Pouch Surgery for Ulcerative Colitis: Navigating Complexity in the Modern Era

Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) remains the preferred surgical treatment for patients with ulcerative colitis (UC) who require surgery but wish to avoid a permanent ileostomy. Since its introduction in 1978, IPAA has undergone continuous refinement in response to advances in both medical therapy and surgical technique. The introduction of advanced medical therapies has indeed significantly transformed the management of UC. Although the introduction of advanced medical therapies has likely reduced the overall need for surgery, it has also reshaped therapeutic decision‐making, increasingly positioning surgery as a last‐line intervention after failure of all medical options. Patients presenting for surgery often exhibit more pronounced, ongoing inflammation, an increased cancer risk, and higher rates of postoperative pelvic sepsis, pouch dysfunction, and pouch failure. In parallel, progress in minimally invasive techniques has enabled reduction of postoperative morbidity, faster recovery, while causing fewer adhesions. Surgical considerations—such as the adoption of minimally invasive and transanal approaches, the type of rectal dissection, and the method of anastomotic technique —continue to evolve as part of ongoing efforts to optimize outcomes, although the evidence remains heterogeneous and long‐term data limited. Uncertainty remains regarding the optimal surgical approach in these often complex clinical scenarios. This narrative review explores how the interplay between medical therapy, evolving patient and disease characteristics, and surgical innovation have shaped current practice in IPAA, while highlighting key controversies, knowledge gaps, and directions for future research.