Indiana Pouch Surgery

What to Expect During an Indiana Pouch

If you have muscle-invasive bladder cancer, your physician will most likely perform a radical cystectomy to treat you. During this surgery, your doctor removes your entire bladder. As a result, you need a new place to store urine.

To urinate, your body normally follows this process:

1. Your kidneys make your urine.
2. The urine travels to your bladder, which stores it until you urinate.
3. To urinate, you pass the urine through a tube called the urethra and out of your body.

During Indiana Pouch surgery:

1. Our urologists build a “new” bladder, or pouch, from your colon tissue.
2. The pouch then connects to a piece of intestine instead of the urethra.
3. This intestine routes to the skin, where it ends at a dime-sized opening called a stoma.

Patients drain urine from the pouch by putting a catheter into a stoma every four to six hours. The stoma is located in your right lower abdomen (self-catheterization). This process is not painful.

We’re among the few centers nationwide to offer an Indiana Pouch option as one of three possible bladder replacement surgeries. We can also help you if you’ve had bad results from an Indiana Pouch received elsewhere.

Benefits and Disadvantages of Bladder Replacement Options

Our urologists take the time to help you choose the best bladder replacement option for you. If there aren’t any medical reasons to choose one procedure over another, most decisions come down to:

• Level of urinary control
• Body image
• Lifestyle

1. Ileal conduit urinary diversion

During this surgery:

1. Your urologist makes a tube from the small intestine.
2. The kidneys drain urine into this tube.
3. The urine then leaves your body through a stoma.
4. You wear an external urostomy bag (about 3 by 10 inches in size) to catch and store the urine.

A urostomy bag is a plastic urine collection pouch. You attach the urostomy bag with adhesive to the outside of your body. Your urologist usually places it on your stomach to the right and slightly below the navel.

Ileal conduit urinary diversions have lower risks for complications than procedures that create a urine pouch inside of the body. But a urostomy bag can affect how you wear your clothes, especially if you prefer low-rise pants or shirts tucked in.

2. Neobladder reconstruction

During this surgery, your urologist makes an artificial bladder using a piece of your intestine. This new bladder stays inside your body.

Benefits of neobladder reconstruction include:

• You avoid a urostomy bag.
• You can urinate normally, without a stoma or catheter.
• Our research shows that people who choose the neobladder option have high body image satisfaction after surgery.

The disadvantages are that:

• Urine control often is not perfect. You may have problems with urine leaking at night, especially right after surgery. Night leaking usually improves as the pouch stretches and gets bigger over time.
• One in 10 patients has to periodically use a catheter (long, thin tube) to drain their urethra.

3. Indiana Pouch

Benefits of the Indiana Pouch include:

• You avoid a urostomy bag.
• You have normal urinary control day and night.
• Your urologist can put the stoma below your belt line. The stoma won’t be visible when you’re shirtless, such as when you’re at the beach.
• It’s a good option when cancer has spread to the urethra, and a neobladder reconstruction cannot be performed.
• Our research shows that, among the three options, people who choose the Indiana Pouch have the highest urine control satisfaction after surgery. Patients are also happy with their body image.

Disadvantages include:

• You can’t urinate normally and need to empty your pouch using a catheter.
• You a need to rinse out your stoma daily since it makes mucus.
• It’s a complex surgery.

Indiana Pouch Surgery at IU Health

The Indiana Pouch procedure is the most complicated of the three available options. Radical cystectomy to treat bladder cancer is also an extremely complex procedure. It carries a 30 to 35% risk for complications. That’s why it’s important to choose an institution that does a large number of bladder cancer surgeries. Research shows that this level of experience leads to more successful outcomes for patients.

Researchers and physicians at the Indiana University School of Medicine first developed and performed this breakthrough surgery in the 1980s. That’s why it’s named after “Indiana.” Today, IU Health is among the small group of U.S. institutions who use this procedure the most. Our urologists each perform several Indiana Pouches every month and around 30 to 60 per year—an extremely high amount.

Personalized care

Our urologists take the time to really get to know you and your goals. This knowledge helps them tailor the procedure to your needs and preferences.

For example, they pay attention to small details, such as how you prefer to wear clothing. That way, they can help you understand how each procedure will affect your daily routines and quality of life. We want you to select the option that will give you the best results while honoring your personal choices.

Preparing for Your Indiana Pouch Surgery

Before your procedure:

• You undergo an extensive evaluation to make sure you are healthy enough for bladder removal and Indiana Pouch surgery.
• You complete a bowel preparation to clean out your colon. This bowel prep is similar to one you would complete before a colonoscopy.

After Indiana Pouch

After your Indiana Pouch procedure:

• You have tubes connected to your body to drain various fluids, such as urine and mucus.
• Patients recover in the hospital for a week on average. Once you start having bowel movements again, you can usually go home.
• You return to our office for an X-ray to make sure the pouch is sealed. If it is, we take the tubes out. You start using a catheter to urinate on your own. If it isn't sealed, we’ll wait longer to take the tubes out.
• Patients typically lose about 10 to 15 pounds during recovery as their bodies adjust. Weight often stabilizes around six to eight weeks after surgery.
• After about a month and a half, you should be back to your normal activities.
• Over the next year, you can wait longer and longer to empty urine as your pouch stretches. Eventually, your pouch will be able to hold as much as a normal bladder.

Questions to Ask Your Surgeon or Urologist

• How much experience do you have performing Indiana Pouch procedures?
• How many Indiana Pouch procedures do you perform each year?
• How much experience do you have performing radical cystectomies?
• How many cystectomies do you perform each year?