Transperineal repairs usually involve clo­sure of the rectum and/or closure of the urethral opening. These outcomes are improved by inter­posing muscle between the rectal and urethral repairs, especially if the pelvis was previously irradiated. The gracilis muscle and dartos mus­cle interposition flaps are well described in the treatment of rectourethral fistulas [15–18]. The preference of the authors is to perform gracilis in­terposition flaps for pelvic fistula disease specifi­cally using the transperineal approach because it provides great access to the fistula, brings a large piece of viable muscle to help buttress the fistula repair, and minimally affects the donor extremity with mild numbness being the main side effect [16, 19–21]. The gracilis muscle is a large muscle dependent on one main neurovascular bundle at its origin, which makes it versatile. All patients should undergo fecal diversion either prior to or occasionally at the time of graciloplasty. The creation of an ileostomy or colostomy should fa­cilitate healing by reducing fecal contamination. Maintenance of an indwelling Foley catheter and occasionally also a suprapubic catheter through­out the duration of treatment is mandatory. The objective is to prevent both urine and stool from entering the area of the repair.