The Indiana Pouch is a continent urinary reservoir, meaning no bag is necessary to store the urine outside the body. Instead of a bag, the right colon is removed from the rest of the bowel and re-fashioned into a pouch that can hold 600mL of fluid (equivalent to about two soda cans). The portion of small bowel that is naturally attached to this part of the colon has a natural valve in it that prevents urine from leaking. This part is brought out to the skin so that a catheter can be inserted six times per day to drain the pouch of its urine. Infections and stone formation can happen, so it is important to also wash the pouch (called irrigating) daily.
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. It is also important to ensure that patients have adequate cognition as well as dexterity.
In 1954, a urologist in Chicago named Kennedy Gilchrist, MD 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 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.
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, Richard Bihrle, MD arrived at IU after completing residency training at the Lahey Clinic where he 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 Bihrle. After seeing both procedures, he proposed that they combine them. This was the beginning of the development of the Indiana Pouch.