“Why do we have to review our experience in managing idiopathic fistula-in-ano regularly?” In order to answer this apparently simple question, we reviewed our clinical and surgical cases and most important relevant literature to find a rational and scientific answer. It would appear that whatever method you adopt in fistula management, there is a price to pay regarding either rate of recurrence (higher with conservative methods) or impairment of continence (higher with traditional surgery). Since, at the moment, reliable data to identify a treatment as a gold standard in the management of anal fistulas are lacking, the correct approach to this condition must consider all the anatomic and clinicopathological aspects of the disease; this knowledge joined to an eclectic attitude of the surgeon, who should be familiar with different types of treatment, is the only guarantee for a satisfactory treatment. As a conclusion, it is worthwhile to remember that adequate initial treatment significantly reduces recurrence, which, when it occurs, is usually due to failure to recognise the tract and primary opening at the initial operation
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