Age is an established risk factor for developing bladder cancer and is associated with increased stage and worse treatment outcomes. Furthermore, elderly patients who require radical cystectomy are more likely to undergo an incontinent urinary diversion compared with younger patients. To evaluate whether evidence exists to support performing an orthotopic neobladder in the elderly, we reviewed the literature to identify studies reporting outcomes, complications, patient-selection criteria, and quality-of-life data on elderly patients who underwent orthotopic neobladder following radical cystectomy. While age was shown to be a risk factor for complications following orthotopic neobladder, similar complication rates were reported between those who received either an orthotopic neobladder or ileal conduit when compared within age groups. Additionally, in properly selected elderly patients, similar outcomes and quality of life can be expected when compared with younger patients. It is appropriate to offer an orthotopic neobladder to well-selected elderly patients following radical cystectomy.