Indiana pouch
Steven C. Campbell, M.D., Ph.D.

# Overview
An Indiana pouch is a surgically-created urinary diversion used to create a way for the body to store and eliminate urine for patients who have had their urinary bladders removed as a result of bladder cancer,, or who are not continent due to a congenital, neurogenic bladder.
With this type of surgery, a reservoir, or pouch, is created out of approximately two feet of the ascending colon and a portiom of the ileum (a part of the small intestine).  The ureters are surgically removed from the bladder and repositioned to drain into the pouch.  A piece of small intestine is brought out through a small opening in the abdominal wall called a stoma.  Since a segment including the large and small intestines are utilized, also included is the ileal-ceceal valve.  This is a one-way valve located between the small and large intestines which normally prevents the passage of bacteria and digested matter from re-entering the small intestine.  Originally, it was thought that removing the ileal-ceceal valve from the digestive tract would result in diarrhea, but this has not shown to be the case.  After a period of several weeks, the body adjusts to the absence of this valve by absorbing more liquids and nutrients.
Patients can usually expect a hospital stay between seven and ten days for this surgery.  The abdominal incision (vertical) may be up to approximately eight inches long and is typically closed with staples on the outside and several layers of dissolvable stitches on the inside.  After surgery, patients will have a three drainage tubes place while tissues heal:  one through the newly-created stoma, one through another temporary opening in the abdominal wall into the pouch, and an SP tube.  In the hospital, the SP tube and external staples will be removed after several days.  The remaining tubes will be connected to collection bags which will be worn on each leg.  After sufficient healing, the tube will be removed from the stoma and the patient will begin to catheterize the pouch every two hours.  Since one other tube will still be in place, patients can sleep through the night since the collection bag can be attached to that tube at night time.  After approximately one month, patients will return to the hospital for an x-ray where dye will be instilled into the pouch to verify that there is no leakage.  If there is no leakage, this last tube will be removed.  Emptying time now may be increased to 3 hours, however, now the patient will need to wake up during the night to empty the pouch.  Over time, emptying time can increased up to 4-6 hours.  The pouch reaches its final size at approximately six months, and will then hold up to 1,200 cubic centimeters (cc's).  Each day, the pouch will need to be irrigated with 60 cc's of sterile water.  This removes mucus, salts, and bacteria.  If consumption of liquids is reduced in the evening, patients should be able to sleep through the night after approximately six months.
In contrast to other urinary diversion techniques like the ileal conduit, the Indiana pouch has the advantage of not using an external pouch adhered to the abdomen to store urine.  This can result in a better body image.  Also, there will not be the worry of an external appliance coming loose and leaking.  Additionally, the cost of urostomy appliances can be significant, and is usually not covered in full by most health insurance.
Indiana pouch surgery can be done in young patients as long as they have the ability to empty the pouch on a schedule.  Indiana pouch surgery also has been done in patients up into their 70's.  Some patients, after having a ileal conduit, which is incontinent and requires an appliance, have opted to have the Indiana pouch as elective surgery, if they are a candidate.  It has been documented that the Indiana pouch may reduce the possibility of kidney damage since the ureters are repositioned lower in the abdomin and this reduces the possible back-flow to the kidneys.  After having the surgery, patients must wear a medical alert bracelet indicating they have an Indiana pouch.