

Four mechanisms have been used over the technique's evolution.[6][7][8]

  1. Intussuscepted ileal nipple (original) — stapled and anchored to the ileocecal valve; stoma at the umbilicus.[2]
  2. In situ submucosally embedded appendix (~1990) — appendix on its mesentery embedded in a submucosal cecal tunnel, brought to the umbilicus as a catheterizable stoma. Preferred when available.[6][8]
  3. Seromuscular bowel flap tube (Lampel 1995) — serosa-lined tube from a pedicled island flap of large bowel.[7]
  4. Full-thickness bowel flap tube (Lampel 1995) — mucosa-lined tube from a pedicled bowel flap.[7]

Orthotopic Modification​

For orthotopic use the cutaneous outlet is omitted; the most dependent portion of the reservoir is anastomosed to the membranous urethra. The native external urethral sphincter provides continence; voiding occurs by Valsalva.[2][9]

Functional Outcomes​

Continent Cutaneous Diversion​

SeriesnFollow-upContinenceKey Findings
Thüroff 1985[5]10Early100% (aug); variable (diversion)First description; 3 functional pillars
Thüroff 1986[1]23Early100% with valveSubmucosal tunnel antireflux confirmed
Thüroff 1988[2]100—93% (aug); 96% (diversion)Staple fixation; umbilical stoma adopted
Lampel 1996[4]440 (CCUD)Mean 57 mo89%4 continence mechanisms compared
Gerharz 1997[8]193Mean 34 moAppendix 92%; nipple 82%Appendix preferred; nipple complications more severe
Wiesner 2006[6]401Long-termAppendix 92%; nipple 82%36% required intervention for stomal complication
Wiesner 2006[3]800+Mean 7.6 yr92.8%Largest CCUD experience worldwide
Stein 2005 (pediatric)[10]70Median 8.7 yr97%Upper tracts stable/improved in 95.8% of RUs

Orthotopic Bladder Substitution — Leissner / Hohenfellner 1999​

ParameterResult
Total patients108 men (3 centers)
Mean follow-up42 months (range 3–132)
Spontaneous voiding85%
Mean pouch capacity720 mL
Daytime continence88% (incl. 17% with 1 safety pad)
Stress incontinence9%
Total incontinence3%
Complete nighttime continence34%
Nighttime continence with 1 pad33%
Nocturnal incontinence11%
Uretero-intestinal stenosis7% (15/205 RUs)
Reflux0%
Anti-acidotic prophylaxis~50% of patients

Source: Leissner 1999.[9]

Bladder Augmentation​

In the 100-case series, 93% of augmentation patients were completely continent day and night, all but 3 voiding spontaneously.[2] In the 561-patient series, 93% were continent, all but 3 voiding by abdominal straining.[4] In the pediatric series, upper tracts remained stable or improved in all 10 augmentation patients and 20/23 RUs with bladder substitution.[13]

Urodynamic Comparison​

Santucci et al. (1999) compared five reservoir types: the Mainz (ileocecal) stomal reservoir achieved 91% continence — second only to the Indiana pouch (100%). As a neobladder, the Mainz achieved 75% continence, comparable to Hautmann (80%) and superior to sigmoid (50%) and gastric (33%).[15]

Continence Mechanisms — Detailed Comparison (Wiesner 2006, n = 401)​

ParameterIntussuscepted Ileal Nipple (n = 205)In Situ Appendix (n = 196)
Complete continence82%92%
Stomal stenosis17% (mean onset 43.8 mo)32% (mean onset 31.4 mo)
Stone formation20% (mean onset 62.8 mo)10% (mean onset 47.5 mo)
Reoperation for incontinence12 (5.9%)3 (1.5%)
Necrosis of mechanism1 (0.5%)4 (2.0%)
Mucous secretionLarger amountsLess
Overall stomal-complication intervention36% of all 401 patients—
Endoscopic treatment of complications63% of all stomal complications—

Source: Wiesner 2006.[6]

Conclusions:[6][8]

  • The appendix provides higher continence (92% vs 82%), lower stone formation (10% vs 20%), and fewer reoperations for incontinence (1.5% vs 5.9%).
  • The ileal nipple has lower stomal stenosis (17% vs 32%) — the higher stenosis with the appendix reflects its smaller diameter.
  • Higher stone formation with the ileal nipple is related to exposed metallic staples.
  • Appendiceal necrosis (2%) is a recognized complication requiring replacement with an ileal nipple.
  • When the appendix is available and suitable, it should be the preferred continence mechanism. Gerharz noted that complications of the ileal nipple (necrosis, dislocation from ileocecal valve, detachment from fascia) were more severe and required more complex reoperations than appendiceal complications (mostly stenosis treatable as minor outpatient procedures).[8]

Antireflux — Submucosal vs Serous-Lined Tunnel (Wiesner 2007, n = 458)​

ParameterSubmucosal Tunnel (ST) — 809 RUsSerous-Lined Extramural Tunnel (ET) — 74 RUs
Anastomotic obstruction7.3%4.1%
Median time to obstruction16.8 mo17.2 mo
Obstruction-free at 1 yr97%100%
Obstruction-free at 5 yr93%96%
Obstruction-free at 10 yr91%96%
Obstruction in dilated upper tracts13.9%3.1%
Obstruction in neurogenic bladder17.1%7.1%
Serum creatinine ≤ 1.6 mg/dL97%98%

Source: Wiesner 2007.[11] In the pediatric series, ureteral stenosis occurred in 16% of RUs with ST vs only 3% with ET.[10] Renal function remained stable with both techniques long-term, but ET is recommended for dilated ureters and neurogenic bladder.

Complications​

ComplicationIncidenceNotes
Early complications12% (561-pt series)—
Overall late complications37% (561-pt series)—
Stomal stenosis (appendix)23.5–32%Smaller diameter; mostly endoscopic management
Stomal stenosis (ileal nipple)15.3–17%—
Stone formation (ileal nipple)10.8–20%Exposed staples
Stone formation (appendix)5.6–10%—
Stoma failure (overall)11%—
Ureterointestinal stricture (ST)6.5–7.3%Higher in dilated ureters (13.9%)
Ureterointestinal stricture (ET)4.1–5.0%Lower, especially in dilated ureters (3.1%)
Pouch calculi (pediatric)15%—
Stoma stenosis (pediatric)23%—
Symptomatic reflux (pediatric)1%—

Sources: Lampel 1996; Wiesner 2006/2007; Stein 2005.[3][4][6][10][11]

Metabolic Long-Term Data (Pfitzenmaier 2003, n = 94, 5–16 yr)​

ParameterResult
Median follow-up9.0 years
Clinical metabolic symptomsNone (no megaloblastic anemia, funicular myelosis, or osteoporosis)
Vitamin B12 supplementation recommended32% (lower-normal or below)
Anti-acidotic prophylaxis (Na/K citrate)37%
Bone density (18 patients)No osteoporosis detected

No clinical symptoms occurred at a median of 9 years, but systematic blood-gas follow-up with alkali supplementation likely prevented bone demineralization, and ~ 1/3 of patients required B12 supplementation.[16] See Vitamin B12 Supplementation and Urinary Acidifiers & Alkalinizers.

Pediatric and Neurogenic Bladder Experience​

The Mainz Pouch I has been extensively used in children and adolescents with neurogenic bladder.[10][13][17]

Mainz pediatric / adolescent series (Stein 2005, n = 70):[10]

  • Median age 15.3 yr (range 5.7–20); median follow-up 8.7 yr (range 0.9–18)
  • Upper tracts stable or improved in 113/118 RUs (95.8%)
  • Complete continence 97%
  • Surgical revisions: incontinence 9%; stoma prolapse 2%; stoma stenosis 23%; pouch calculi 15%; symptomatic reflux 1%; ureteral stenosis ST 16% vs ET 3%

Comprehensive Mainz neurogenic-bladder experience (Stein 2000, n = 149, 1967–1997):[17]

  • Mean follow-up 11.8 yr
  • Upper tracts improved or stable in 97% with colonic conduit or Mainz Pouch I, and 95% with orthotopic bladder substitution
  • Complete continence 98% with continent stoma
  • All bladder-substitution patients continent during the day

After failure of conservative treatment, the Mainz Pouch I provides a safe long-term compromise with high continence rates and excellent upper-tract preservation in this population.

Comparison with Other Continent Diversions​

Mainz Pouch I vs Kock Pouch​

FeatureMainz Pouch IKock Pouch
Bowel segmentsCecum + 2 ileal loopsIleum only (~60–80 cm)
Antireflux mechanismSubmucosal tunnel or SLET into cecumIntussuscepted afferent nipple
Continence mechanismAppendix or ileal nipple (anchored to ileocecal valve)Intussuscepted efferent nipple
Continence rate92.8%84–95%
Stone formation5.6–10.8%16.7–44%
Reoperation rate11% stoma failure; 36% any stomal intervention22–53%
B12 deficiency risk32% need supplementation33–80% malabsorption
Ileum used~20–30 cm~60–80 cm

Mainz Pouch I vs Indiana Pouch​

FeatureMainz Pouch IIndiana Pouch
ReservoirDetubularized cecum + 2 ileal loopsDetubularized right colon + terminal ileum
AntirefluxSubmucosal tunnel or SLETRefluxing (Bricker) or tunneled
Continence mechanismAppendix or ileal nipplePlicated/tapered terminal ileum through ileocecal valve
Continence rate92.8%89–100%
Stomal stenosis15.3–32%12–19%
Stone formation5.6–10.8%5.4–19%
VersatilityAugmentation + orthotopic + cutaneousPrimarily cutaneous

References for Indiana pouch comparison: Cheng 2021;[18] Ahlering 1989.[19]

Mainz Pouch I (Orthotopic) vs Abol-Enein / Ghoneim Ileal (Bedük 2003)​

ParameterMainz (n = 19)Abol-Enein/Ghoneim (n = 36)
Ureterointestinal stenosis10.5%5.7%
Pouch-urethral stenosis5.3%5.5%
Pouch-ureteral reflux7.9%4.2%
Pyelonephritis15.8%13.8%
Daytime incontinence5.3%5.5%
Nighttime incontinence21%8.4%
Capacity (12 mo)426 ± 34 mL442 ± 27 mL
Max flow rate19.6 ± 3.7 mL/s16 ± 6.1 mL/s
Residual urine37 ± 8.2 mL45 ± 7.1 mL

Urodynamic parameters were comparable, though the Abol-Enein/Ghoneim procedure showed lower nighttime incontinence and reflux rates.[14]

Secondary Malignancy Risk​

In a multicenter German analysis of 17,758 urinary diversions (Kälble 2011), the tumor risk in ileocecal pouches (including Mainz Pouch I) was 0.14% — not significantly different from ileal neobladders (0.05%, p = 0.46) but significantly lower than ureterosigmoidostomy (2.58%) and cystoplasty (1.58%).[20][21] Lifelong endoscopic surveillance of the pouch is nonetheless recommended at the discretion of the treating center.

Strengths and Limitations​

Strengths

  • Most versatile continent diversion — used for cutaneous diversion, orthotopic substitution, and bladder augmentation.[1][2][4]
  • Largest CCUD experience worldwide — 800+ patients with mean 7.6-year follow-up.[3]
  • High continence rate (92.8%) with the appendix mechanism.[3][6]
  • Excellent upper-tract preservation, especially with the SLET in dilated ureters.[10][11]
  • Less ileum used than the Kock pouch (~20–30 cm vs 60–80 cm), reducing B12-deficiency burden.[1][16]
  • Robust long-term data including 9-year metabolic safety.[16]
  • Validated in pediatric / neurogenic-bladder populations with 95.8% upper-tract preservation.[10][17]

Limitations

  • 36% require intervention for stomal complications (mostly endoscopic).[6]
  • Stomal stenosis with appendix (32%) — smaller diameter is the trade-off for higher continence.[6]
  • Stone formation with ileal nipple (20%) — exposed staples.[6]
  • Sacrifice of the ileocecal valve — risk of bile-salt malabsorption / diarrhea.
  • Technically more complex than the Indiana pouch (multiple potential continence mechanisms).
  • Most published data come from two German centers (Mainz, Wuppertal); broader external validation is more limited than the Indiana pouch.

Current Status and Legacy​

The Mainz Pouch I remains a contemporary continent cutaneous diversion in many European centers and a benchmark for both ileocecal CCUD and pediatric / neurogenic-bladder reconstruction. It has been validated across augmentation, orthotopic substitution, and cutaneous diversion, with arguably the widest indication footprint of any continent diversion.[1][2][3][4][6][10] Its key contributions include:

  1. Establishing the three functional pillars of continent ileocecal reservoir construction.[1][5]
  2. Demonstrating that the in situ appendix outperforms the intussuscepted ileal nipple as a continence mechanism (92% vs 82%) with fewer severe complications.[6][8]
  3. Providing the definitive long-term head-to-head of submucosal tunnel vs serous-lined extramural tunnel for ureteral reimplantation, establishing SLET as preferred for dilated ureters and neurogenic bladder.[10][11]
  4. Establishing safety and efficacy in the pediatric / neurogenic bladder population with median 8.7-year follow-up.[10][17]

Key Takeaways​

  1. The Mainz Pouch I is a detubularized ileocecal reservoir (cecum + two ileal loops) with submucosal-tunnel or SLET ureteral reimplantation and appendix or ileal nipple as the continence mechanism — versatile across cutaneous, orthotopic, and augmentation indications.[1][2][5]
  2. The 800+ patient series achieved 92.8% continence at mean 7.6-year follow-up — the largest CCUD experience worldwide.[3]
  3. The appendix is the preferred continence mechanism (92% continence, 10% stones, 1.5% reoperation for incontinence) when available; the ileal nipple has lower stomal stenosis but higher stone formation and more severe complications.[6][8]
  4. The serous-lined extramural tunnel is preferred for dilated ureters and neurogenic bladder (3.1% vs 13.9% obstruction in dilated upper tracts).[10][11]
  5. Pediatric / neurogenic-bladder outcomes are excellent — 97% complete continence and 95.8% upper-tract preservation at median 8.7-year follow-up.[10][17]
  6. Metabolic safety is favorable at 9-year follow-up — no clinical symptoms when systematic blood-gas surveillance and alkali / B12 supplementation are used.[16]

See Also​

References​

1. Thüroff JW, Alken P, Riedmiller H, et al. "The Mainz Pouch (Mixed Augmentation Ileum and Cecum) for Bladder Augmentation and Continent Diversion." J Urol. 1986;136(1):17–26. doi:10.1016/s0022-5347(17)44714-8

2. Thüroff JW, Alken P, Riedmiller H, Jacobi GH, Hohenfellner R. "100 Cases of Mainz Pouch: Continuing Experience and Evolution." J Urol. 1988;140(2):283–8. doi:10.1016/s0022-5347(17)41584-9

3. Wiesner C, Bonfig R, Stein R, et al. "Continent Cutaneous Urinary Diversion: Long-Term Follow-Up of More Than 800 Patients With Ileocecal Reservoirs." World J Urol. 2006;24(3):315–8. doi:10.1007/s00345-006-0078-y

4. Lampel A, Fisch M, Stein R, et al. "Continent Diversion With the Mainz Pouch." World J Urol. 1996;14(2):85–91. doi:10.1007/BF00182563

5. Thüroff JW, Alken P, Engelmann U, et al. "The Mainz Pouch (Mixed Augmentation Ileum 'N Zecum) for Bladder Augmentation and Continent Urinary Diversion." Eur Urol. 1985;11(3):152–60. doi:10.1159/000472481

6. Wiesner C, Stein R, Pahernik S, et al. "Long-Term Followup of the Intussuscepted Ileal Nipple and the in Situ, Submucosally Embedded Appendix as Continence Mechanisms of Continent Urinary Diversion With the Cutaneous Ileocecal Pouch (Mainz Pouch I)." J Urol. 2006;176(1):155–9. doi:10.1016/S0022-5347(06)00571-4

7. Lampel A, Hohenfellner M, Schultz-Lampel D, Thüroff JW. "In Situ Tunneled Bowel Flap Tubes: 2 New Techniques of a Continent Outlet for Mainz Pouch Cutaneous Diversion." J Urol. 1995;153(2):308–15. doi:10.1097/00005392-199502000-00004

8. Gerharz EW, Köhl U, Weingärtner K, et al. "Complications Related to Different Continence Mechanisms in Ileocecal Reservoirs." J Urol. 1997;158(5):1709–13. doi:10.1016/s0022-5347(01)64105-3

9. Leissner J, Stein R, Hohenfellner R, et al. "Radical Cystoprostatectomy Combined With Mainz Pouch Bladder Substitution to the Urethra: Long-Term Results." BJU Int. 1999;83(9):964–70. doi:10.1046/j.1464-410x.1999.00049.x

10. Stein R, Wiesner C, Beetz R, et al. "Urinary Diversion in Children and Adolescents With Neurogenic Bladder: The Mainz Experience. Part II: Continent Cutaneous Diversion Using the Mainz Pouch I." Pediatr Nephrol. 2005;20(7):926–31. doi:10.1007/s00467-005-1848-2

11. Wiesner C, Pahernik S, Stein R, et al. "Long-Term Follow-Up of Submucosal Tunnel and Serosa-Lined Extramural Tunnel Ureter Implantation in Ileocaecal Continent Cutaneous Urinary Diversion (Mainz Pouch I)." BJU Int. 2007;100(3):633–7. doi:10.1111/j.1464-410X.2007.06991.x

12. Alcini E, D'Addessi A, Racioppi M, et al. "Results of 4 Years of Experience With Bladder Replacement Using an Ileocecal Segment With Multiple Transverse Teniamyotomies." J Urol. 1993;149(4):735–8. doi:10.1016/s0022-5347(17)36195-5

13. Stein R, Wiesner C, Beetz R, Schwarz M, Thüroff JW. "Urinary Diversion in Children and Adolescents With Neurogenic Bladder: The Mainz Experience. Part I: Bladder Augmentation and Bladder Substitution — Therapeutic Algorisms." Pediatr Nephrol. 2005;20(7):920–5. doi:10.1007/s00467-005-1847-3

14. Bedük Y, Türkölmez K, Baltaci S, Göğüş C. "Comparison of Clinical and Urodynamic Outcome in Orthotopic Ileocaecal and Ileal Neobladder." Eur Urol. 2003;43(3):258–62. doi:10.1016/s0302-2838(03)00042-3

15. Santucci RA, Park CH, Mayo ME, Lange PH. "Continence and Urodynamic Parameters of Continent Urinary Reservoirs: Comparison of Gastric, Ileal, Ileocolic, Right Colon, and Sigmoid Segments." Urology. 1999;54(2):252–7. doi:10.1016/s0090-4295(99)00098-9

16. 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):1884–7. doi:10.1097/01.ju.0000091900.57347.ee

17. Stein R, Fisch M, Ermert A, et al. "Urinary Diversion and Orthotopic Bladder Substitution in Children and Young Adults With Neurogenic Bladder: A Safe Option for Treatment?" J Urol. 2000;163(2):568–73. PMID: 10647687

18. 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):1521–9. doi:10.1007/s00345-020-03348-z

19. Ahlering TE, Weinberg AC, Razor B. "A Comparative Study of the Ileal Conduit, Kock Pouch and Modified Indiana Pouch." J Urol. 1989;142(5):1193–6. doi:10.1016/s0022-5347(17)39026-2

20. Austen M, Kälble T. "Secondary Malignancies in Different Forms of Urinary Diversion Using Isolated Gut." J Urol. 2004;172(3):831–8. doi:10.1097/01.ju.0000134890.07434.8e

21. Kälble T, Hofmann I, Riedmiller H, Vergho D. "Tumor Growth in Urinary Diversion: A Multicenter Analysis." Eur Urol. 2011;60(5):1081–6. doi:10.1016/j.eururo.2011.07.006