Ulcerative colitis requiring surgical removal of the colon can be approached via four surgical options: previously (until 1975) by a Brooke ileostomy or ileorectostomy, and more recently by a Kock's continent reservoir ileostomy and ileal pouch-anal anastomosis. This review assesses the current surgical alternatives with particular emphasis on ileal-pouch anastomosis. Ileal pouch-anal anastomosis is described in detail, since this is the preferred method at the Mayo Clinic in patients in whom proctocolectomy is recommended. 390 patients operated on for chronic ulcerative colitis by this method were followed up for at least 6 months postoperatively. Ninety-four percent of the patients were ultimately satisfied with their results despite a few postoperative complications. Twenty-four patients had their ileal pouch-anal anastomosis taken down and either a Brooke ileostomy or a continent ileostomy established because of pelvic sepsis or subsequent appearance of Crohn's disease or poor functional results. In some cases a Kock pouch was fashioned. When all is said and done, ileal pouch-anal anastomosis is the only procedure that promises to meet the criteria for an ideal operation. If appropriately timed and done by experienced surgeons, the beneficial effect of such a curative, yet continence-preserving procedure could be profound.