Florida Pouch
The Florida pouch is a continent cutaneous reservoir made from detubularized right colon, emptied through a doubly plicated distal ileal outlet reinforced at the ileocecal valve. Lockhart, Pow-Sang and colleagues developed the procedure at the University of South Florida beginning in 1986. The group's experience helped establish direct, nontunneled ureterocolonic implantation as an option in a low-pressure reservoir.[1][2][3]
Its evidence base is predominantly historical, uncontrolled institutional experience.
Historical Development
- 1986. The first Florida pouch operations were performed at the University of South Florida.[1][3]
- 1989. Bejany and Politano (Miami) described nontunneled, nonrefluxing ureterocolonic implantation in 32 patients with a continent colonic reservoir and a tapered distal ileum, and in six with bladder replacement or unidiversion using an ileocolonic segment. The success rate was 96% in 76 anastomoses (January 1986 to June 1988).[16]
- 1990. Lockhart reported 92 patients (65 followed for 6–46 months) and compared three reimplantation techniques.[1]
- 1991. The series was expanded to 107 patients.[6]
- 1992. Pow-Sang reported 20 conversions to a Florida pouch I or II.[7]
- 1993. Helal analyzed direct reimplantation in 190 patients.[2]
- 1995. Helal described a trans-reservoir technique for refractory ureterointestinal obstruction.[9]
- 1999. Masel compared a flap-valve outlet with the doubly plicated outlet.[8]
- 2003. Webster reported the long-term cohort (mean follow-up 133 months).[3]
Selection and Operative Principles
As with other continent cutaneous reservoirs, the patient needs suitable bowel, motivation and manual ability for lifelong catheterization, and adequate renal and hepatic reserve. The EAU guideline lists debilitating neurologic or psychiatric illness, limited life expectancy, and severe renal or liver impairment as contraindications to continent diversion.[4] Discuss the demands of catheterization and mucus management alongside conduit and orthotopic alternatives. Age alone is not a reason to select or exclude a reservoir.[4][5]
| Component | Description |
|---|---|
| Storage reservoir | Extended right colon opened and reconfigured to reduce storage pressure. Detubularization reduces coordinated contraction but does not eliminate bowel activity. |
| Catheterizable outlet | Distal ileum narrowed by double-row plication, with reinforcement at the ileocecal valve. The construction must provide resistance to leakage while allowing reliable catheter passage. |
| Ureteral anastomoses | The early series included tunneled techniques; subsequent experience used direct mucosa-to-mucosa ureterocolonic implantation. |
| Abdominal stoma | A catheterizable outlet requiring attention to reach, blood supply, alignment and the patient's access. |
The operative sequence is bowel isolation with preservation of its vascular supply, restoration of ileocolic continuity, reservoir reconfiguration, ureteral implantation, outlet construction and secure initial drainage. Segment dimensions, channel calibration, stoma configuration and catheter duration vary by modification and intraoperative findings.[1][3][6]
Florida pouch I construction
The USF group's description follows this sequence.[1][3][6]
- Isolate the right colon (cecum and ascending colon) and the distal ileum, preserving the ileocolic vascular pedicle. Published Florida-pouch constructions may also include the right half of the transverse colon.[19]
- Restore bowel continuity.
- Open the colon along its antimesenteric border to make a wide bowel plate.
- Fold and suture the plate into a spheroidal reservoir, closing the posterior wall first.
- Implant the ureters directly: make a small colotomy, then anastomose each spatulated ureter mucosa to mucosa over a stent, without a submucosal tunnel.[2]
- Taper the distal ileum with two rows of plication sutures along its antimesenteric border and reinforce the plication at the ileocecal valve.
- Close the anterior wall.
- Bring the distal end of the plicated ileum through the abdominal wall as a flush catheterizable stoma, usually in the right lower quadrant.
- Leave a drainage tube in the reservoir during initial healing.
The published reports give segment lengths and catheter sizes that vary by series. The stoma is covered with a small gauze, cap or adhesive strip to protect clothing from mucus and occasional dribbling.[6]
Primary Construction and Conversion
Florida pouch I describes the right-colon reservoir construction. Florida pouch II describes a conversion that preserves a usable pre-existing conduit and functioning ureteroenteric anastomoses, incorporating that bowel into the new reservoir. Other conversions discard the old conduit or use it as a patch with new implantation. The operative plan therefore depends on conduit condition, renal drainage and the existing anastomoses.[7]
In the Florida II technique, the preserved conduit is opened along its antimesenteric border and patched onto the new right-colon reservoir. Functioning ureteroileal anastomoses are left undisturbed, and the doubly plicated ileal outlet is built as in Florida I. In six conversions, the conduit was preserved and functioning ureterointestinal reimplantations were left undisturbed (Florida pouch II). Those reimplantations drained satisfactorily without postoperative obstruction, and reflux was not demonstrated in six of them.[7]
| Feature | Florida pouch I | Florida pouch II |
|---|---|---|
| Indication | Primary construction or conversion with new ureteral implantation | Conversion preserving a usable conduit and functioning ureteroenteric anastomoses |
| Reservoir | New right-colon reservoir | Right-colon reservoir with the detubularized conduit as a patch |
| Ureteral implantation | New direct implantation into the colonic reservoir | Functioning existing anastomoses left in place |
| Outlet | Doubly plicated distal ileum | Doubly plicated distal ileum, newly constructed |
Pow-Sang's 1992 report included 20 conversions, with both Florida I and II approaches. Patients reported improved quality of life. Pre-existing obstruction was important: five of seven previously obstructed renal units failed to recover after reimplantation. Preserving a functioning anastomosis is different from leaving a diseased or obstructed unit unaddressed.[7]
Conversion may increase the amount of bowel excluded from gastrointestinal function. In Webster's later cohort, seven of 12 patients converted from another diversion (58%) had metabolic alterations, compared with 6.4% of the remainder (p = 0.0001).[3] The authors related this to the longer bowel segments resected. In Webster's small conversion subgroup, the 58% rate supports careful metabolic surveillance.[3] In the conversion series, 15 of 20 patients (75%) had mild hyperchloremia and two (10%) had acidosis.[7]
Functional Results and Their Limits
| Study | Population and follow-up | Findings |
|---|---|---|
| Lockhart 1990 | 92 operated; 65 followed for 6–46 months, mean 17 months | 63/65 continent between catheterizations; four required reoperation. The approximately 6% reoperation figure belongs to this early follow-up.[1] |
| Lockhart 1991 | Expanded institutional report of 107 patients | Seven reoperations were reported. Serial urodynamic stability at 3–4 years was assessed in only six patients.[6] |
| Webster 2003 | 179 originally operated during 1986–1991; 105 died of primary disease or were lost, leaving 74 for analysis | Mean follow-up 133 months; five had incontinence.[3] |
In the first series, urodynamics in 28 patients showed mean capacity 747 mL and mean maximum reservoir pressure 35 cm H₂O, with wide ranges.[1] Catheterization must be individualized to output, capacity, pressure and drainage; the early reports used 4–6-hour intervals. New leakage should prompt assessment of storage and outlet function rather than automatic tightening of the channel.[1][8]
A 13-patient pilot compared the doubly plicated outlet (8 patients, mean 51 months from surgery) with a flap-valve outlet (5 patients, mean 14 months). It included only successfully functioning reservoirs.[8]
| Parameter | Doubly plicated | Flap valve |
|---|---|---|
| Volume at first desire to empty | 692.7 mL | 403 mL |
| Maximal enterocystometric capacity | 876.5 mL | 515 mL |
| Pressure at first desire to empty | 19.5 cm H₂O | 19.2 cm H₂O |
| Maximal reservoir pressure | 25.9 cm H₂O | 24.6 cm H₂O |
| Maximal outlet pressure, reservoir empty | 57.5 cm H₂O | 51.2 cm H₂O |
| Maximal outlet pressure, reservoir full | 50.5 cm H₂O | 52.6 cm H₂O |
| Functional outlet length | 24.3 cm | 24.6 cm |
Volume at first desire and maximal capacity were significantly lower with the flap valve (p < 0.05). Outlet pressure varied more in the doubly plicated group.[8]
Direct Versus Tunneled Ureteral Implantation
Helal's 1993 experience included 165 patients with 326 directly implanted ureters within a 190-patient Florida-pouch cohort. Obstruction occurred in 16/326 directly implanted ureters (4.9%), compared with 4/30 earlier tunneled implants (13.3%). The sequential, nonrandomized comparison is affected by selection and technical evolution.[2]
| Series | Technique | Ureters | Success (no reflux or obstruction) |
|---|---|---|---|
| Lockhart 1990 | Modified Le Duc (tunneled) | 4 | 75% [1] |
| Goodwin transcolonic (tunneled) | 26 | 88.6% [1] | |
| Direct nontunneled | 91 | 90.1% [1] | |
| Lockhart 1991 | Modified Le Duc (tunneled) | 4 | 75.0% [6] |
| Goodwin transcolonic (tunneled) | 26 | 84.7% [6] | |
| Direct nontunneled | 165 | 87.4% [6] |
In the 1991 series, obstruction occurred in 13.3% of tunneled and 4.2% of nontunneled reimplantations.[1][6]
Reflux was observed in 23 direct implants (7%), without demonstrated deterioration during the reported conservative follow-up. Three of six plicated megaureters with direct implantation obstructed.[2]
Obstruction and revision
Suspected obstruction requires assessment of renal drainage and salvageable function. Helal's historical trans-reservoir revision report treated five ureteral anastomoses after failed balloon dilation and stenting. All drained adequately at follow-up of up to 45 months. The approach avoids transabdominal adhesiolysis. A preoperative percutaneous stent helps locate the meatus, the ureter is mobilized into the reservoir lumen, the scarred segment is excised, and a new direct mucosa-to-mucosa reimplantation is done over a stent.[9]
In Helal's series, 23 obstructed units were managed as follows.[2]
- Three obstructed renal units (13%) lost function through autonephrectomy.[2]
- Twenty (87%) had percutaneous balloon dilation and internal stenting for 6–8 weeks.[2] Twelve of the 20 (60%) recovered function, three (15%) had pyelonephritis requiring nephrectomy, and five (25%) stabilized after a new reimplantation.[2] See Upper Tract Reconstruction Principles.
Long-Term Complications
Webster's 74-patient cohort had mean follow-up of 133 months. Patient-based outcomes and ureter-based outcomes have different denominators.[3]
| Outcome | Observed count |
|---|---|
| Peristomal hernia | 3/74 patients |
| Incontinence | 5/74 |
| Stomal stenosis | 3/74 |
| Difficult catheterization | 1/74 |
| Reservoir stones | 4/74 |
| Persistent diarrhea | 2/74 |
| Renal failure | 2/74 |
| Low B12 | 3/74 |
| Severe acidosis | 4/74 |
| Obstruction after primary ureteral implantation | 7/108 ureters |
| Obstruction after repeat implantation | 4/24 ureters |
| Obstruction in irradiated ureters | 4/14 ureters |
Irradiated ureters had more obstruction than primary implants in this selected series (28.4% versus 6.3%, p = 0.02). Repeat reimplantation also had more obstruction (16.4%), without a significant difference (p = 0.23).[3]
Relationship to the Miami and Other Right-Colon Pouches
Florida, Indiana and Miami reservoirs share ileocolic tissue and an ileocecal outlet concept, with differences in reservoir reconfiguration, plication and ureteral implantation.[10][11]
A modern Miami series included 15 patients at median 39 months.[12] Its continence definition required catheterization at intervals of no more than four hours; two patients reported nocturnal leakage when intervals extended to 5–7 hours.[12] In a separate retrospective comparison, continence was 11/14 for Miami versus 12/17 for ileal Mitrofanoff/Monti reservoirs, while cutaneous-tube stenosis occurred in one versus eight patients.[13]
For the relevant construction, see Indiana Pouch, Right Colon Pouch, Mainz Pouch I, and Kock Pouch.
Follow-up
Lifelong functional follow-up should address catheterization, continence, stoma condition, stones, renal drainage, acid–base status and bowel symptoms. New difficulty catheterizing, pain, fever or impaired drainage warrants assessment. Acute abdominal pain warrants urgent evaluation for pouch rupture, especially after overdistension or traumatic catheterization.[18] Hematuria, chronic urinary infection or hydronephrosis in a catheterizable ileocecal reservoir also warrants consideration of pouch endoscopy to evaluate for a secondary tumor.[17] Following cancer cystectomy, AUA/ASCO/SUO Statement 31 advises laboratory assessment every 3–6 months for 2–3 years and annually thereafter.[5] The EAU bladder cancer guideline states that B12 should be measured annually after cystectomy with bowel diversion (guideline text, not a graded recommendation).[14] Increase monitoring when renal or metabolic abnormalities are present.[5][14]
In routine follow-up, the 2026 EAU guideline gives a Strong recommendation not to screen or treat asymptomatic bacteriuria in patients with reconstructed lower urinary tracts.[15] Obtain cultures for clinical indications; before a urological procedure breaching urinary mucosa, the 2026 EAU guideline gives a Strong recommendation to screen for and treat asymptomatic bacteriuria.[15] Cancer follow-up should reflect the original disease, separately from lifelong reservoir surveillance.
See Urinary Diversion Principles, Vitamin B12 Supplementation, Urinary Acidifiers and Alkalinizers, and Mucus Management.
References
1. Lockhart JL, Pow-Sang JM, Persky L, et al. "A Continent Colonic Urinary Reservoir: The Florida Pouch." J Urol. 1990;144(4):864–7. doi:10.1016/s0022-5347(17)39610-6
2. Helal M, Pow-Sang J, Sanford E, Figueroa E, Lockhart J. "Direct (Nontunneled) Ureterocolonic Reimplantation in Association With Continent Reservoirs." J Urol. 1993;150(3):835–7. doi:10.1016/s0022-5347(17)35626-4
3. Webster C, Bukkapatnam R, Seigne JD, et al. "Continent Colonic Urinary Reservoir (Florida Pouch): Long-Term Surgical Complications (Greater Than 11 Years)." J Urol. 2003;169(1):174–6. doi:10.1016/S0022-5347(05)64061-X
4. European Association of Urology. EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. 2026. Urinary diversion, section 6.7.5. Guideline.
5. American Urological Association / American Society of Clinical Oncology / Society of Urologic Oncology. Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/SUO Guideline (2017; Amended 2020, 2024). Statements 13–14 and 31–32 and discussions. Guideline.
6. Lockhart JL, Pow-Sang JM, Persky L, Sanford E, Helal M. Results, complications and surgical indications of the Florida pouch. Surg Gynecol Obstet. 1991;173(4):289–296. PMID:1925899.
7. Pow-Sang JM, Helal M, Figueroa E, et al. "Conversion From External Appliance Wearing or Internal Urinary Diversion to a Continent Urinary Reservoir (Florida Pouch I and II): Surgical Technique, Indications and Complications." J Urol. 1992;147(2):356–60. doi:10.1016/s0022-5347(17)37236-1
8. Masel JL, Austin PF, Spyropoulos E, et al. "Evaluation of Flap Valve as an Alternative Continence Mechanism in the Florida Pouch." Urology. 1999;53(3):506–9. doi:10.1016/s0090-4295(98)00566-4
9. Helal MA, Figueroa TE, Pow-Sang J, Sanford E, Lockhart JL. A trans-reservoir technique for correction of ureterointestinal obstruction in continent urinary diversion. J Urol. 1995;153(4):1108–1109. doi:10.1016/S0022-5347(01)67521-9. PMID:7869474.
10. Farnham SB, Cookson MS. "Surgical Complications of Urinary Diversion." World J Urol. 2004;22(3):157–67. doi:10.1007/s00345-004-0429-5
11. Fisch M, Thüroff JW. "Continent Cutaneous Diversion." BJU Int. 2008;102(9 Pt B):1314–9. doi:10.1111/j.1464-410X.2008.07976.x
12. Baboudjian M, Gondran-Tellier B, Michel F, et al. "Miami Pouch: A Simple Technique for Efficient Continent Cutaneous Urinary Diversion." Urology. 2021;152:178–83. doi:10.1016/j.urology.2021.02.004
13. Pattou M, Baboudjian M, Pinar U, et al. "Continent Cutaneous Urinary Diversion With an Ileal Pouch With the Mitrofanoff Principle Versus a Miami Pouch in Patients Undergoing Cystectomy for Bladder Cancer: Results of a Comparative Study." World J Urol. 2022;40(5):1159–65. doi:10.1007/s00345-022-03954-z
14. European Association of Urology. EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. 2026. Functional follow-up, section 7.4. Guideline.
15. European Association of Urology. EAU Guidelines on Urological Infections. 2026. Reconstructed lower urinary tracts and asymptomatic bacteriuria, sections 3.3.5.d.5 and 3.3.7. Guideline.
16. Bejany DE, Suarez G, Penalver M, Politano VA. "Nontunneled ureterocolonic anastomosis: an alternate to the tunneled implantation." J Urol. 1989;142(4):961–963. doi:10.1016/s0022-5347(17)38953-x
17. Kälble T, Hofmann I, Riedmiller H, Vergho D. "Tumor growth in urinary diversion: a multicenter analysis." Eur Urol. 2011;60(5):1081–1086. doi:10.1016/j.eururo.2011.07.006
18. Kalogirou C, Kocot A, Mulfinger P, et al. "Diagnosis and Clinical Management of Ruptured Ileocecal Pouches for Continent Cutaneous Urinary Diversion." Urol Int. 2017;98(3):274–281. doi:10.1159/000452452
19. Barone B, Napolitano L, Reccia P, et al. "Advances in Urinary Diversion: From Cutaneous Ureterostomy to Orthotopic Neobladder Reconstruction—A Comprehensive Review." J Pers Med. 2024;14(4):392. doi:10.3390/jpm14040392