How effective are VEDs for penile rehabilitation after radical prostatectomy compared with PDE‑5 inhibitors?

1. The PDE‑5 inhibitor evidence: clinical signal but methodological limits

Multiple systematic reviews and randomized trials conclude that PDE‑5Is are more efficacious than placebo or no treatment for penile rehabilitation after radical prostatectomy, and PDE‑5Is are the most commonly adopted strategy in practice, yet many trials are small, of variable duration, and yield conflicting long‑term results after washout periods, limiting certainty about durable recovery of spontaneous erections ^{[1] [3] [4] [5]}.

2. The VED evidence: successful for erections, sparse for long‑term recovery

Clinical series and some trials report that VEDs reliably produce satisfactory erections in a high proportion of users and can preserve penile morphology by improving corporal oxygenation, with authors describing convincing evidence for VEDs’ success as a treatment modality after radical prostatectomy, but the overall trial database is smaller and evidence for VEDs producing sustained, unaided erectile function recovery is limited ^{[6] [2] [3]}.

3. Head‑to‑head comparisons and combination therapy: synergy more than rivalry

Direct comparative data are scant; some institutional series showed higher intercourse success rates with VED alone than PDE‑5Is alone and even higher rates with combined therapy, but differences were not always statistically significant and studies were often underpowered, while meta‑analyses and reviews emphasize that combination therapy (VED + PDE‑5I) appears to act synergistically and is commonly recommended when monotherapy fails ^{[7] [2] [3] [4]}.

4. Patient experience, adherence and satisfaction tilt the balance clinically

Although VEDs can generate erections in many post‑prostatectomy patients and are cost‑advantageous in some settings, patient satisfaction and long‑term adherence to VEDs are variably lower than efficacy rates imply, and PDE‑5Is are generally well tolerated though dropout in some trials raises questions about real‑world adherence and the optimal dosing schedule (nightly vs on‑demand) for rehabilitation purposes remains unresolved ^{[6] [8] [9] [10]}.

5. Which patients are likely to benefit from each approach?

Evidence suggests men with nerve‑sparing procedures and better baseline function are likelier to regain erectile function and may respond to PDE‑5Is, whereas VEDs remain a useful option for those who do not respond to or cannot take PDE‑5Is, and early initiation of rehabilitation (including VED) may preserve penile size and facilitate earlier return to sexual activity, though patient selection protocols are still debated ^{[11] [12] [8]}.

6. What the literature cannot yet prove: long‑term recovery and optimal protocols

Across multiple reviews authors emphasize that preclinical rationale exists for penile rehabilitation but solid prospective randomized trials comparing long‑term recovery after PDE‑5Is, VEDs, ICI or their combinations are lacking, so claims of superiority for either VEDs or PDE‑5Is regarding permanent, unaided erectile function recovery remain unproven in high‑quality, long‑term trials ^{[3] [13] [5]}.

7. Practical takeaways for clinical strategy

Given the current evidence, PDE‑5Is are supported by systematic reviews as effective versus placebo and are first‑line in many centers, VEDs are a valuable adjunct or alternative—particularly when PDE‑5Is fail or are contraindicated—and combination therapy shows the most consistent clinical promise, but individualized decisions should account for nerve‑sparing status, baseline function, cost, tolerance and patient preference while acknowledging the need for larger definitive comparative trials ^{[1] [2] [4] [3]}.