Transposition of the gracilis muscle is an option for treatment of complex rectourethral fistulas. This video shows a 72 year old male with a rectourethral fistula secondary to external beam radiation and brachytherapy for prostate cancer. He initially underwent laparoscopic transverse colostomy formation in April 2003 followed by transposition of the left gracilis muscle to his perineum in June 2003. Subsequent fistula recurrence was managed by two endorectal advancement flaps in August and November 2003. A Gastrografin enema in January of 2004 revealed a persistent 3mm sinus in the anterior rectal wall. Transposition of the right gracilis to the perineum was deemed necessary to manage this sinus and prevent fistula recurrence in anticipation of colostomy reversal. The patient is placed in the lithotomy position for gracilis muscle harvest. The muscle is dissected in length, perforating vessels are carefully ligated, and the neurovascular bundle identified and preserved. The patient is then placed in the prone position to facilitate dissection in the perineum above the level of the sinus. An endorectal advancement flap is performed in combination with transposition of the gracilis providing healthy, well-vascularized tissue grafts to the area of the recurrent sinus.