What is the role of VEDs in penile rehabilitation after radical prostatectomy and which protocols do urologists follow?
Executive summary
Vacuum erectile devices (VEDs) are a widely used, noninvasive tool in penile rehabilitation after radical prostatectomy (RP), intended to preserve penile length and tissue health by promoting arterial inflow and oxygenation to the corpora cavernosa; they are commonly combined with other therapies, but high‑quality randomized trials proving long‑term restoration of natural erectile function remain limited [1] [2] [3]. Urologists follow a range of protocols—early initiation, daily short sessions, and combination regimens with phosphodiesterase‑5 inhibitors (PDE5i) or injections are typical—yet no universally accepted standard exists and practice patterns vary by center and surgeon [4] [5] [6].
1. The physiology and intended role of VEDs
VED therapy uses negative pressure to distend the corporal sinusoids and increase blood inflow into the penis, which raises tissue oxygenation and is hypothesized to exert anti‑apoptotic, anti‑fibrotic and anti‑hypoxia effects that could protect penile smooth muscle and endothelial structure after nerve injury from RP [1] [7] [8]. That increased arterial perfusion may also carry growth factors and nutrients supportive of tissue recovery, a mechanistic concept supported by preclinical work though still needing clinical confirmation [1] [7].
2. Evidence: supportive mechanisms and clinical outcomes
Preclinical and physiological data consistently support the rationale for VED use after RP, and multiple clinical series and systematic reviews report benefits such as preservation of penile length, improvement in erectile‑function scores and patient satisfaction when compared to controls or no rehab, but the literature includes heterogeneous studies and conflicting long‑term outcome data [2] [4] [3]. Systematic and scoping reviews conclude that while many studies find short‑term gains and functional benefits—especially in combination regimens—robust prospective randomized evidence proving durable recovery to preoperative erectile function is still lacking [4] [3].
3. Protocol variations and common clinical practice
Therapeutic schedules vary widely: in the literature roughly half of studies report daily VED use and total rehabilitation durations range from under 12 months to more than a year, with some centers prescribing daily 10‑minute sessions soon after surgery and others using three times weekly or tailored schedules based on preoperative function [4] [5]. Surveys of urologists show regular PDE5i use for 12–18 months is the single most common strategy, with VEDs frequently used as a component or alternative—reflecting no single consensus protocol across practices [6].
4. Combination therapies and how urologists implement them
Clinical practice increasingly favors combination approaches—VED plus PDE5i or VED plus intracavernosal injections—to exploit potentially synergistic effects on oxygenation and smooth muscle preservation and to improve the chances of intercourse‑capable erections; several studies and reviews explicitly recommend or report superior short‑term recovery with combination therapy versus monotherapy [9] [10] [11]. Dedicated VED clinics and patient education programs that boost compliance also appear to enhance outcomes reported in observational series [4] [12].
5. Patient selection, timing and practical considerations
Urologists typically consider preoperative erectile function, nerve‑sparing status, age and comorbidities when recommending VEDs, and many programs start VED use early—within weeks after RP—to counteract penile shrinkage and hypoxia; device tolerability, low complication rates and cost advantages in some settings make VEDs attractive where PDE5i are contraindicated or less effective [13] [14] [2]. Nevertheless, individual adherence and realistic counseling about expected outcomes remain crucial components of any protocol [12].
6. Limits, controversies and research gaps
Despite physiologic plausibility and supportive observational data, the field lacks large, high‑quality randomized controlled trials definitively proving that VED‑based rehabilitation restores long‑term spontaneous erectile function to preoperative baselines, and optimal duration, frequency and combination regimens remain debated; systematic reviews explicitly note these evidence gaps and call for standardized protocols and longer follow‑up [3] [4]. Reporting biases, heterogeneity of study designs and varying outcome measures further complicate interpretation of existing data [4] [3].
7. Bottom line
VEDs play a validated role as a noninvasive element of penile rehabilitation after radical prostatectomy—most clearly in preserving penile length, improving short‑term functional metrics and as part of combination strategies—yet clinicians and patients must recognize that protocol heterogeneity and limited randomized evidence leave the question of optimal schedules and the magnitude of long‑term erectile recovery unresolved [2] [4] [3].