Gross painless hematuria often prompts patients to seek medical attention. For some persons, especially those aged 55 to 80 years, this hematuria will prove to be the result of bladder cancer. Patients found to have muscle-invasive disease commonly undergo radical cystectomy and urinary diversion. The decision about which urinary diversion will be best suited to the individual patient is complex and depends on multiple factors relating to the patient and the tumor as well as a clear understanding about the risks and benefits of each diversion. This article will discuss issues such as cancer control, preoperative and postoperative care, management of the condition at home, and quality of life associated with the various urinary diversion options, with a special emphasis on orthotopic neobladder reconstruction. Awareness of the special issues associated with this procedure is needed to safely counsel and care for patients with these forms of bladder substitution.