Background <p>The management of complex transsphincteric fistulae is challenging and surgical repair must be balanced against the risk of continence impairment. This study aims to demonstrate that multiple, carefully selected procedures can achieve long-term clinical healing without sphincter division for the majority of patients in this cohort.</p> Methods <p>This was a prospective cohort study in a large university hospital with a dedicated colorectal surgery unit. Patients underwent between one and four sphincter-preserving procedures, including advancement flap (AF), ligation of the intersphincteric fistula tract (LIFT), and fistula plug placement. The primary outcome was overall clinical healing at the end of the study period. Secondary outcomes included the incidence of incontinence and the success rates of individual sphincter-preserving procedures.</p> Results <p>Out of 120 patients, 101 were eligible for final analysis. The mean patient age was 43.3&#xa0;years, with a median follow-up duration of 21&#xa0;months (IQR 11–31). The overall clinical healing rate was 90.1% (91/101), achieved after a mean of 1.6 procedures (SD 0.85, Range 1–4). Among patients who did not undergo sphincter division, the healing rate was 88.4% (76/86). The advancement flap demonstrated the highest success rate (85.7%), compared with LIFT (56%) and plug (38.8%) as first-stage procedures, with a statistically significant difference (<i>p</i> = 0.007).</p> Conclusions <p>Complex transsphincteric fistulae can be successfully treated with a 90.1% success rate using a combination of sphincter-preserving surgical procedures. Patients should be informed of the likelihood of multiple operations to achieve long-term healing.</p>