Ulcerative colitis (UC) is a type of inflammatory bowel disease that can be managed medically with steroids, immunomodulators, biologics, and advanced therapies. Dysplasia screening is important in patients with longstanding disease owing to the significantly increased risk of malignancy. Surgery is indicated for medically refractory disease, dysplasia, or cancer. Ileal pouch anal anastomosis is the standard operation for UC and may be performed in one, two, or three stages depending on various patient factors. Ileorectal anastomosis and Koch pouch are alternative approaches to achieve bowel continuity and may be considered in select cases.