The Koch pouch is a continent ileal reservoir. It has several advantages over the standard ileal conduit. The pouch can be attached to the skin (cutaneous type) or the male urethra (orthotopic type). Both variations have special imaging considerations. The suggested imaging protocol is based upon experience with 47 patients (22 with orthotopic and 25 with cutaneous pouches). The normal appearance of the new and mature pouch and its complications and their management are presented.