Endoscopic techniques have been used extensively, however with mixed results, but are generally accepted now, when more selectively applied, taking the importance of adequate phenotyping of BPS/IC into account. Neurosurgical procedures have a decreasing role. Major surgery has an important but limited role; the various procedures are extensive and in principle irreversible for a condition that otherwise implies a very modest risk of death or life-threatening complications. Many factors must be taken into account. Apart from the more immediate problems intra- and postoperatively, there are less obvious ones like metabolic consequences [1] and the late development of cancer after incorporation of bowel into the urinary tract [2]. Since 1990 the attitude has not changed but rather been strengthened: reconstructive procedures have been and are still to be regarded as last resorts, to be used very selectively when there is nothing else with reasonable efficacy to be offered.

The decision of which type of reconstruction to choose in BPS/IC might be difficult, especially since a somewhat greater selection of methods has been used during the last decades. The judgement to perform a big operation evolves over a longer period of time and should always be preceded by thorough and appropriate patient counselling, to communicate not only possible gains but even more the potential risks with the procedure, and to give the patient realistic expectations. Every patient scheduled for a complicated reconstruction must be thoroughly assessed. He/she must cope with the long-term consequences; continent urinary diversion and cystoplasty both require a patient with cognitive ability and a good manual dexterity to be able to perform intermittent catheterization if and when necessary. A fact to discuss is the high risk of reoperation for patients with a continent cutaneous stoma. A careful preoperative assessment of renal and bowel function is a necessity when calculating the amount of bowel needed for the reconstruction [3]. In contrast to the urothelium the bowel mucosa has a significant permeability to ammonium chloride, the resorption of which may bring about hyperchloremic metabolic acidosis. A patient with compromised kidney function can have difficulties in compensating for this and as a consequence, continent urinary diversion can only be offered to patients with a glomerular filtration rate in excess of 40 mL/min/1.73 m² body surface. Furthermore, the isolation of an ileal segment may compromise bile acid reabsorption which in turn may result in diarrhea and even, particularly in patients with preoperatively compromised anal sphincter function, anal incontinence [1]. Uptake of folic acid/cobolamin may likewise be compromised.

Cystoplasty with supratrigonal cystectomy is standard with a long tradition (see e.g. Kay and Straffon) [4–6]. In Chap. 22 of the book from 1990 it is stated that the “treatment goal is to convert a high-pressure, non-compliant, small capacity bladder to a low-pressure, compliant, high capacity reservoir”. When sticking to that goal you are essentially on the safe side. In fact, our hard-earned experience is that the patient who definitely benefits from a major operation, with incorporation of bowel into the urinary tract, is the patient with end-stage classic interstitial cystitis and severely reduced bladder capacity, at the stage when bladder wall inflammation has burned out [7]. Before that fact is realized and severe symptoms rather than critical clinical parameters determine indications for surgery, frustration for the patient and the doctor is unavoidable [8] even with more extensive surgery including continent and incontinent urinary diversion [9].