The Indiana Pouch is a type of continent urinary diversion, a surgical procedure that creates a new internal reservoir for storing urine after the original bladder has been removed or is no longer functional. This reservoir is constructed entirely inside the body, allowing the patient to manage urine storage without needing an external collection bag. Instead, the patient empties the pouch by inserting a thin tube, known as a catheter, through a small, surgically created opening in the abdominal wall called a stoma. This method offers the patient control over when and where they choose to empty the stored urine.
Medical Necessity for Continent Diversion
Patients often require a urinary diversion following a radical cystectomy, which is the surgical removal of the bladder, typically performed for severe diseases. The most common reason for this procedure is the presence of invasive bladder cancer that has penetrated the muscle layer of the bladder wall. Other serious conditions that may necessitate bladder removal include severe radiation injury to the bladder, chronic and debilitating inflammation like interstitial cystitis, or congenital conditions such as bladder exstrophy.
The Indiana Pouch is a preferred option for patients seeking a continent solution, meaning they can store the urine internally until a convenient time for drainage. This contrasts with an incontinent diversion, such as an ileal conduit, where urine continuously drains into an external collection bag worn on the abdomen. The ability to store urine internally and empty it via a small, discreet stoma—often placed in the navel or lower abdomen—can significantly improve a patient’s quality of life and body image. However, candidates for this complex surgery must possess the manual dexterity and cognitive ability to consistently perform self-catheterization and pouch maintenance.
Surgical Creation and Storage Mechanism
The creation of the Indiana Pouch involves using a segment of the patient’s own gastrointestinal tract to build the new reservoir. Surgeons typically isolate a section of the large intestine, including the right colon and the cecum. This intestinal segment is then surgically reshaped and opened up to transform its tubular structure into a spherical, low-pressure reservoir. This reshaping, known as detubularization, prevents the intestinal segment from contracting, ensuring the pouch can safely store urine without high internal pressure.
The mechanism that maintains continence and prevents urine leakage is a critical component of the pouch. The procedure incorporates the ileocecal valve, the natural one-way valve located where the small intestine joins the large intestine. This valve is reinforced and utilized to prevent the involuntary escape of urine. The ureters, which carry urine from the kidneys, are then reattached to the back wall of the newly formed pouch to allow continuous drainage.
The channel used for catheterization is constructed from a short segment of the small intestine (ileum). One end of this segment is sewn into the pouch, and the other end is brought through the abdominal wall to form the stoma. The reinforced ileocecal valve acts as an internal, pressure-sensitive barrier. When the pouch is full, the increased internal pressure compresses the valve, keeping the stoma sealed until the patient inserts a catheter to drain the contents.
Living with and Managing the Indiana Pouch
Managing the Indiana Pouch requires a consistent routine of intermittent self-catheterization to empty the reservoir throughout the day. Patients insert a clean catheter directly into the stoma, gently guiding it through the continent channel and into the pouch until urine begins to flow. This process is generally painless because the stoma channel has very few nerve endings.
The typical schedule requires emptying the pouch every three to five hours during the day, aiming for a functional capacity of about 500 to 600 milliliters. Patients may need to set an alarm to empty the pouch overnight to prevent overfilling, which can cause leakage or long-term stretching of the reservoir. Complete drainage is important, and patients may need to slightly adjust the catheter’s position to ensure all urine has been removed.
Long-term maintenance involves managing the natural production of mucus by the intestinal tissue used to construct the pouch. Since this tissue is designed to line the bowel, it continues to secrete mucus in its new role as a urinary reservoir. This mucus can accumulate, clogging the catheter or acting as a nidus for the formation of urinary stones. To combat this, patients must perform regular pouch irrigation, typically once a day, using a sterile saline solution flushed through the catheter. This flushing action helps to break up and clear the mucus, maintaining the health and function of the pouch.