Long-term complications related to the modified Indiana pouch

To describe a single-institution, single-surgeon experience with 125 modified Indiana pouches performed during a period of 14 years and their long-term complications. The modified Indiana pouch is a widely accepted and often used form of continent urinary diversion. Few studies have established the long-term complication rates associated with the procedure.

A retrospective chart review of 129 modified Indiana pouches constructed from March 1985 to August 1998 was performed, and the long-term complications and reoperation rates were tabulated.

Complete information was obtained for 125 of the 129 charts, with a mean follow-up of 41.1 months (range 3 to 127). Complications occurred in 112 patients (89.6%; several patients had more than one complication), with a mean onset of 20.4 months (range 1 to 125) postoperatively. Seventy-three complications (58.4%) were due to the efferent limb, of which incontinence (defined as any leakage) was the most common (35 [28.0%]), followed by stomal stenosis in 19 (15.2%) and difficult catheterization in 12 (9.6%). Of the 26 pouch-related problems (21.8%) that occurred, the most common were stones in 13 (10.4%), perioperative leaks in 5 (4.0%), and perforations in 4 (3.2%). Ureteral anastomotic strictures were seen in 9 (7.2%). Other complications included gallstones in 32 (25.6%), kidney stones in 8 (6.4%), and small bowel obstruction in 6 (4.8%). Reoperation was performed in 65 patients (52.0%; several patients with more than one reoperation). Twenty-six (20.8%) of the patients required an open operation, and 39 (31.2%) received minimally invasive (percutaneous, endoscopic, extracorporeal shock wave lithotripsy) procedures. Sixty percent of the reoperations were minimally invasive. Reoperation was due to stomal stenosis in 18 (14.4%), pouch stones in 13 (10.4%), ureteral strictures in 9 (7.2%), and parastomal hernias in 6 (4.8%). Small bowel obstruction required reoperation in 5 patients (4.0%).

In our experience, long-term complications of the modified Indiana pouch were mostly related to the efferent limb, and reoperations were usually due to stomal stenosis. Our data suggest that with longer follow-up, the complication and reoperation rates of the modified Indiana pouch appear to be higher than previously reported.