When a urinary reservoir intended to replace the bladder is made from bowel, it should meet several requirements: good capacity, viscoelasticity and compliance, voluntary control of micturition without residual (infected) urine, a sensation of the filled state and urinary continence. In addition, there should be no major metabolic changes due to malabsorption after bowel resection or due to reabsorption of urinary constituents by the reservoir. In this review several conflicting aspects of bladder reconstruction are addressed: the persisting intestinal peristalsis and urinary incontinence, the volume of the reservoir and its metabolic impact, the bowel segment to be used and the amount that can be resected without the risk of long-term sequelae. Our clinical experience with ileal bladder substitutes in 80 patients underlines the theoretical aspects. After careful instruction, our patients increased the functional capacity of their reservoirs to 500 ml, a precondition for good urinary continence. Provided that the patients were regularly followed-up, the functional, clinical and metabolic results were good. The operative procedure was easy to perform, and no major metabolic sequelae occurred during a maximal observation time of 6 years. Nevertheless, continuing careful follow-up for the detection of potential long-term sequelae, such as disturbances in lipid metabolism or chronic bone demineralisation, are required before definitive statements on the role of intestinal bladder substitutes can be made.The therapeutic benefits of a radical cystectomy for invasive bladder cancer must be considered in the light of the impact of urinary diversion on the quality of life and the associated morbidity. Although today the ileal conduit is still considered to be the standard urinary diversion with * To whom correspondence should be addressed which any other form must be compared, the first attempt at continent urinary drainage, a case of ureterosigmoidostomy, was reported as early as in 1852 by J. Simon [40]. Various forms of intestinal segments were in use for continent urinary reservoirs and bladder substitutes at the turn of this century [46]. High rates of surgical, metabolic and infectious complications have precluded the widespread use of bladder substitutes. However, a better understanding of intestinal physiology, the metabolic implications of the use of the intestine as part 0fthe urinary tract and increasing knowledge of the urodynamic aspects of urinary continence have led to a r~ni~issance of continent diversion first in the 1950s and then again in recent years.The intestinal bladder substitute should be a low-pressure, capacious and high compliance reservoir that can be voided without residual urine as the patient desires. The state of fullness should be appreciable by the patient. The bladder should provide voluntary control of urine as well as continence. Renal functions must be preserved, but at the same time intestinal malabsorption, fluid and electrolyte imbalances and metabolic long-term sequelae caused by...