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To assess optimal treatment for patients with anal fistulae.In thisprospective study we treated five patientspresenting with low transphincteric fistulae with injection of dermal collagen (Permacol injectionTM). In addition a literature review was performed to find out the current techniques available and their effectiveness to delineate a gold standard treatment algorithm.After local injection with anaesthetic 2.5 ml of Permacol suspension was injected inside the fistula track and all around the fistula external opening through a 20 gauge needle. Neither during nor after theprocedure were major complications observed. Four patients healed withprimary treatment and in one case the low trans-sphincteric fistula, located on the posterior midline, healed after a second injection 1 month after the first treatment. No recurrence was observed at 3-6 months follow up.Management of low anal fistulae is usually straightforward and fistulotomy is quite effective but high complex fistulae are challenging. Conventional fistula surgery techniques have their place; but new technologies such as dermal collagen injection, anal fistula plugs and stem cells injection offer alternative approaches whose long term efficacy needs to be further clarified in large long term randomized trials.