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Indiana Augmentation Cystoplasty (IAC)

Indiana augmentation cystoplasty (IAC), also described within the continent cutaneous ileocecocystoplasty (CCIC) family, uses a colonic augment joined to the native bladder and a tapered terminal-ileal channel with a reinforced ileocecal continence mechanism. It provides reservoir enlargement and an abdominal catheterizable route from one bowel harvest. The ureters can remain in the native bladder when no separate ureteral reconstruction is indicated, avoiding routine ureteroenteric anastomoses.[1][2]

This differs from the Indiana Pouch, a separate urinary reservoir commonly constructed after cystectomy. For design rules common to every catheterizable channel, see Principles of Continent Catheterizable Channels.

Lineage and Concept​

The Indiana pouch was developed in 1984 as a modification of the Gilchrist ileocecal reservoir. Full detubularization of the reservoir was recognized early and was achieved either with an ileal patch on the cecal reservoir or with an antimesenteric incision of the cecum, folding and transverse closure. The efferent limb and continence mechanism were modified to ease catheterization and improve continence, and these changes gave lower reoperation rates.[5][6]

StepModification
1984Original Indiana pouch, developed from the Gilchrist procedure[5]
1991 (Ahlering)Modified Indiana pouch: complete detubularization of the colonic segment, an easier appendectomy, transcolonic ureteral reimplantation and reinforced plication of the ileocecal junction[7]
1992 (Sarosdy)Cutaneous ileocecocystoplasty incorporated the native bladder into the reservoir and avoided routine ureterointestinal anastomoses.[19]
1994 (Rowland and Kropp)Full detubularization, stapled tapering of the efferent limb, plication of the ileocecal valve and tunneled tenial implants[6]
1996 (Rowland)Absorbable GIA and TA55 staples used to detubularize and close the reservoir in 20 patients, with shorter operating times[5]
IAC (Khavari, Boone)Adaptation of the Indiana principle to augment a native bladder in neurogenic patients[1]

Video-urodynamic study of the Indiana pouch found that continence depends on the combined effect of ileocecal valve resistance, resistance from plication of the ileal segment, ileal peristalsis and the low intraluminal pressure of the detubularized bowel.[8]

Selection​

Consider IAC when both a low-pressure reservoir and a catheterizable abdominal channel are needed, with suitable bowel anatomy and the ability of the patient or caregiver to manage lifelong catheterization. Assess renal and metabolic reserve, bowel function, prior ileocecal resection, abdominal access, and stoma reach. A channel alone may be sufficient when storage capacity and pressures are already safe. AUA/SUFU states that clinicians may offer augmentation cystoplasty to select NLUTD patients who are refractory to or intolerant of less invasive therapies for detrusor overactivity and/or poor bladder compliance , and may offer continent catheterizable channels with or without augmentation to facilitate catheterization .[1][3][4]

The ureters may remain implanted in the native bladder when no separate ureteral reconstruction is indicated. IAC does not automatically correct obstruction, reflux independent of storage pressure, or an unsafe outlet. Bladder-neck closure, a sling, or an AUS may be selected for outlet dysfunction, but none is an obligatory step.[1] Before an outlet procedure in a patient with relevant NLUTD, assess bladder storage parameters with urodynamics when the procedure could worsen compliance and raise storage pressure, threatening the upper tracts.[4]

Operative Principles​

  1. Plan the whole urinary and bowel reconstruction. Determine reservoir size, outlet management, stoma site, and catheterization access. Mark the site with the patient's usual posture and mobility aids in mind.
  2. Harvest a well-vascularized ileocecal segment. Length and extent of colonic mobilization depend on the chosen configuration and anatomy. Preserve perfusion and restore bowel continuity without tension. Ahlering's modified Indiana pouch used the terminal 8 to 12 cm of ileum and 26 to 30 cm of right colon on the ileocolic pedicle, with an appendectomy.[7] In a single-surgeon CCIC series, 10–15 cm of cecum and ascending colon plus 10–13 cm of terminal ileum were harvested en bloc; the ileal channel was tapered over a 12–14 Fr catheter.[20]
  3. Detubularize the reservoir component. Open the colon along its antimesenteric border, reconfigure the augment and leave the intended ileal channel tubular. Incomplete detubularization of the cecum produced pouch deformity in the first two Indiana pouches in one series.[13] Avoid narrowing the junction with the native bladder.
  4. Construct the continence mechanism. Taper the terminal ileum by suture plication or by linear stapling along the antimesenteric border, and reinforce the ileocecal junction with seromuscular plication according to the selected technique. Confirm easy catheter passage; excessive narrowing risks obstruction.[9][7]
  5. Join the augment to the widely opened bladder. Tailor accompanying ureteral or outlet procedures to documented anatomy and function.
  6. Route and mature the stoma. Avoid tension, mesenteric twist, and angulation. Establish dependable early drainage and a plan for later catheterization or stoma failure.[1][3]

Historical Indiana-pouch descriptions used different bowel lengths, sutures, and stapling modifications. Staple composition depends on the device; native-bladder augmentation dimensions vary by technique.[5][6][7]

The continence mechanism depends on the valve or channel construction and low reservoir pressure. A 21-reservoir urodynamic comparison of plicated versus stapled ileum found only a nonsignificant trend toward higher mean contraction pressure with stapling (p=0.054).[8][9]

Direct Outcomes and Maintenance Burden​

StudyFindingsLimits
Khavari 2012, 34 neurogenic patients, median 31 monthsAll were continent at last follow-up; 15/34 (44.1%) had long-term complications, including four stomal revisionsRetrospective, selected single-center cohort; additional outlet procedures in some patients; 1993–2010 was the treatment period[1]
Cheng 2020, 114 adults, median 40 monthsMajor complications by three months in 18/114 (15.8%); 24/114 (21.1%) readmitted; 48/114 (42.1%) had additional related surgery; 23/114 (20.2%) had channel revision; 11/114 (9.6%) abandoned the channelMulticenter retrospective CCIC experience[2]
Redshaw 2014, 61 adults, median 16 monthsChannel intervention in 4/31 CCIC versus 15/30 tunneled-channel patients (OR 6.4, 95% CI 1.8–28 for tunneled channels); reported stomal leakage 29% versus 43% was not significantly differentShort, nonrandomized comparison; 30-day postoperative complications occurred in 51.7% after CCIC versus 40% after tunneled channels[10]

Patients need to understand both functional benefit and the long-term care burden.

Standard Indiana Pouch and IAC Compared​

FeatureStandard Indiana pouchIAC
Usual indicationDiversion after cystectomyNeurogenic bladder needing augmentation and a continent stoma
Native bladderRemoved at cystectomy or left in situ but excluded from the pouch[18][21]Preserved and augmented
ReservoirStand-alone ileocecal pouchNative bladder plus ileocecal augment
UretersReimplanted into the pouchMay remain in the native bladder when separate reconstruction is not indicated
Continence mechanismPlicated ileocecal valve and tapered ileumSame
OutletNot applicableClosed, slung, given an AUS or left intact according to function

In the Khavari series, concurrent procedures were bladder neck closure (n = 3), pubovaginal sling (n = 4), hysterectomy (n = 3), artificial urinary sphincter (n = 1) and cystolithotomy (n = 1) among 34 patients.[1]

Indiana Pouch Reference Data​

The post-cystectomy and benign-indication Indiana pouch has a longer literature than IAC and uses the same continence mechanism.

StudyPopulationFindings
Rowland and Kropp 1994[6]First 69 patients treated with the evolved technique, minimum 2-year follow-upDay and night continence 97% by 1 year; pouch-related reoperation 17% (early plus late)
Arai 1993[13]76 Kock and 39 Indiana pouches; long-term group 68 Kock (mean 53 months) and 37 Indiana (mean 34 months)Surgical revision 22.1% (Kock) vs 10.8% (Indiana); stones 26.5% vs 5.4%; continence satisfactory in both. Kock complications were mostly nipple-valve malfunction and reactions to a nonabsorbable collar
Holmes 2002[14]125 modified Indiana pouches, mean follow-up 41.1 monthsAny complication in 112/125 (89.6%); 73 efferent-limb complication events (58.4 per 100 patients), including leakage in 35/125 (28.0%), stomal stenosis in 19/125 (15.2%), and difficult catheterization in 12/125 (9.6%). Pouch stones occurred in 13/125 (10.4%), perforation in 4/125 (3.2%), ureteral anastomotic stricture in 9/125 (7.2%), gallstones in 32/125 (25.6%), kidney stones in 8/125 (6.4%), and small bowel obstruction in 6/125 (4.8%); 65/125 (52.0%) underwent reoperation, 60% by minimally invasive methods
Wilson 1994[15]130 modified Indiana pouchesLate complications 12%; ureteral obstruction 7%. Balloon dilation with or without incision of ureteral strictures failed in 83%, and ureteral reimplantation succeeded in 10 of 11. Of the late complications, 56% occurred in patients with 3,000 to 6,500 rad of prior pelvic radiation; the authors advised shorter ureteral tunnels and an ileal patch at initial construction in irradiated patients
Burns 2022[16]137 open cystectomy with Indiana pouch, 2012 to 2018Reoperation 7.3% within 90 days and 8% at 90 to 365 days; readmission 18.2% early and 13.1% midterm
Kim 2024[17]97 pouches after robot-assisted cystectomy, median follow-up 93 monthsContinence 99.0%; Clavien III to V complications 17.5% at 30 days and 22.7% at 90 days; readmission 21.4%
Polm 2024[18]33 tertiary-center surveillance attendees (23 female) after pouch creation without a urologic cancer indication (including three with gynecologic malignancy), median follow-up 258 months22/33 (67%) had at least one surgical revision (45 revision procedures); estimated mean revision-free survival 198 months

Complications accumulate with follow-up, and short series understate the burden. When the ureters remain in the native bladder, IAC avoids new ureteroenteric anastomoses; native-tract obstruction remains possible.[1][14]

Complications​

  • Stomal or channel obstruction. Stenosis, angulation, redundancy, or a tight continence mechanism can impair catheterization. Repeated forceful catheter attempts risk false passage, and an acutely undrainable reservoir needs prompt urologic care. In a patient with SCI at or above T6, suspect autonomic dysreflexia if drainage fails; monitor blood pressure and restore drainage urgently.[23]
  • Leakage. Evaluate reservoir pressure, emptying, and the outlet or channel.
  • Stones, mucus, and symptomatic infection. They are common reasons for ongoing treatment or intervention. Bacteriuria alone is not an indication for antibiotics in a stable NLUTD patient.
  • Bowel and abdominal complications. Ileus, obstruction, bowel anastomotic problems (including ileocolic leak), and hernia remain relevant after bowel harvest. A single-surgeon retrospective CCIC series reported ileocolic anastomotic leak in 2/56 (3.6%) patients.[20]
  • Metabolic and nutritional effects. Intestinal urine contact may cause hyperchloremic acidosis. Terminal ileal or ileocecal harvest may contribute to B12 or bile-salt malabsorption and altered bowel function.
  • Perforation and malignancy. Long-term augmentation risks persist and require symptom awareness and follow-up.[1][11][12][3][2][4]

Ileocecal harvest sacrifices the ileocecal valve. Transit time shortens, and malabsorption and diarrhea may follow, particularly after prior bowel resection or in patients with myelomeningocele who already have frequent defecation. Fisch described functional reconstruction of the valve by embedding ileum in the ascending colon through a submucosal tunnel; the report combined experiments in 15 dogs with first clinical experience in 12 patients.[11]

Terai measured B12 in 27 Indiana pouch patients. None had a serum level below 200 pg/mL, and the mean was lower than in ileal conduit patients (536 vs 727 pg/mL). On the Schilling test, 4 of 6 Indiana pouch patients (and 3 of 9 with Kock pouches) were B12 malabsorbers, and none had megaloblastic anemia or neurologic symptoms.[12] In a later 33-patient Indiana pouch series without a urologic cancer indication (median follow-up 258 months), 6/33 (18%) required B12 supplementation for deficiency.[18] Record the actual bowel segment used and monitor nutritional status over time.[4]

Follow-Up​

For NLUTD patients who have had lower urinary tract reconstruction incorporating bowel, the AUA/SUFU guideline states that the clinician should assess the patient annually with a focused history, physical examination and symptom assessment, a basic metabolic panel and urinary tract imaging .[4] For patients who remain at high risk of upper-tract deterioration, the 2026 EAU guideline describes upper-tract ultrasonography approximately every six months and strongly recommends risk-adjusted follow-up.[24] Clinicians should perform cystoscopy when gross hematuria or symptomatic recurrent UTI develops after such reconstruction .[4] The AUA/SUFU diagnosis and evaluation guideline advises against treating asymptomatic bacteriuria in NLUTD patients , except during pregnancy or before procedures expected to disrupt urothelium or manipulate the upper tract.[22]

The statement text advises monitoring B12 over time, with supplementation if appropriate, when terminal ileum is used.[4] For NLUTD patients whose impaired storage or voiding places the upper tracts at risk, the AUA/SUFU guideline recommends repeat urodynamics at an appropriate interval after treatment .[4] Reviews of catheterization, stoma function and irrigation needs fit into the same visit. Sudden abdominal pain or sepsis may indicate reservoir perforation.

Videos​

Continent Catheterizable Ileal Cecocystoplasty
Neurogenic Bladder Research Group, University of Utah
Hand-Assist Laparoscopic Continent Cutaneous Ileocecal Cystoplasty
Sean Elliott, MD (2026)

References​

1. Khavari R, Fletcher SG, Liu J, Boone TB. A modification to augmentation cystoplasty with catheterizable stoma for neurogenic patients: technique and long-term results. Urology. 2012;80(2):460–464. doi:10.1016/j.urology.2012.03.038

2. Cheng PJ, Keihani S, Roth JD, et al. Contemporary multicenter outcomes of continent cutaneous ileocecocystoplasty in the adult population over a 10-year period: A Neurogenic Bladder Research Group study. Neurourol Urodyn. 2020;39:1771–1780. doi:10.1002/nau.24420.

3. Cheng PJ, Myers JB. Augmentation cystoplasty in the patient with neurogenic bladder. World J Urol. 2020;38(12):3035–3046. doi:10.1007/s00345-019-02919-z

4. Ginsberg DA, Boone TB, Cameron AP, et al. The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-Up. J Urol. 2021;206(5):1106-1113. doi:10.1097/JU.0000000000002239.

5. Rowland RG. Present experience with the Indiana pouch. World J Urol. 1996;14(2):92–98. doi:10.1007/BF00182564

6. Rowland RG, Kropp BP. Evolution of the Indiana continent urinary reservoir. J Urol. 1994;152(6 Pt 2):2247–2251. doi:10.1016/s0022-5347(17)31651-8

7. Ahlering TE, Weinberg AC, Razor B. Modified Indiana pouch. J Urol. 1991;145(6):1156–1158. doi:10.1016/s0022-5347(17)38561-0

8. Juma S, Morales A, Emerson L. The mechanisms of continence in the Indiana pouch: a video-urodynamic study. J Urol. 1990;143(5):973–974. doi:10.1016/s0022-5347(17)40154-6

9. Carroll PR, Presti JC. Comparison of plicated and stapled continent ileocecal stoma. Urology. 1992;40(2):107–109. doi:10.1016/0090-4295(92)90504-p

10. Redshaw JD, Elliott SP, Rosenstein DI, et al. Procedures needed to maintain functionality of adult continent catheterizable channels: a comparison of continent cutaneous ileal cecocystoplasty with tunneled catheterizable channels. J Urol. 2014;192(3):821–826. doi:10.1016/j.juro.2014.03.088

11. Fisch M, Wammack R, Spies F, et al. Ileocecal valve reconstruction during continent urinary diversion. J Urol. 1994;151(4):861–865. doi:10.1016/s0022-5347(17)35107-8

12. Terai A, Okada Y, Shichiri Y, et al. Vitamin B12 deficiency in patients with urinary intestinal diversion. Int J Urol. 1997;4(1):21–25. doi:10.1111/j.1442-2042.1997.tb00133.x

13. Arai Y, Kawakita M, Terachi T, et al. Long-term followup of the Kock and Indiana pouch procedures. J Urol. 1993;150(1):51–55. doi:10.1016/s0022-5347(17)35394-6

14. Holmes DG, Thrasher JB, Park GY, Kueker DC, Weigel JW. Long-term complications related to the modified Indiana pouch. Urology. 2002;60(4):603–606. doi:10.1016/s0090-4295(02)01945-3

15. Wilson TG, Moreno JG, Weinberg A, Ahlering TE. Late complications of the modified Indiana pouch. J Urol. 1994;151(2):331–334. doi:10.1016/s0022-5347(17)34940-6

16. Burns R, Speir R, Kern SQ, et al. Early and midterm complications of the continent catheterizable Indiana pouch urinary diversion: a 7-year experience. Urology. 2022;167:229–233. doi:10.1016/j.urology.2022.04.016

17. Kim AH, Ruel NH, Yamzon J, et al. Indiana pouch continent cutaneous urinary diversion after robotic-assisted radical cystectomy: a 16-year experience. Urology. 2024;183:e325–e327. doi:10.1016/j.urology.2023.10.023

18. Polm PD, Wyndaele MIA, de Kort LMO. Very long-term follow-up of Indiana pouches proves durability. Neurourol Urodyn. 2024;43(5):1090–1096. doi:10.1002/nau.25344

19. Sarosdy MF. "Continent urinary diversion using cutaneous ileocecocystoplasty." Urology. 1992;40(2):102–106. doi:10.1016/0090-4295(92)90503-o

20. Fendereski K, Daryabari SS, Stockard R, McCormick B, Myers JB. "Bowel complications and anastomotic leak after ileocolic anastomosis in urinary diversion surgery: a comparative 12-year retrospective single-center study." Transl Androl Urol. 2024;13(11):2468–2481. doi:10.21037/tau-24-453

21. Vrijens D, Oerlemans D, Delaere K. "Continent urinary diversion in women with spinal cord injury." ICS/IUGA Annual Meeting; 2010; abstract 559. Conference abstract

22. Ginsberg DA, Boone TB, Cameron AP, et al. "The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Diagnosis and Evaluation." J Urol. 2021;206(5):1097–1105. doi:10.1097/JU.0000000000002235

23. NSW Agency for Clinical Innovation. "Treatment of Autonomic Dysreflexia for Adults and Adolescents with Spinal Cord Injuries: A Guide for Clinicians in Non-specialist Units." Sydney: ACI; 2024, revised March 2025. Guideline

24. Blok B, Hamid R, Hentzen C, et al. "EAU Guidelines on Neuro-Urology." EAU Guidelines Office, Arnhem; limited update March 2026. Full guideline