Late complications of the modified Indiana pouch

The modified Indiana pouch is currently an accepted and widely used form of continent cutaneous urinary diversion. However, results of long-term followup and potential late complications are still being established. We report our experience with 130 modified Indiana pouches performed between September 1987 and September 30, 1991. In 16 patients (12%) late complications developed between 1 and 16 months after the pouch procedure. Ureteral obstruction developed in 9 of these patients (7%), including bilateral obstruction in 4. Balloon dilation with or without incision of ureteral strictures in 6 patients resulted in an 83% failure rate, while ureteral reimplantation was successful in 91% (10 of 11 cases). Reservoir dysfunction was the late complication in the remaining 7 patients. Urodynamic evaluation was essential in determining appropriate treatment for incontinence with either replication of the ileal segment or pouch augmentation with an ileal patch. Of the 16 late complications 56% occurred in patients who received between 3,000 and 6,500 rad of pelvic radiation before the urinary diversion. We conclude that the modified Indiana pouch is a successful form of urinary diversion with an acceptable complication rate. Ureteral balloon dilation with or without endoscopic incision of ureteral strictures has not been successful. However, patients can usually undergo successful ureteral reimplantation via an extraperitoneal approach with minimal morbidity. Previously radiated patients are at higher risk for complications and require shorter ureteral tunnels to avoid stricture, in addition to an ileal patch at initial construction.