The treatment of transsphincteric anal fistulas is a balance between the elimination of the sepsis and the functional outcome. In the last few decades sphincter preserving methods have been developed. Fibrin glue and the anal fistula plug are methods with excellent functional outcomes, but the success rates have decreased in recent years. The endorectal advancement flap is the gold standard with a high success rate, but with a risk of minor incontinence. The procedure of the ligation of the intersphincteric fistula tract is the latest option with excellent result so far. The tailored treatment with enhanced glues looks promising.