Orthotopic reconstruction to the native urethra has revolutionized urinary diversion, allowing patients to void per the urethra. This form of urinary diversion was initially performed solely in male patients after cystectomy. More recently, however, with a better understanding of the female continence mechanism, including the urethral/vaginal support mechanism, and the ability to select appropriate female candidates properly for this type of surgery, orthotopic reconstruction has become a viable option in women. Since November 1986, 24 women aged 53 years (range 17-76) have undergone orthotopic reconstruction using the ileal neobladder. Indications for cystectomy included transitional cell carcinoma of the bladder (8), fibrotic radiated bladder (4), interstitial cystitis (5), tuberculotic bladder (2), urge incontinence (2), neurogenic fibrotic bladder (2), and fibrotic bladder of unknown etiology (1). Nineteen patients are available with a median follow-up of 48 months (range 3 to 109 months). There were no perioperative deaths, with few early and late complications. Two women previously irradiated developed a neovesicovaginal fistula and had to be diverted by an ileal loop. Three patients from the far East are no longer available for follow-up. Ten years of experience with 24 patients have led to a nerve- and urethral-support-sparing cystectomy technique with the ileal neobladder anastomosed to the proximal urethra. However, even then, retention in 20% of the patients rather than the expected incontinence is the critical issue. Incontinence has never been a problem. The advent of orthotopic lower urinary reconstruction in women is a major achievement in the evolution of urinary diversion. With our increasing understanding of the continence mechanism in women and with increasing evidence that the female urethra can be safely preserved after cystectomy, orthotopic lower urinary tract reconstruction by the ileal neobladder can now be offered safely not only to males, but also to female patients undergoing cystectomy, and the functional results are superb.