Which rehabilitation protocols using VEDs after radical prostatectomy show the best long‑term return of spontaneous erections?
Executive summary
Early vacuum erectile device (VED) use—started in the weeks after nerve‑sparing radical prostatectomy—and especially when combined with regular phosphodiesterase‑5 inhibitors (PDE5i) or intracavernosal agents, is the protocol most consistently associated with better long‑term rates of return of spontaneous erections in the published literature, but high‑quality randomized trial evidence specifically isolating VED benefit for spontaneous erection recovery remains limited [1] [2] [3].
1. Why VEDs are used early and what they do biologically
VED therapy is designed to increase arterial inflow, tissue oxygenation and to oppose tadalafil‑sized hypoxia and fibrosis in the corpora cavernosa after nerve injury; basic science and pathophysiology papers describe VEDs producing anti‑apoptotic, anti‑fibrotic and anti‑hypoxia effects that theoretically preserve penile endothelial and smooth muscle structure during the months of neuropraxia after prostatectomy [4] [5].
2. The protocols actually studied in patients: timing, frequency and combinations
Clinical protocols in the literature vary, but the most commonly studied regimens initiate VED use within the first few weeks after surgery and apply daily or near‑daily sessions—examples include randomized and prospective cohorts using daily 10‑minute sessions for six months or combined programs that aimed for induced erections three times weekly using either sildenafil or intracavernosal alprostadil alongside VED use [6] [7] [1].
3. Which protocols show the best long‑term spontaneous erection outcomes
Observational series and clinic reports point to early VED initiation plus adjunctive pharmacotherapy as producing the highest rates of later spontaneous erections: studies cited that used early VED with or without PDE5i reported substantial improvements in International Index of Erectile Function (IIEF) scores, preservation of penile length and, in some series, a majority of men regained intercourse‑capable erections—with one review noting a 60–80% improvement in spontaneous erections or intercourse success in cohorts using early VED protocols [1] [8] [6]. Practice surveys of urologists also show that the common pragmatic approach—regular PDE5i for 12–18 months with VED as a frequent adjunct—reflects real‑world belief that combination therapy gives the best chance of natural recovery [9].
4. The strongest counterpoint: randomized evidence is sparse and mixed
Systematic reviews and guideline‑level discussions caution that incontrovertible proof that any penile rehabilitation strategy materially improves long‑term return to baseline spontaneous erectile function is lacking; randomized trials have more consistently tested nightly or on‑demand PDE5i than VEDs, and while some RCTs favor early medical regimens, large RCTs isolating VED versus no VED with long‑term spontaneous erection endpoints are limited—leaving room for selection bias in positive cohort reports [3] [10].
5. Practical interpretation: what constitutes the “best” VED protocol today
Given available evidence, the protocol most defensible as “best” for maximizing later spontaneous erections is early initiation (within weeks post‑op), daily or near‑daily VED sessions for months, avoidance of prolonged constriction ring use when the goal is rehabilitation, and routine combination with PDE5i or targeted intracavernosal therapy when tolerated—an approach supported by mechanistic rationale, multiple cohort studies and urology practice patterns even though high‑level definitive RCT confirmation is still needed [6] [1] [9].
6. What patients and clinicians should know about expectations and limitations
VEDs reliably preserve penile length and enable intercourse sooner, and when used early in combination protocols they are associated with higher rates of spontaneous erection recovery in many series; however, clinicians must convey that evidence quality is imperfect, that outcomes depend on nerve‑sparing status and individual factors, and that some guideline reviews label penile rehabilitation strategies as promising but not definitively proven to restore preoperative erectile function in every patient [1] [3] [5].