Restorative proctocolectomy with ileo-pouch-anal anastomosis has become the elective surgical procedure of choice for most of our patients with ulcerative colitis and for selected patients with familial adenomatous polyposis. This report reviews the results of the outcome of patients who have undergone a more radical reconstructive approach for salvage of the pelvic pouch where multiple local procedures have failed. A group of 24 patients were reviewed (19 females, 5 males). The indication for surgery was ulcerative colitis in 22 patients; 10 of the 24 patients were referred from other centers. The 24 patients underwent a mean of 2.9 local salvage procedures per patient. Of the 19 females within the group, 12 had an anastomotic vaginal fistula. The 24 patients were divided into two groups. The first group consisted of 14 patients whose initial pouch was used once again for revisionary surgery. Group 2 comprised 10 patients whose initial pouch was removed and a redo pouch was constructed. Of the 24 patients, only 2 have had their pouches removed. More than 75% of the patients have had a successful outcome using a reconstructive approach. Four patients still have an ileostomy; of these four, two are awaiting closure of their loop ileostomy. Of 18 patients who were evaluable, 13 were considered to have normal daytime continence, and 17 of 18 were sexually functional. Of the 18 evaluable patients, 15 were satisfied with the outcome. Radical reconstructive surgery can be performed where local procedures to effect pouch salvage have failed, and it should be considered as a first-line management where factors dictate that local procedures might fail. The commitment of the surgeon and the patient to achieving a successful outcome is essential. Severe pouch-specific complications can be managed successfully by surgeons who have a specific interest in pelvic pouch surgery and have considerable experience dealing with complications that arise.