Safety and effectiveness of a modified technique for three-piece inflatable penile prosthesis implantation under local anesthesia with a minimal scrotal incision (Wang’s incision) in the treatment of erectile dysfunction

Introduction

Erectile dysfunction (ED) is a common disorder in adult males that can seriously affect quality of life. For patients with moderate-to-severe ED who are unresponsive to first- or second-line treatments, penile prosthesis implantation (PPI) is the definitive treatment recommended by international guidelines (1,2). PPI was first described by Scott et al. in 1973, and has since been widely adopted worldwide (3,4). Conventional PPI is typically performed under general or spinal anesthesia; however, some elderly patients or those with comorbid cardiopulmonary dysfunction or lumbar spine diseases cannot tolerate such anesthesia. Additionally, the traditional penoscrotal incision typically measures 4–5 cm (5,6). Despite reports of two-piece penile prostheses implanted under local anesthesia (7), few studies have evaluated this approach for the more commonly used three-piece devices.

To address these limitations, we developed a modified technique combining local anesthesia with a minimal scrotal incision (Wang’s incision) for AMS 700^TM three-piece penile prosthesis implantation. This study retrospectively analyzed the clinical data to evaluate its safety, feasibility, and clinical effectiveness. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0562/rc).

Methods

General data

The clinical data of 220 patients who underwent three-piece inflatable penile prosthesis (IPP) implantation at the Department of Urology, The Second People’s Hospital of Nantong from January 2022 to December 2025 were retrospectively analyzed. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The Second People’s Hospital of Nantong (approval No. 2021002). Informed consent was taken from all the patients.

Patients were assigned to a control group (n=118) and a modified group (n=102) based on the chronological period of surgery. The control group comprised patients who underwent conventional surgery under general or spinal anesthesia between January 2022 and December 2023. The modified group comprised patients who underwent the novel technique between January 2024 and December 2025, after the surgeon had demonstrated proficiency in the modified approach. The two groups were treated in consecutive time periods, with no other changes in surgical team, perioperative protocols, or patient selection criteria during the study period.

The inclusion criteria were as follows: (I) a diagnosis of moderate-to-severe ED with inadequate response or intolerance to first-line (oral PDE5 inhibitors) and second-line treatments (intracavernosal injection therapy and/or vacuum erection devices); and (II) a strong desire for surgical intervention to achieve long-term improvement in erectile function. The exclusion criteria included active or untreated severe psychiatric disorders that could impair decision-making capacity or compliance with postoperative care, active genital or systemic infections, severe hepatic or renal insufficiency, and poorly controlled diabetes or hypertension (8). Patients with well-controlled psychiatric conditions (e.g., stable depression on maintenance therapy) were not excluded.

All patients underwent preoperative penile rigidity monitoring using the RigiScan^® Plus Monitor (GOTOP Medical, Inc., Minnetonka, Minnesota, USA), as well as related examinations such as penile color Doppler duplex ultrasonography, and International Index of Erectile Function (IIEF) scoring. All the included patients were diagnosed with organic ED based on preoperative auxiliary examinations and had previously received non-surgical treatments, including oral PDE5 inhibitors, sequential vacuum erection devices, and intracavernosal injections, all with poor results.

All the surgeries were performed by the same surgeon (J.W. from The Second People’s Hospital of Nantong). The AMS 700^TM three-piece IPP (Boston Scientific Corporation, Marlborough, MA, USA) was implanted, including CXR cylinders in 81 cases, CX cylinders in 115 cases, and LGX cylinders in 24 cases. Surgical procedures and perioperative management followed standardized protocols. Pain was assessed using various scales by researchers who had undergone standardized training to minimize measurement bias.

A primary efficacy endpoint of this retrospective case-control study was the IIEF-5 score at 3 months postoperatively. It was assumed that the modified technique was non-inferior to the conventional approach, and the non-inferiority margin was set at 2 points (i.e., a difference in postoperative IIEF-5 scores of ≥−2 between the two groups was considered non-inferior). With a one-sided α value of 0.05 and a power (1 − β) of 0.80, the mean postoperative IIEF-5 score for both groups was estimated to be approximately 22 points, with a standard deviation of 2.0 points. The sample size calculation was performed using the PASS software, which indicated that at least 75 patients were required per group. The study was powered for the primary efficacy outcome (IIEF-5 score), not for complications, given the expected low complication rates.

Between January 2022 and December 2025, a total of 255 patients underwent AMS 700^TM three-piece IPP implantation in the Department of Urology at the Second People’s Hospital of Nantong. After applying the inclusion and exclusion criteria, 22 patients were excluded. Among the remaining eligible patients, 13 were lost to follow-up or had incomplete postoperative data and were therefore excluded from the final analysis. Ultimately, 220 patients (118 in the control group and 102 in the modified group) were included in the final analysis, all of whom successfully completed the 2-year postoperative follow-up, with no additional dropouts during the study period.

Measures

Intraoperative pain intensity was assessed using the 11-point Numeric Rating Scale (NRS), on which 0 represents no pain, 1–3 represents mild pain (tolerable pain with minimal impact on daily activities and sleep), 4–6 represents moderate pain (obvious discomfort that may affect sleep but is usually tolerable), and 7–10 represents severe pain (intense and unbearable pain). Pain levels were assessed and recorded at three time points (anatomic dissection, corpus cavernosum dilation, and reservoir placement), as well as 2 hours postoperatively.

Perioperative surgical data were recorded, including cylinder placement time, total operative time, length of hospital stay, intraoperative blood loss, and incision length. During preoperative visits and outpatient follow-ups at 3 months postoperatively, patients were asked about their sexual activity and the presence/absence of complications and discomfort symptoms, and were required to complete the IIEF questionnaire. Preoperative and postoperative Erection Hardness Scale (EHS) scores and IIEF scores were then compared and analyzed. Regarding the IIEF, the IIEF-5 (items 2, 4, 5, 7, and 15) was used to assess erectile function, with a total score of ≥22 indicating the restoration of normal erectile function. Additionally, preoperative and postoperative scores for intercourse satisfaction (items 6–8) and overall sexual satisfaction (items 13–14) were also compared.

Statistical analysis

The normality of continuous data was tested using the Shapiro-Wilk test. Normally distributed continuous data are expressed as mean ± standard deviation, while categorical data are expressed as counts (n) and percentages (%). Statistical analysis was performed using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA). Normally distributed continuous data are expressed as mean ± standard deviation, while categorical data are expressed as counts (n) and percentages (%). Intra-group comparisons were performed using the paired samples t-test. Inter-group comparisons were performed using the independent samples t-test to analyze differences in the preoperative and postoperative indicators between the two groups. A P value of ≤0.05 was considered statistically significant.

Anesthesia steps

In this study, 1% lidocaine was prepared by mixing four vials of lidocaine (0.1 g/5 mL) with 20 mL of normal saline at a 1:1 ratio, resulting in a total volume of 40 mL. The solution was administered using a 10-mL syringe fitted with a 25-G (1.5-inch) needle. Anesthesia was administered in stages, during both the preoperative and intraoperative phases. No intravenous sedation or systemic analgesia was administered to patients in the modified group. All procedures were performed using local anesthesia alone, with patients remaining fully awake and cooperative throughout the surgery. The anesthetic injection sites and the sequential procedural steps are depicted in Figure 1 (schematic diagram of injection points) and Figure 2 (intraoperative photographs), respectively.

Figure 1 Schematic diagram of local anesthesia around the penis. (A) Number 1 indicates the insertion point for the dorsal penile nerve block; (B) numbers 2, 3, and 4 indicate the insertion points for the peripenile space block, intracavernosal block, and retropubic (prevesical) space of Retzius block, respectively.

Figure 2 Local anesthesia steps: (A) dorsal penile nerve block; (B) peripenile space block; (C) subcutaneous infiltration of local anesthetic; (D) intracavernosal block; and (E) block of the retropubic (prevesical) space of Retzius.

Dorsal penile nerve block

After routine draping and disinfection, the penis was lifted upward to expose the penopubic skin folds. A needle was inserted to inject 2 mL of anesthetic solution toward the 1 o’clock and 11 o’clock positions on the dorsal aspect of the penis to complete the dorsal penile nerve block.

Peripenile space block

Following the dorsal penile nerve block, a needle was inserted 1 cm below the penoscrotal junction. The peripenile space was infiltrated by injecting 2 mL of anesthetic solution in three separate directions.

Subcutaneous infiltration of local anesthetic

At the surgical incision located 2 cm below the penoscrotal junction, 4 mL of anesthetic solution was injected subcutaneously to achieve local skin anesthesia.

Intracavernosal block

After exposure of the corpora cavernosa during surgery, 3 mL of anesthetic solution was injected into the cavity of each corpus cavernosum, targeting the dorsal penile nerve endings and cavernous nerve fibers. Aspiration was performed during injection. Transient abnormal penile erection might occur during this step but typically resolved spontaneously within a short period.

Block of the retropubic (prevesical) space of Retzius

Prior to reservoir placement, after the retropubic (prevesical) space of Retzius was isolated, 5 mL of anesthetic solution was injected into the space and allowed to diffuse throughout the area to block the nerve endings passing through this region. If reservoir placement was difficult or the patient experienced significant intraoperative pain, an additional dose of anesthetic solution was administered as appropriate. No patient in the modified group required an abdominal counterincision for reservoir placement.

Surgical steps

After satisfactory anesthesia was achieved, the patient was placed in the supine position with the hips slightly elevated and the legs separated. The operative field was disinfected with iodophor. Following routine draping, the scrotum was supported with a rolled towel, and a Foley catheter was inserted. The surgeon then performed surgical hand antisepsis, after which the skin was disinfected three additional times. The penis was straightened to facilitate accurate localization of the incision. Satisfactory anesthesia was evaluated prior to skin incision using pinprick testing with a 25-gauge needle at the incision site and gentle tissue grasping with a forceps to confirm absence of sharp pain. Patients were also asked to report any discomfort during each surgical step, and NRS scores were recorded at predetermined time points. Only after confirmation of adequate anesthesia did the surgeon proceed with the skin incision.

We designate this minimal scrotal incision as Wang’s incision. A longitudinal incision, approximately 1.5–2.5 cm in length, was made 2 cm below the penoscrotal junction. The tissues were dissected layer by layer along the incision to expose the tunica albuginea of both corpora cavernosa. One suture (7-0) was pre-placed on each side of the tunica albuginea, and a 1.5–2 cm incision was made between them. (In the conventional penoscrotal approach, two parallel rows of two to three stay sutures are typically placed on each side.) The incision was located approximately 5 cm from the penile root (directly beneath the surgical incision under direct visualization). These technical modifications are described in detail to facilitate reproducibility of the combined approach.

The length of each corpus cavernosum was measured to select an appropriately-sized cylinder. Rear tip extenders were used selectively when the measured length did not match the available cylinder sizes, to ensure proper proximal anchoring and minimize the risk of cylinder migration or crural perforation. The urethra was inspected for injury, and air was expelled from the pump and the cylinders. Using a suture passer, the cylinder was guided through the tunica albuginea cavity and exited 1 cm lateral to the urethral meatus. The cylinder was then advanced to the distal end, and the rear tip extender was placed into the proximal end. The reservoir was pushed into the retropubic space using a ring clamp, and excess tubing was trimmed. An appropriate amount of sterile saline was then injected into the reservoir, and the pump was connected to the reservoir to ensure a secure connection. The inflation and deflation functions of both cylinders were tested for effectiveness.

The pre-placed sutures (one on each side) were tied to close the tunica albuginea incision (traditionally three sutures are used on each side). The pump was placed in the sub-dartos space in the anterior midline of the scrotum. If necessary, a drainage tube was placed and passed through the skin on one side of the groin. The penile prosthesis was left in a semi-erect state. The operative field was checked for active bleeding, and the incision was closed layer by layer. The key intraoperative maneuvers, including corporotomy, cylinder placement, and the final healed incision, are shown in Figure 3.

Figure 3 Key surgical steps and postoperative incision status: (A) operative field after thorough disinfection and draping; (B) corporotomy following pre-placement of one stay suture on each side of the tunica albuginea; (C) administration of an additional dose of anesthetic solution prior to reservoir placement; (D) advancement of the cylinder to the distal end with upward angulation; (E) connection and testing of the AMS 700™ prosthesis; (F) postoperative healed incision measuring <2 cm in length.

Postoperative management

Patients received routine prophylactic broad-spectrum antibiotic therapy from 1 day before surgery to 3 days after surgery (9). Fluid therapy and incision care were provided, and dressings were kept clean and dry to reduce the risk of infection (10). The penile prosthesis was left in a partially inflated state immediately after surgery, and the surgical incision at the penoscrotal junction was mildly compressed with a cruciate dressing (11). The incision site was closely observed for any signs of redness, swelling, exudate, or tissue necrosis, and the color and perfusion of the glans penis were also monitored.

At 2–3 days postoperatively, the fluid in the cylinders was returned to the reservoir, returning the penile prosthesis to a flaccid state. For patients with an indwelling drainage tube, the character and volume of drainage were recorded. The drainage tube was removed when the daily drainage volume decreased to <5 mL. The indwelling urinary catheter was maintained for 1–2 days (12), during which urine color was monitored. Patients returned for follow-up visits 4 to 6 weeks postoperatively, at which time they received physician-guided training on operating the penile prosthesis.

Results

General data

After screening and exclusion of patients who did not meet the eligibility criteria, a total of 233 patients were eligible for inclusion. Among these, 13 patients were lost to follow-up or had incomplete postoperative data and were therefore excluded from the final analysis. Ultimately, 220 patients (118 in the control group and 102 in the modified group) were included in the final analysis, all of whom successfully completed the 2-year postoperative follow-up, with no additional dropouts during the study period. The etiologies included traumatic ED (n=15), post-prostatectomy ED (n=23), diabetic ED (n=95), and idiopathic ED (n=87). We acknowledge that some patients may have had overlapping risk factors; classification was based on the predominant etiological factor. There were no statistically significant differences in age, body mass index (BMI), time since the onset of ED, and preoperative RigiScan monitoring parameters between the control group (n=118) and the modified group (n=102) (all P>0.05, Table 1). The two groups were also comparable in terms of baseline characteristics, disease severity, and erectile function status.

Perioperative data and reoperations

All 102 patients in the modified group completed surgery under local anesthesia, with no intraoperative conversion to other anesthesia methods such as general anesthesia or spinal anesthesia. No obvious anesthetic toxicity or severe systemic symptoms were observed postoperatively. All reservoirs were placed in the retropubic (prevesical) space of Retzius. No postoperative drain was required in 58 patients.

In the control group (n=118), one patient developed obvious scrotal edema and ecchymosis on postoperative day 4 and was discharged after improvement following placement of a drain disc, dressing changes, and hormone therapy. Another patient was found to have poor local incision healing during a dressing change on postoperative day 9, and was discharged after improvement with open dressing management and antibiotic treatment. No patients required reoperation for revision or device removal.

The modified group had significantly shorter cylinder placement time, total operative time, and incision length compared with the control group (all P<0.001, Table 2). No significant differences were observed in intraoperative blood loss, reoperation rate, or length of hospital stay between the two groups (Table 2).

Pain scores at different time points

In the modified group, the overall NRS scores remained below 6 points during the surgery and 2 hours postoperatively after the effects of the anesthetic had worn off (Table 3), indicating that intraoperative pain could be tolerated under the modified local anesthesia technique. Notably, the patients reported greater pain during exposure and separation of the corpora cavernosa than during dilation, which contrasts with conventional assumptions, while reservoir placement was reported to be the most painful step overall (Table 3).

Erectile function and sexual satisfaction

Analysis of follow-up data (Table 4) revealed no significant inter-group differences in EHS scores, IIEF-5 scores, or satisfaction metrics (intercourse and overall) before and after surgery. Intra-group analysis showed significant postoperative improvements in both groups across all measures, including EHS, IIEF-5, intercourse satisfaction, and overall sexual satisfaction, compared to baseline (all P<0.05) (Table 4).

Adverse reactions

Patients were followed up at 3 months postoperatively, with a focus on adverse events not requiring surgical reintervention, including genitourinary pain, foreign body sensation, edema, subcutaneous ecchymosis, erythema, and dysuria. Among the 220 patients, 206 (93.64%) reported no adverse reactions. Nine patients (4.09%) experienced postoperative pain or foreign body sensation, which had completely resolved by the time of follow-up. Additionally, 5 patients (2.27%) still reported mild, tolerable pain at follow-up.

Only the following long-term complications were noted during follow-up: one patient (0.45%) required prosthesis removal due to infection caused by a ruptured scrotal furuncle at 6 months postoperatively; and one patient (0.45%) underwent prosthesis removal due to mechanical failure (reservoir rupture) 2 years after surgery. No other complications were observed in the remaining patients.

Discussion

With accelerating global population aging, ED—a major determinant of quality of life in middle-aged and older men—is gaining increasing attention (13). However, medical consultation rates for ED remain low due to socio-cultural barriers and inadequate sexual education (14). Clinical studies indicate that a considerable proportion of patients fail to achieve satisfactory improvement with first- and second-line therapies (e.g., oral medications and vacuum erection devices) (15). Accordingly, IPP implantation, endorsed by international guidelines as a standard of care, represents a definitive treatment option for sexual rehabilitation in this patient population (16). Third-generation three-piece penile prostheses, currently the standard of care, offer a reliable solution for patients with moderate-to-severe ED refractory to medical therapy, due to their superior biocompatibility, concealability, and ease of use (17,18). However, traditional PPI typically requires general or spinal anesthesia and involves extensive incisions and tissue trauma, thereby limiting its use in elderly patients with multiple comorbidities (19).

In 1982, Kaufman (7) performed two-piece PPI under local anesthesia in a day-surgery setting; however, the clinical applicability of this approach is limited by the relatively low technical difficulty of two-piece prostheses (which involve the implantation of cylinders only) and the need for additional analgesia or even conversion to general anesthesia during the procedure. South Korean researchers have attempted three-piece PPI under local anesthesia combined with intravenous anesthesia rather than local anesthetic infiltration alone (20). However, domestic reports on this technique remain limited, possibly due to the high procedural complexity of the three-piece implantation, the limited duration of local anesthesia, and the high level of surgical proficiency required. To address this clinical gap, we developed a modified protocol combining local anesthesia with Wang’s incision for AMS 700 three-piece PPI, with the aim of evaluating its safety, feasibility, and effectiveness.

The key finding of the present study was that the modified protocol provided adequate analgesia for the complex three-piece PPI while simultaneously reducing surgical trauma. The NRS scores during all key surgical steps remained within a tolerable range, peaking during reservoir placement (4.51±1.72). This may be related to the dense nerve distribution in the retropubic space and the inadequate diffusion of local anesthetics in this area, warranting further investigation.

Given the anatomical expanse of the retropubic (prevesical) space of Retzius, our technique involved layered infiltration from point to area within a defined 1 cm × 1 cm zone superior to the pubic symphysis and adjacent to the rectus abdominis muscle, thereby maximizing anesthetic coverage and enhancing nerve block efficacy. Pain scores were significantly higher during corporal exposure and isolation than during dilation (3.41±1.35 vs. 2.37±0.96; P<0.001). This finding counters conventional assumptions, suggesting that sharp dissection of fine nerve endings elicits a more pronounced pain response than blunt dilation, which indirectly supports the effectiveness of our staged, multi-level local anesthetic block strategy.

Anesthesia mode: local anesthesia broadens surgical eligibility and is particularly suitable for elderly patients and those with comorbidities who cannot tolerate spinal or general anesthesia. It also reduces anesthesia-related costs and facilitates faster postoperative recovery. The main limitation is the steep learning curve, which requires surgeons to have detailed knowledge of penile and pelvic anatomy, and to accumulate substantial experience to achieve proficiency. In the present study, all the surgical procedures in the modified group were successfully completed. No procedure was terminated due to intolerance to anesthesia, and no serious anesthesia-related complications occurred, demonstrating the safety of this protocol in patients at high risk for general or spinal anesthesia. Notably, although local anesthesia imposes lower requirements on patients’ general condition compared to traditional general and spinal anesthesia, a comprehensive preoperative assessment is still necessary. It is recommended that patients complete electrocardiograms, chest X-rays, and necessary laboratory tests in accordance with conventional anesthesia standards to minimize perioperative risks.

Incision length: the Wang’s incision design (1.5–2.5 cm) significantly reduces tissue injury compared to traditional incisions (4–5 cm) while ensuring adequate surgical visualization. In the present study, the modified group had a significantly shorter cylinder placement time (19.74±3.64 vs. 31.52±5.21 min) and total operative time (50.36±7.72 vs. 61.58±10.39 min) than the control group (both P<0.01), which may be attributed to several technical refinements that work synergistically with the local anesthesia approach. First only one suture was placed on each side of the tunica albuginea, instead of the traditional 2–3 stitches. Second, in the absence of abnormalities in preoperative urinalysis, routine intracavernous irrigation with antibiotics was no longer performed. Third, drainage tubes were placed selectively based on the patient’s intraoperative bleeding risk; in the modified group, 58 patients did not receive drainage, and none developed serious postoperative complications. Therefore, compared with the traditional technique, the modified scrotal PPI using Wang’s incision under local anesthesia reduced the operative time and facilitated faster postoperative recovery. While there was no statistically significant difference in infection rates between the two groups, the shorter incision may theoretically reduce the risk of wound-related complications, though this hypothesis requires confirmation in larger studies. In terms of aesthetic outcomes, the smaller incision (1.5–2.5 cm) appeared to result in a less conspicuous scar, although formal cosmetic assessment using a validated instrument was not performed and this observation remains subjective. However, a small incision increases the surgical difficulty, especially in patients with penile cavernosal atrophy or scarring. In the present study, none of the 102 patients in the modified group required incision extension during the operation. All the surgeries were completed successfully, and the patients recovered well postoperatively. These findings demonstrate the feasibility of the modified small-incision technique, showing its potential for widespread adoption.

Health economics: the modified procedure may offer potential cost advantages by avoiding general or spinal anesthesia, reducing the length of hospital stay, and minimizing the use of consumables such as drainage tubes. However, we acknowledge that formal cost-effectiveness analysis was not performed in this study. The three-piece IPP is not yet covered by medical insurance in most regions in China, and cost remains a major consideration for patients. Future studies should include formal health economic analyses to quantify these potential benefits.

Functional recovery and efficacy assessment: the present study yielded encouraging results in functional recovery and efficacy. Postoperative EHS scores, IIEF-5 scores, intercourse satisfaction, and overall sexual satisfaction improved significantly in both groups compared to preoperative levels (all P<0.01). In the modified group, the IIEF-5 score increased from 7.95±1.97 preoperatively to 21.73±1.76 postoperatively; while in the control group, it increased from 8.29±2.14 to 22.58±1.87. The erectile function of most patients returned to normal levels. These efficacy outcomes are comparable to those reported for traditional surgeries performed under general anesthesia, demonstrating that the modified protocol achieves minimal invasive surgery and effective anesthesia without compromising efficacy.

It is important to note that Wang’s incision and the local anesthesia protocol are complementary components of a unified technique. The smaller incision (1.5–2.5 cm) is a prerequisite for the success of the local anesthesia approach, as it minimizes tissue dissection and reduces the volume of local anesthetic required. Conversely, the local anesthesia approach enables more precise tissue handling that facilitates the minimal incision. This interdependence underscores the rationale for evaluating these components together, rather than in isolation.

Minimally invasive approaches for IPP implantation have evolved considerably over the past decade. The infrapubic approach, particularly the technique popularized by Di Pierro et al., has gained popularity due to its small incision and avoidance of scrotal dissection, which may reduce the risk of infection and hematoma (21). However, the infrapubic approach typically requires general or spinal anesthesia and may be technically challenging in patients with prior pelvic surgery or obesity. Our modified approach differs in several important aspects. First, it represents the first description of a standardized local anesthesia protocol specifically designed for three-piece IPP implantation, whereas prior reports of local anesthesia have been limited to two-piece devices or have required supplemental intravenous sedation. Second, our approach uses a penoscrotal rather than infrapubic incision, which may offer advantages in terms of access to the corpora cavernosa and pump placement in the sub-dartos space. Third, we provide detailed technical guidance on staged multi-site nerve blocks to achieve adequate anesthesia without sedation, which may facilitate wider adoption.

The current study had certain limitations. First, it was a single-center, retrospective study with a small sample size. Multivariable analysis was not performed due to the relatively small sample size and the fact that the two groups were well-balanced in baseline characteristics. The mean BMI in both groups was approximately 22 kg/m², and the distribution was similar between the groups. However, we acknowledge that the modified technique may be more challenging in obese patients (BMI ≥ 30 kg/m²) due to increased tissue depth and difficulty in identifying anatomical landmarks. The applicability of this technique to obese patients warrants further investigation. Future studies with larger cohorts should employ multivariable analysis to adjust for potential confounders. Second, the short follow-up period limited the assessment of long-term efficacy, prosthesis survival, and complications, highlighting the need for larger studies with extended follow-up. Third, as a retrospective single-center study with chronological group assignment, it was subject to selection bias and potential confounding related to the temporal effect of surgical experience. Although biases were minimized by standardizing the surgical procedures and assessments, and the surgeon had completed the learning curve before the modified group was enrolled, high-level evidence from prospective randomized controlled trials remains lacking. In addition, we acknowledge that the modified incision (Wang’s incision) and the local anesthesia protocol represent two intertwined innovations evaluated together in this study. The success of local anesthesia for three-piece IPP implantation depends critically on minimizing surgical trauma through a smaller incision, while the local anesthesia approach enables more precise tissue handling that facilitates the minimal incision technique. Future studies with factorial designs may help isolate the independent contributions of each component. Nonetheless, we believe the combined approach represents a clinically meaningful advancement that addresses the practical needs of patients who are unfit for general or spinal anesthesia. Finally, the learning curve for this procedure may have contributed to the observed differences in operative time and outcomes between the groups; the modified group was enrolled after the surgeon had completed the learning curve and demonstrated proficiency, which may have introduced bias. To mitigate this, we standardized the surgical procedures and assessments and ensured that the surgeon had performed at least 20 cases using the modified technique before enrolling patients in the modified group. The learning curve for this procedure remains unclear. Based on our experience, the modified procedure requires a significant surgical volume and a thorough understanding of pelvic floor anatomy; thus, widespread adoption should await the establishment of structured training programs.

Conclusions

In summary, this study innovatively proposed a modified procedure for three-piece PPI via Wang’s incision under local anesthesia and systematically evaluated its safety and efficacy. The results indicated that our modified procedure offers significant advantages in reducing surgical trauma, minimizing intraoperative blood loss, and improving cosmetic outcomes. It also significantly broadens the population eligible for surgery, providing a new treatment option for patients with moderate-to-severe ED who cannot tolerate general or spinal anesthesia due to advanced age, cardiopulmonary insufficiency, or lumbar spine lesions. With the continued development of minimally invasive techniques and precision anesthesia, this modified technique for three-piece PPI via Wang’s incision under local anesthesia may have wider application and promotion prospects in the future, offering benefits to a greater number of ED patients refractory to drug therapy.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0562/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0562/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0562/prf

Funding: This work was supported by Project of Nantong Health Commission (grant No. MS2023068).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0562/coif). All authors report that this work was supported by Project of Nantong Health Commission (grant No. MS2023068). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The Second People’s Hospital of Nantong (approval No. 2021002) and informed consent was taken from all the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: L. Huleatt)