Background <p>Several surgical approaches are available for managing complex cryptoglandular perianal fistulas. However, a gold standard surgical technique has not yet been established. This network meta-analysis aims to assess and compare postoperative failure and anal incontinence pooled rates for different available surgical techniques for complex cryptoglandular anal fistulas.</p> Methods <p>Systematic searches were carried out on Pubmed, Ovid, the Cochrane Library database and ClinicalTrials.gov up to June 2023. All randomized comparative trials of nine surgical techniques for cryptoglandular complex perianal fistulas in adult patients were included. A systematic review and network meta-analysis was conducted using the PRISMA-NMA methodology. The endorectal advancement flap was used as the control technique, and the odds ratios (ORs) were calculated through pairwise and network meta-analysis with random effects.</p> Results <p>16 randomized trials were included in this study. Network meta-analysis was conducted for each outcome. Techniques, such as cutting seton, fistulotomy with sphincter reconstruction, LIFT, and VAAFT, obtained similar results in terms of technique failure to the transanal advancement flap with no statistically significant differences. PLUG (OR = 3.6 [95%CI 1.1–11.5]), fibrin glue (OR = 7.5 [95%CI 2.2–25], and platelet-rich plasma (PRP) (OR = 11.5[95%CI 1.3–99]) demonstrated a statistically significant increase in the pooled failure rate. For anal incontinence, only the cutting seton technique exhibited a higher risk of postoperative incontinence (OR = 8.6 [95%CI 1–72.5]).</p> Conclusion <p>Our research highlights effective therapeutic approaches for complex anal fistulas, stressing the need to customize treatment based on location, anatomy, patient characteristics, and preferences. However, it advises against using plugs, fibrin glue, PRP therapy due to lower healing rates, and the seton technique because of its potential impact on anal continence. PROSPERO number CRD42022304345.</p>