Living with an Indiana Pouch

Reviewed by: HU Medical Review Board | Last review date: September 2017.

Radical cystectomy is a type of surgery that is used to treat patients with invasive bladder cancer, in which the cancer cells have spread into the muscle of the bladder wall or there are tumors that are located in more than one area of the bladder.1 During a radical cystectomy, the surgeon typically removes the patient’s entire bladder, part of the ureters (the thin tubes that connect the bladder to the kidneys), and the lymph nodes that surround the bladder. In male patients, the surgeon usually removes the prostate and seminal vesicles in addition to the bladder, parts of the ureters, and lymph nodes. In female patients, the surgeon may also remove the uterus, ovaries, fallopian tubes, cervix, and sometimes part of the vagina.

What is an Indiana pouch (continent diversion)?

After the bladder is removed, the surgeon typically uses reconstructive surgery to create a different way for the patient to store and pass urine out of the body. One option for this is called a continent diversion, which is also called an Indiana pouch reservoir.

Diagram of an Indiana Pouch, connected to a stoma

To create a continent diversion, the surgeon creates a pouch out of a small part of the patient’s own intestines. The pouch is used to store urine inside the patient’s body until the patient is ready to drain the urine out of the body. One end of the pouch is attached to the ureters, with connection to the kidneys and allows urine to flow into the pouch. The other end of the pouch is connected to a small opening in the patient’s abdomen, which is called a stoma.

How does an Indiana pouch work?

The surgeon creates a one-way valve to keep urine inside the pouch until the patient is ready to empty it.1,2 When the patient is not emptying the pouch, a small bandage is placed over the stoma. Typically, a patient will empty the pouch every four to six hours using a catheter (a thin, flexible tube) that is inserted through the stoma and into the pouch. This allows urine to flow out of the pouch reservoir and into the toilet. Before and after inserting the catheter into the stoma, patients should wash their hands as well as wash and then dry the stoma and the skin around the stoma. Patients also need to regularly use a syringe to flush out any mucus that collects in or around the stoma.

What are the advantages of an Indiana pouch?

The different types of reconstructive options following radical cystectomy all have advantages and disadvantages.1 Your healthcare providers will talk with you about whether the Indiana pouch reservoir is a good option for you. Some patients prefer the Indiana pouch reservoir because it allows urine to be kept in a pouch inside the body, rather than in an external pouch outside the body (which is used in an ileal conduit or incontinent diversion). The Indiana pouch also has a lower chance of leaking or creating an odor than an ileal conduit, for example.

What are the disadvantages of an Indiana pouch?

However, the surgery to create an Indiana pouch takes a longer time and is more complex than the surgery to create an ileal conduit. Patients are also required to empty the Indiana pouch reservoir on a regular basis around the clock, while patients with an ileal conduit have other options that do not require nighttime emptying. If urine is left for too long in the pouch without emptying it, it can cause bacteria to grow and lead to infections.

Adjusting to an Indiana pouch

Adjusting to life with a continent diversion takes time, but many patients find they are able to resume their normal routines and activities, including most sports and other types of physical exercise.2 Patients usually have no problem returning to work as usual after they have recovered from surgery, unless they have certain jobs that require strenuous physical activities that may need to be adjusted.

To help reduce the chance of vitamin B deficiency that can sometimes develop in patients with a continent diversion, healthcare providers may recommend that some patients receive regular vitamin B injections.

Self-consciousness and sexual effects

Some patients may feel self-conscious or worried about how other people may react to their continent diversion. However, because the Indiana pouch reservoir stores urine inside of the body, most people would never notice that the patient has one.

Patients may also be concerned about the sexual effects of a radical cystectomy and continent diversion. However, many patients are able to return to having a comfortable and enjoyable sex life after they recover from surgery. Your healthcare providers can talk with you about special techniques and other ways to protect the stoma during sexual activities.

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