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CASE REPORT Table of Contents   
Year : 2002  |  Volume : 12  |  Issue : 1  |  Page : 87-88
Case report : Calculi in a continent urinary diversion [Indiana] pouch

Department of Radiology, Regional Cancer Centre, Trivandrum, 695024, India

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Keywords: Calculi, Continent urinary diversion, Indiana pouch

How to cite this article:
Kumar B, Ramachandran K, Jayaprakash P G, Krishnakumar A S, Venugopal M. Case report : Calculi in a continent urinary diversion [Indiana] pouch. Indian J Radiol Imaging 2002;12:87-8

How to cite this URL:
Kumar B, Ramachandran K, Jayaprakash P G, Krishnakumar A S, Venugopal M. Case report : Calculi in a continent urinary diversion [Indiana] pouch. Indian J Radiol Imaging [serial online] 2002 [cited 2020 Jul 9];12:87-8. Available from:
A variety of urinary diversion procedures are used for patients following cystectomy for invasive carcinoma of the urinary bladder. With continent urinary diversions, an external appliance for collection of urine is not required. Instead, bowel segments are used to create a reservoir that can be self-emptied by clean intermittent catheterization by the patient through a continent abdominal stoma. Indiana pouch is such a cutaneous pouch which uses the caecum as the reservoir. Calculi formation in the pouch is one of the complications associated with continent urinary diversions. Here we present a case of calculi in an Indiana pouch with a brief review of literature.

   Case Report Top

A 57 year old woman presented at our Review clinic with right flank pain of six months duration. She had undergone total cystectomy and cutaneous continent urinary diversion [Indiana pouch] seven years back for transitional cell carcinoma of the urinary bladder. One year following surgery, the patient was diagnosed to have adenocarcinoma of the cervix following bleeding per vagina and underwent chemotherapy and radiotherapy. The patient had been advised to be on regular follow-up after the diversion surgery but was non-compliant and did not have a medical checkup for the previous two years. On examination, the patient was afebrile and had a non-tender hard mass in the right iliac fossa and lumbar region. Her abdominal stoma was patent and she used to empty about 1.5 liters of urine by self-catherisation daily.

A plain radiograph of the abdomen obtained revealed multiple faceted pyramid shaped radio-opaque shadows clumped in the right iliac fossa suggestive of calculi in the urinary diversion pouch [Figure - 1]. Trans-abdominal sonogram showed hyper-echoic areas with dense posterior shadowing consistent with calculi in the region of the palpable lump. A Foley's catheter introduced through the patient's abdominal stoma could be pushed to reach the calculi. The kidneys were normal without any calculi. Plain CT sections obtained showed the calculi as hyper-dense areas of around 1000 HU. The patient was advised surgical removal of the calculi but refused further treatment.

   Discussion Top

Continent urinary diversion procedures have become the widely accepted surgical treatment for patients with invasive carcinoma of the urinary bladder [1],[2]. Most use the caecum and/or the ileum as the reservoir. Organised peristaltic contractions which increase pressure in the reservoir leading to urinary reflux and hydronephrosis, can be avoided by detubularization-methods that disrupt the tubular nature of the bowel[1],[3]. Urinary reservoirs that open on the abdominal wall are referred to as cutaneous [3]. If the urethra is intact, the reservoir can be anastomosed with it; such a pouch is called an orthotopic neobladder. One of the popular continent urinary diversions is the Indiana pouch which used the detubularized caecum as the reservoir. Here, the ureters are tunneled into the posterior taenia of the caecal segment and the plicated terminal ileum is used as the catheterizing channel. The intact ileo-caecal valve contributes to maintain continence[4].

Complications of continent urinary diversions can be broadly classified into early and late[5],[6]. Early postoperative complications include urine leak, fistula formation, small bowel obstruction, abscess formation and pyelonephritis. Late complications are incontinence, difficult catheterization, urinary tract infection and stone formation in the reservoir. Radiology plays an important role in the assessment of these complications. In the immediate postoperative period, contrast studies are performed to assess the pouch volume, leakage and reflux. Upper tracts can be evaluated with intravenous pyelogram or ultrasound. Abscesses can be evaluated with USG or CT. Calculi in the urinary reservoir are well demonstrated with plain radiographs.

Stones may form in the pouch as early as four to five months post-operative. The reported incidence of calculi in the Indiana pouch diversion is 2.9 to 12.9% [2],[6],[7]. Most of these stones are composed of struvite [magnesium ammonium phosphate] and are thought to be secondary to infection by urea splitting organisms. Small crystals and intestinal mucus that remain in the reservoir can act as the nidus for stone formation. Incidence of pouch calculi was noted to be higher in patients with lower 24- hour urine volume. Periodic urine culture and eradication of infection, proper emptying and irrigation of the pouch and a good water intake help prevent calculi formation in the pouch. Our patient was negligent in pouch irrigation and did not have a urine examination for an unacceptably long period. Pouch calculi can be removed surgically or by using an endoscope. Trans-stomal management of calculi in the Indiana pouch is time consuming and may compromise the continence mechanism. A percutaneous surgical approach is therefore generally performed for removal of calculi in Indiana pouches [2],[6],[8].

In summary, continent urinary diversion procedures following radical cystectomy have been widely accepted. Calculi formation in the pouch is one of the complications associated with these procedures. When present, these calculi are well demonstrated with plain radiographs.

   References Top

1.Amis ES Jr, Newhouse JH, Olsson CA. Continent urinary diversions: Review of current surgical procedures and radiological imaging, Radiology 1988; 168: 395-401.  Back to cited text no. 1    
2.Terai A, Ueda T, Kakehi Y et al. Urinary calculus as a late complication of the Indiana continent urinary diversion: Comparison with the Koch pouch procedure. J Urol 1996; 155: 66-68.  Back to cited text no. 2    
3.Chris Ng, Amis ES Jr. Radiology of continent urinary diversion. RCNA 1991; 29 (3): 557-570.  Back to cited text no. 3    
4.Rowland RG, Mitchell ME, Bihrle R, Kahnoski RJ, Piser JE. Indiana continent urinary reservoir. J Urol 1987; 137: 1136-1139.  Back to cited text no. 4  [PUBMED]  
5.Keogan MT, Can L, McDermott VG, Leder RA, Webster GE. Continent urinary diversion procedures: Radiographic appearances and potential complications. AJR 1997; 169: 173-178.  Back to cited text no. 5    
6.Benson MC, Olsson CA. Continent urinary diversions. UCNA 1999; 26 (1): 125-147.  Back to cited text no. 6    
7.Rowland RG, Kropp BP. Evolution of the Indiana continent reservoir. J Urol 1994; 152: 2247.  Back to cited text no. 7  [PUBMED]  
8.Assimos DG. Editorial: Nephrolithiasis in patients with urinary diversion. J Urol 1996; 155: 69-70.  Back to cited text no. 8  [PUBMED]  

Correspondence Address:
B Kumar
Department of Radiology, Regional Cancer Centre, Trivandrum, 695024
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Source of Support: None, Conflict of Interest: None

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