Since its creation in 1985 at Indiana University, the continent ileocecal reservoir, or Indiana Pouch, has been a standard urinary diversion option for patients who desire a continent urinary diversion. Indiana University School of Medicine Department of Urology professor emeritus Richard Bihrle, MD was one of the original developers of this technique and has performed over 300 of these surgeries. Below, Bihrle answers some common questions about this procedure.
What were the main unmet needs that led to the development of the Indiana Pouch?
To answer that question, we need to review some history of the urinary diversion options. In 1954, Kennedy Gilchrist, MD in Chicago had described his experience with an ileocecal segment. The cecum was nondetubularized, the ileocecal valve was not plicated and the full diameter of the ileum was used. Around that same time, Eugene Bricker, MD from Washington University described the ileal conduit. Due to its relative simplicity, the Bricker method was more widely-adopted and remains the most commonly employed urinary diversion option at cystectomy to this day.
In the 1980s, there were several key developments in the field of urinary diversion that led to the development of the Indiana Pouch. In 1980, Paul Mitrofanoff, MD described continent diversion utilizing a catheterizable appendicovesicostomy. This established what has since been termed “the Mitrofanoff principle.” In 1981, Nils Kock, MD described the continent catheterizable ileal reservoir (Kock Pouch), which relied on an intussuscepted ileal nipple valve for continence. In 1984 Maurice Camey, MD described his experience with Camey Enterocystoplasty. In this procedure, the ileum essentially serves as a “Y” conduit between the ureters and the urethra.
The summative effect of the work of all of these pioneers was that the pediatric, reconstructive and urologic oncology communities were pooling their experience, knowledge and surgical acumen in the developing of continent alternatives to Bricker’s ileal conduit. Interestingly, at IU School of Medicine, this collaboration was facilitated by a chief resident named Vince Thomalla, MD. In the early 1980s, Michael Mitchell, MD began performing the Gilchrist ileocecal reservoir procedure on children with neurogenic bladders. Subsequently, I arrived at IU after completing my residency training at the Lahey Clinic where I had trained with John Libertino, MD and Leonard Zinman, MD in performing their ileocecal segment procedure. Thomalla had performed the Gilchrist procedure with Mitchell and was subsequently scrubbed into an ileocecal segment diversion with me. After seeing both procedures, he proposed that we combine the them. This was the beginning of the development of the Indiana Pouch.
What was the most difficult hurdle to overcome in the initial development of the Indiana Pouch?
When we first started constructing the Indiana Pouch, we were not detubularizing the colon and cecum. We performed the procedure this way on the first 10 patients and they were incontinent, as the reservoir was too high pressure. Therefore, we decided to detubularize the colonic segment from that point on and went back and detubularized six of the first 10. This resulted in significantly improved continence. This was the most important alteration in technique in achieving continence, as it prevented unicontraction of the colon and resulted in a low-pressure reservoir. There was actually a period of time where we would take a segment of detubularized ileum and patch the reservoir to increase capacity. Eventually we found that if we detubularized all the way down into the cecum longitudinally and folding to colon over, we could achieve similar capacity while also simplifying the surgery (figure 1).
What part of the Indiana Pouch procedure has the steepest learning curve? Do you have any tips for someone who is learning this surgery?
I believe that plication the ileocecal valve is the most difficult part of the surgery to master and one of the most important parts in achieving continence.
After using a stapler to narrow the caliber of the ileal afferent limb (a technique that we borrowed from Lockhart at University of Miami that improved ease of catheterization, figure 2), the surgeon should place a 12-Fr red robinel catheter into the afferent limb and through the ileocecal valve. Then they should squeeze the ileocecal valve around the catheter and mark it with a pen right below their fingers. Imbricating seromuscular stitches should then be placed along this pen mark with nonabsorbable suture (figure 3).
It will feel tighter than one would think it needs to be. The surgeon should feel a gentle pop when passing a 14-Fr soft red rubber catheter (notice the catheter change) across the imbricated valve. I like doing the plication after detubularizing the colon, but before closing it horizontally so that I can actually see the internal side of the valve.
What are the most important points to cover when counseling a patient on whether or not to pursue an Indiana Pouch?
As with any reconstructive surgery, patient selection is the most important aspect to ensuring a good outcome. Extensive counseling is required before a patient can make a truly informed decision. Patients have to be willing to be strictly compliant with catheterization every four to six hours. Also, it is important to ensure that patients have adequate cognition as well as dexterity. These last two factors are particularly important, given that many of these patients are elderly and/or have neurologic disorders. Constructing a perfectly functioning Indiana Pouch in the wrong patient can turn into a real problem for patients, family members and their urologists.
Is there an ideal patient for an Indiana Pouch?
Not necessarily, but I would say that younger patients tend to do better. Also, they need to be truly motivated by their desire to avoid an external appliance.
Along those same lines, what do you find to be the main factor the leads to a patient selecting an Indiana Pouch vs. orthtopic continent urinary diversions and visa-versa?
I find that the factor that leads patients to choose the Indiana Pouch of the neobladder is the concern for neobladder hypercontinence requiring urethral catheterization. Conversely, the patient perception of being more anatomically intact tends to motivate patients to choose the neobladder over the Indiana Pouch.
Richard Bihrle, MD is the Dr. Norbert M. Welch, Sr. and Louise A. Welch Professor Emeritus of Urology at Indiana University School of Medicine Department of Urology. He continues to provide care for our patients and training for our medical students, residents, and fellows at Indiana University Health University Hospital as well as the Richard L. Roudebush Veterans Affairs Medical Center in Indianapolis.