Indiana pouch for Extrophy bladder

1. INDIANA POUCH
in
EXSTROPHY BLADDER
Dr HAROON SABIR KHAN
FCPS (Surgery)
FCPS (Urology)

2. PATIENT PROFILE:
 Name: XYZ
 Age: 12 yrs
 Sex: Male
 Address: Multan, Pakistan

3. Presenting Complaints:
 Socially isolated
 Total incontinence of urine
 Short & broad phallus tethered upward

4. Past History :
Bladder closure in infancy
Personal History :
Family History :

5. GENERAL PHYSICAL
EXAMINATION:
 A shy boy with an offensive odor from his clothes
 Vital Signs:
BP: 120/ 80 mm Hg Pulse: 78/ min
Temp: 980F, Resp rate: 14/ min
 Other Signs:

6. Local Examination:
 Broad & short phallus
 Epispadiac meatus
 Old suprapubic scar

7. Local Examination:

8. Biochemical Profile:
 Hb 13.4gm
 TLC 5000/ml
 Urea 10mg/dl
 Creatinine 0.9mg/dl

9. Pre-Op Work Up:
 USG – KUB
 Bilaterally normal in size & echotexture
 Negligible size bladder
 CYSTOSCOPY
 Small and scarred bladder with negligible capacity

10. NEGLECTED CASE
of
EXSTROPHY BLADDER

11. PLAN
Continent Urinary Diversion
INDIANA POUCH

12. Pre-Op preparation:
 Parents counseling
 Blood 03 pints
 Bowel preparation
 Liquid diet for 02 days
 Picolax a day before op
 Oral antibiotics
 Stoma site marked

13. INDIANA POUCH

15. Ileocaecal plication

17. Closure of Reservoir

38. POST OPERATIVE CARE
 NPO & NG tube
 Ambulation 2nd PO day
 Oral fluids 5th PO day
 Pouch care daily saline wash
 Ureteric catheters removed on 12th PO day
 Intermittent catheterization 14th PO day

41. 06 MONTHS AFTER

45. FINAL OUTCOME
A HAPPY LAD WHO WAS FOR
THE
FIRST TIME SOCIALLY
ACCEPTABLE

46. CASE
DISCUSSION

47. TYPES OF URINARY
DIVERSIONS
 Incontinent
 Conduit
 Continent
 Catheterizable
 Orthotopic
 Rectosigmoid pouches

48. INDICATIONS for URINARY
DIVERSION
 Bladder cancer requiring cystectomy
 Neurogenic bladder conditions that threaten
renal function
 Severe radiation injury to the bladder
 Intractable incontinence in females

49. Brief History of Diversion
 Ureterosigmoidostomy
 First form of continent diversion
 Reported by Simon in 1852 (bladder exstrophy)
 Complications : sigmoid cancer, pyelonephritis,
ureteral stricture
 Ileal Conduit
 Described by Bricker in 1950
 Traditional gold standard for urinary diversion

50.  1851 - Ureteroproctostomy (Simon)
 1878 - Ureterosigmoidostomy
(direct anastomosis) (Smith)
 1898 - Rectal bladder (Gersuny)
 1950s - Ileal loop (Bricker)
 1959 - Ileal neobladder (Camay)
 1970s - Koch pouch
 Early 1980s - Indiana pouch
 Late 1980s - Orthotopic diversion

51. Catheterizable Diversions

52. Catheterizable Diversions
Name Bowel
segment
Continence
Mechanism
Primary comp
Kock Ileum Nipple valve Continence
mech failure
Indiana Ileocecal Tapered ileal
segment
Stones
Miami/Florida Right colon Tapered ileal
segment
Ureteral
obstruction
Penn Right colon Appendix Stomal revision
Mainz Ileum Intussuscepted
Ileal nipple
Nipple valve
malfunction

53. INDIANA POUCH
Easy and fast to make
Continence rate 94%
Dry intervals 4-6hrs
Pouch capacity 450-500ml
Transient Bowel obstruction 4.9%
Stone
Vitamin B12
Hyperchloremia

54. Conclusion:
INDIANA pouch remains one of the
most reliable of all catheterizable
reservoirs. It is amongst the easiest to
construct, and it has very low short- and
long-term complications.

55. Thank you.