Continent cutaneous diversion (Indiana pouch)
After the bladder is removed, a pouch made from the right side of the colon stores urine inside the body. You empty it by passing a thin catheter through a small, flat opening on the belly every 4 to 6 hours, and no bag is worn.
Also called Indiana pouch, continent cutaneous urinary diversion, continent urinary reservoir, continent urostomy, catheterizable pouch, Miami pouch, Kock pouch, Mitrofanoff
- Where
- Hospital operating room
- Anesthesia
- General anesthesia, often with an epidural or nerve block for pain control
- Time in the room
- 6 to 8 hours
- Hospital stay
- Usually 5 to 8 days
- Going home with
- A tube draining the pouch through the lower belly and a catheter in the stoma for about 3 weeks; stents for 1 to 3 weeks
- Back to normal
- About 3 months
- Back to work
- 8 to 12 weeks, depending on the job
Overview
A continent cutaneous diversion is a way to store urine inside the body after the bladder is removed. The best-known version in the United States is the Indiana pouch. The surgeon uses the right side of the colon (large bowel) to build a pouch, and the end of the small bowel attached to it to make a narrow channel that runs to a small opening on the belly, called a stoma. The ureters, which bring urine from the kidneys, are joined to the pouch.
Continent means the pouch holds urine without leaking. A natural one-way valve where the small bowel meets the colon is tightened to keep urine in. The stoma is small and flat, usually in the belly button or on the right lower belly, and is covered with a small bandage. Several times a day you pass a thin catheter through it to drain the pouch, and no bag is worn.
This option suits people who need their bladder removed, do not want an outside bag, and cannot have or do not want a neobladder, for example when cancer involves the urethra. It requires catheterizing about every 4 to 6 hours for life, flushing out mucus, good use of your hands, and kidneys that work well.
The bladder removal is the same operation as for an ileal conduit. Building the pouch adds time, and the recovery and follow-up take more effort. Many people who choose it value the freedom of not wearing a bag.
The parts of your body involved
Urine made by the kidneys flows down the ureters into the bladder and out through the urethra. On the right side of the belly, the small bowel ends where it joins the colon. This junction has a natural one-way valve, called the ileocecal valve, which normally keeps colon contents from flowing back. The first part of the colon, the cecum and ascending colon, is wide and stretchy. These features make the right colon and the end of the small bowel well suited to building a pouch with a built-in valve.
- Bladder and urethra
Removed with the cancer. In many people having this operation, the urethra is removed as well.
- Right colon
The first part of the large bowel. About a foot of it is reshaped into the pouch that stores urine.
- Ileocecal valve
The natural valve between the small bowel and colon. It is tightened to keep urine from leaking out of the stoma.
- End of the ileum
The last few inches of small bowel are narrowed to make the channel you pass the catheter through.
- Ureters
Joined to the pouch so urine flows into it from the kidneys.
- Belly button
A common place for the stoma because it is easy to reach and hidden from view.
Why it’s done
A continent pouch is chosen by people who need their bladder removed and want to avoid wearing a bag, when a neobladder joined to the urethra is not possible or not the best fit.
- The urethra cannot be used
If cancer involves the urethra, or the urethra must be removed, a neobladder is not possible. A continent pouch is the main bag-free option.
- No outside bag
Many people value a flat stoma covered by a small bandage, especially for swimming, intimacy and body image.
- When a neobladder may not work well
A weak sphincter, past pelvic radiation, or a high risk of trouble emptying can make a neobladder a poor fit.
- Problems with an earlier diversion
Some people with long-term problems from a conduit or neobladder are converted to a continent pouch.
- Commitment and ability
You need steady hands and good eyesight, or a reliable helper, and willingness to catheterize every few hours for life.
Other options
- Ileal conduit
A short piece of bowel carries urine to a stoma and into a bag. It is the simplest diversion, with the quickest recovery and the fewest later procedures.
- Neobladder
A bowel pouch joined to the urethra, so you urinate through the usual opening. It needs a cancer-free urethra and a working sphincter.
- Bladder-sparing chemoradiation
For selected muscle-invasive cancers, a thorough TURBT followed by radiation with chemotherapy can keep your own bladder, with lifelong cystoscopy.
- Partial cystectomy
Removing only the part of the bladder with the tumor. Suitable for very few bladder cancers.
Getting ready
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Weeks before
The week before
The day before
The morning of surgery
In the operating room, step by step
Press play or pick a step. Each drawing shows what your surgeon is doing at that moment. Your team may do some steps differently.
1. Anesthesia and positioning
You are given general anesthesia and lie flat on your back. Your skin is cleaned and covered with sterile drapes. A catheter is placed in your bladder.
More detail
Most Indiana pouches are built through open surgery. Some centers remove the bladder robotically and build the pouch through a smaller incision, or build it entirely with the robot.
After the operation
In the hospital
- Waking up
You wake with a pouch tube in the lower belly, a catheter in the stoma, stents, an IV and perhaps a drain. Most people go to a surgical floor.
- Flushing the tubes
The colon lining makes thick mucus that can block the tubes. Nurses flush the pouch with salt water several times a day and teach you and a helper how to do it.
- Moving early
Walk the evening of surgery or the next morning, and aim for 4 or more walks a day.
- Eating
Sips of liquid start early and food is added as the bowels wake up. Passing gas is a key sign of progress.
- Pain control
An epidural or nerve block, acetaminophen, anti-inflammatory medicine when safe, and as little opioid as possible.
- Preventing blood clots
Leg squeeze sleeves and blood thinner shots, which usually continue at home for about 4 weeks.
- Going home
Usually 5 to 8 days after surgery, with the tubes in place and draining into bags.
At home
- Tube care and flushing
Flush the tubes with sterile salt water as taught, usually 2 to 4 times a day, and any time they stop draining. Keep them taped securely so they do not pull.
- Tubes out at about 3 weeks
An X-ray with dye in the pouch checks for leaks. If it has healed, the stoma catheter is removed and you start catheterizing. The pouch tube is often capped and kept for a short time as a backup, then removed.
- Your catheter schedule
At first, catheterize every 2 to 3 hours by day and once or twice at night. Lengthen the gap by about 1 hour each week, aiming for every 4 to 6 hours by day, as your team advises. Never go much longer than 6 hours.
- Flushing out mucus
Flush the pouch with salt water through the catheter about once a day, or more if mucus is thick, to prevent blockage and stones.
- Always carry a catheter
Keep a spare catheter, lubricant and wipes with you at all times, and wear a medical ID that says you have a continent urinary pouch.
- Fluids
Drink about 8 to 10 cups a day to thin the mucus and avoid dehydration, unless told otherwise.
- Eating and bowels
Small, frequent meals with protein. Stools may be looser than before; fiber and, if needed, medicines from your team can help.
- Activity, lifting and driving
Walk daily. No lifting more than about 10 pounds for 6 weeks. Most people drive again after 2 to 4 weeks, once off opioid pain medicine.
- Showering
Showers are fine once your team says so. Avoid baths and swimming until the incision is healed and the tubes are out.
- Sex
Usually after about 6 weeks. Empty the pouch first. Men may need help with erections, and orgasm happens without fluid. Women may notice vaginal changes.
Recovery timeline
- Before surgeryChemotherapy, if recommended
About 2 to 4 months of cisplatin-based chemotherapy, then surgery 4 to 8 weeks later.
- Day 0Surgery
Most of the day in the operating room. You wake with several tubes.
- Days 1 to 4Walking, eating, flushing
Walking several times a day, first foods, and learning to flush the tubes.
- Days 5 to 8Home with tubes
Most people go home once eating and able to manage the tubes with help.
- About 3 weeksTubes out
After an X-ray confirms healing, the stoma catheter comes out and you start catheterizing on a schedule.
- Weeks 3 to 8Stretching the pouch
You catheterize often at first and slowly lengthen the time between, as the pouch stretches.
- 2 to 3 monthsSettling in
Most people are catheterizing every 4 to 6 hours and back to normal activities. The first follow-up scan is often around 3 months.
- Long termRegular checks
Scans and blood tests for kidney function, acid balance and vitamin B12, plus periodic checks of the pouch for stones.
What it feels like
People who choose a continent pouch usually do so for freedom from a bag. The early weeks with tubes and frequent catheterizing are demanding, and most people say that once the routine is set, it becomes as ordinary as brushing teeth.
Choosing it
A strong wish to avoid a bag, mixed with worry about catheterizing for life.
What helpsHold the catheters, see a picture of a healed stoma, and ask how often people in your surgeon's practice need further procedures.
Waking up
Many tubes, a sore belly and fatigue can feel overwhelming.
What helpsEach tube has a purpose and a planned removal date. Ask your nurse to explain each one.
Mucus and flushing
Thick mucus and frequent flushing can feel unpleasant and tiring in the first weeks.
What helpsMucus is normal. Flushing on a regular schedule prevents blockages and gets easier with practice.
The first catheterization
Nervousness about hurting the stoma or not finding the way in.
What helpsUse plenty of lubricant, relax, and slide the catheter in gently at a slight angle. The stoma is not painful to touch. Your nurse will guide you the first times.
The first nights
Alarms for catheterizing at night can be exhausting.
What helpsThe night gaps get longer as the pouch stretches. Many people eventually sleep through with one catheterization before bed and one on waking.
Carrying supplies
At first, many people worry about being caught without a catheter.
What helpsA small kit in a pocket, bag or car becomes second nature. Some people keep spares at work and with family.
Getting your life back
Relief at swimming, dressing and being intimate without a bag.
What helpsA small round bandage over the stoma is usually all that is needed between catheterizations.
How well it works
Success means the cancer is removed, the pouch holds urine without leaking between catheterizations, and the catheter passes easily every time. Most people achieve this, though a later minor procedure is more often needed than with a conduit.
- A dry stoma
Most people stay dry at the stoma between catheterizations once the pouch has healed and stretched.
- Easy catheterization
The catheter should slide in smoothly. Difficulty passing it is a reason to call, because the channel may be narrowing.
- Pouch size
Over a few months the pouch stretches to hold about 2 to 3 cups, which allows 4 to 6 hours between catheterizations.
- Blood tests and scans
Regular checks of kidney function, acid balance, salts and, after a few years, vitamin B12, plus imaging of the kidneys and pouch.
- Cancer follow-up
Scans every 3 to 6 months for the first 2 to 3 years, then yearly.
Risks
Every operation has risks. These are the ones people ask about most, with honest odds where good numbers exist. Your surgeon’s own results matter more than averages.
Common
Expected, especially early. Managed with regular flushing.
Bacteria often live in a pouch without harm. Infections with fever or pain are treated with antibiotics.
Bloating, nausea and vomiting while the bowels wake up after surgery.
Losing the valve between small bowel and colon can speed up digestion. Usually manageable with diet and medicines.
Often for dehydration, infection or slow bowels, as with any cystectomy.
Most men have weaker erections unless nerves could be spared, and no man ejaculates fluid. Women may notice vaginal changes.
Less common
The stoma or channel can narrow and make the catheter hard to pass, or the valve can leak between catheterizations. Leaking may improve as the pouch stretches. Either problem is often fixed with a small procedure.
Mucus and staples can form a seed for stones. Regular flushing lowers the risk; stones are removed with a scope.
The colon lining absorbs some acid and salt from stored urine, treated with fluids and bicarbonate tablets. Vitamin B12 can run low years later and is treated with shots or pills. Regular blood tests catch both.
Can block a kidney, sometimes months or years later. Treated with a tube, stent or surgery.
Prevented with walking, leg sleeves and blood thinner shots.
As with any cystectomy, a small number of people die within 90 days, more often older people and those with other serious illnesses.
Rare
Overfilling, often from a missed catheterization, or a blow to the belly can tear the pouch. This is an emergency that needs surgery.
Scar tissue can kink the bowel, sometimes years later.
Urine can leak from the pouch or where the ureters join it. Usually managed by keeping tubes in longer.
Rarely the channel heals poorly and needs to be rebuilt.
Call your care team or go to the emergency room if
- You cannot pass the catheter into the stoma after a few gentle tries with fresh lubricant and a change of position, and your pouch feels full: go to the emergency room and tell them you have a continent urinary pouch.
- Fever of 101°F (38.3°C) or higher, or shaking chills.
- A tube stops draining and flushing does not clear it within 1 hour.
- Sudden severe belly pain, especially after a fall or a long time without catheterizing.
- Repeated vomiting, a swollen hard belly, or no gas or stool for more than 2 days.
- Unusual tiredness, weakness, confusion or deep fast breathing.
- The stoma turns dark or black, or the incision is red, swollen or draining pus.
- Pain or swelling in one leg, or sudden chest pain or shortness of breath: call 911.
Questions to ask your surgeon
- Why do you recommend a continent pouch for me instead of a neobladder or a conduit?
- How many continent pouches do you build each year?
- Will the stoma be in my belly button or on my right lower belly?
- Will my urethra be removed?
- How long will the tubes stay in, and who will teach me to flush them?
- What catheter schedule should I follow, and how quickly can I lengthen it?
- What should I do if I cannot pass the catheter, especially at night?
- How often do your patients need a later procedure on the stoma or pouch?
- What blood tests and scans will I need long term?
- Can nerves or, for women, the uterus and vagina be spared?
Words you may hear
- Continent cutaneous diversion
- An internal urine pouch emptied with a catheter through a small opening on the skin.
- Indiana pouch
- A continent pouch made from the right colon, with the end of the small bowel as the catheter channel.
- Ileocecal valve
- The natural one-way valve where the small bowel joins the colon, used to keep the pouch dry.
- Stoma
- The small opening on the belly through which the catheter is passed.
- Catheterizable channel
- The narrow tube of bowel leading from the stoma into the pouch.
- Clean intermittent catheterization
- Passing a catheter a few times a day to drain urine, then removing it.
- Pouch tube
- A larger tube through the lower belly that drains the pouch while it heals.
- Pouchogram
- An X-ray with dye in the pouch to check for leaks before the tubes come out.
- Mucus
- Slippery material made by the bowel lining that collects in the pouch.
- Irrigation
- Flushing the pouch with sterile salt water to clear mucus.
- Mitrofanoff channel
- A related type of channel made from the appendix, used in some continent diversions.
Common questions
Does catheterizing hurt?
No. The stoma and channel have no pain nerves like skin does. It may feel like pressure at first.
How long does each catheterization take?
Usually a few minutes, including draining. Flushing out mucus adds a minute or two.
Can I swim and exercise?
Yes, once you are healed. Only a small bandage is needed over the stoma.
What happens if I miss a catheterization?
The pouch fills up and may leak or feel uncomfortable. Overfilling again and again can stretch the pouch or, rarely, cause a rupture. Try not to go much longer than 6 hours.
Can I use any catheter?
Use the size and type your team recommends. Many people reuse catheters after washing, depending on their insurance and their team's advice.
Will my urine look different?
Yes. It will contain mucus, which looks like white strands or cloudiness. This is normal.
Is cancer control the same as with a conduit?
Yes. The cancer operation is the same; only the way urine is stored and drained differs.
Sources this page draws on
- American Urological Association, ASCO, ASTRO and Society of Urologic Oncology, Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline
- European Association of Urology, EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer
- International Consultation on Urological Diseases and European Association of Urology, ICUD-EAU International Consultation on Bladder Cancer 2012: Urinary Diversion (Hautmann and colleagues, European Urology) (2013)
- Journal of Urology, The Indiana continent urinary reservoir (Rowland, Mitchell and Bihrle) (1987)
- American Cancer Society, Bladder Cancer Surgery
Written November 2026. This page explains what usually happens. It is not medical advice and does not replace a conversation with your own surgeon, whose plan for you comes first.