Indiana pouch
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, pelvic exenteration, bladder exstrophy or who are not continent due to a congenital, neurogenic bladder. This particular urinary diversion results in a continent reservoir that the patient must catheterize to empty urine. This concept and technique was developed by Drs. Mike Mitchell, Randall Rowland, and Richard Bihrle at Indiana University.[1]
Description
With this type of surgery, a reservoir, or pouch, is created out of approximately two feet of the ascending colon and a portion of the ileum (a part of the small intestine). The ureters are surgically removed from the bladder and repositioned to drain into this new pouch. The end of the segment 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 is utilized, also included in this new system is the ileal-cecal valve. This is a one-way valve located between the small and large intestines. This valve normally prevents the passage of bacteria and digested matter from re-entering the small intestine. Originally, it was thought that removing the ileal-cecal valve from the digestive tract would likely 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 (from the digestive tract) by absorbing more liquids and nutrients. Importantly, this valve, in its new capacity, will now effectively prevent the escape of urine from the stoma. The passage of the conduit through the abdominal wall allows the rectus abdominis muscle to aid with continence.
Recovery and function
The surgery itself along with recovery time take 7-10 days total. The abdominal incision for this surgery may be up to eight inches in length and is typically closed with staples on the outside and several layers of dissolvable stitches on the inside. After surgery, patients will have 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 (to drain non-specific post-surgical abdominal fluid). In the hospital, the SP tube and external staples will be removed, after several days. The remaining two tubes will each be connected to collection bags worn on each leg and the patient is usually sent home like this. After sufficient healing, and another doctor's visit, the tube will be removed from the stoma. The patient will now begin to catheterize the pouch every two hours. Since one other tube will still be in place, patients can still sleep through the night, since a larger collection bag is attached to that tube at night time. After approximately one month, patients will return to the hospital for a special x-ray. Dye will be instilled into the pouch to verify that there is no leakage of urine. 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 (every 3 hours) to empty the pouch. Over time, emptying time can increased up to 4–6 hours. The pouch will continue to expand and will reach its final size at approximately six months. The pouch will then hold up to 1,200 cubic centimeters (cc). Each day, the pouch will need to be irrigated with 60 cc 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.
Advantages
In contrast to other urinary diversion techniques, such as the Ileal conduit urinary diversion, 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 and broader clothing options. 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 plans. Nor will there be the need to monitor how many appliances are left or ordering more and waiting for them to be shipped.
Treatment
Indiana pouch surgery can be done in very young patients, as long as they understand how to catheterize the pouch and can empty the pouch on a schedule. Indiana pouch surgery also has been successful in patients of advanced ages, also as long as they are able to empty and irrigate the pouch on a schedule. Some patients, after having had an ileal conduit, requiring an external appliance, have opted to have the Indiana pouch, as elective surgery. Such a surgery is usually recommended, if possible, since it has been documented that the Indiana pouch may reduce the possibility of kidney damage because the ureters are repositioned lower in the abdomen. This positioning reduces the possible back-flow of urine to the kidneys. After having an Indiana pouch surgery, patients may choose to wear a medical alert medallion indicating they have an Indiana pouch.
References
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