© 2007 THE AUTHORS 858 JOURNAL COMPILATION © 2 0 0 7 B J U I N T E R N A T I O N A L | 1 0 0 , 8 5 8 – 8 6 2 | doi:10.1111/j.1464-410X.2007.07161.x Sexual Medicine EARLY USE OF THE VACUUM ERECTION DEVICE AFTER RADICAL RETROPUBIC PROSTATECTOMY KÖHLER et al. A pilot study on the early use of the vacuum erection device after radical retropubic prostatectomy Tobias S. Köhler, Renato Pedro, Kari Hendlin, William Utz*, Roland Ugarte*, Pratap Reddy*, Antoine Makhlouf, Igor Ryndin, Benjamin K. Canales, Derek Weiland, Nissrine Nakib, Anup Ramani, J. Kyle Anderson and Manoj Monga University of Minnesota, Minneapolis, and *Urology Associates, Edina, MN, USA Accepted for publication 13 April 2007 criterion for inclusion in the study. Only patients in whom unilateral or bilateral nerves were spared were subsequently randomized. Patients in group 1 followed a daily rehabilitation protocol consisting of 10 min/ day using the VED with no constriction ring, for 5 months. Patients were evaluated with the IIEF-5 questionnaire and measurements of penile flaccid length, stretched length, prepubic fat pad, and midshaft circumference before and at 1, 3, 6, 9 and 12 months after RP; the mean (range) last follow-up visit was 9.5 (6–12) months after RP. RESULTS The mean (SD) baseline IIEF scores were similar in groups 1 and 2, at 21.1 (4.6) and 22.3 (3.3), respectively ( P = 0.54). The IIEF scores were significantly higher in group 1 than group 2 at 3 months, at 11.5 (9.4) vs 1.8 (1.4) ( P = 0.008) and at 6 months, at 12.4 (8.7) vs 3.0 (1.9) ( P = 0.012) after RP. There were no significant changes in penile flaccid length, prepubic fat pad, or mid-shaft circumference in either group. Stretched penile length was significantly decreased at both 3 and 6 months, by ≈ 2 cm ( P = 0.013) in group 2. By contrast, stretched penile length was preserved in group 1 at all sample times. At the last follow-up, the proportion of men with a mean loss of penile length of ≥ 2 cm was significantly lower in group 1 than group 2 (two/17, 12%, vs five/11, P = 0.044). CONCLUSIONS Initiating the use of a VED protocol at 1 month after RP improves early sexual function and helps to preserve penile length. KEYWORDS vacuum erection device, erectile dysfunction, penile rehabilitation, penile length, radical prostatectomy Study Type – Therapy (RCT) Level of Evidence 1b OBJECTIVE To evaluate the effect of the early use of the vacuum erection device (VED) on erectile dysfunction (ED) and penile shortening after radical retropubic prostatectomy (RP), as these are important concerns for men choosing among treatment alternatives for localized prostate cancer. PATIENTS AND METHODS Twenty-eight men undergoing RP were randomized to early intervention (1 month after RP, group 1) or a control group (6 months after RP, group 2) using a traditional VED protocol. An International Index of Erectile Function (IIEF) score of > 11 (no, mild or mild to moderate ED) was required as a baseline INTRODUCTION Erectile dysfunction (ED) after radical prostatectomy (RP) for prostate cancer has decreased as a result of improvements in surgical technique. The most important predictor of ED after RP is pre-existing erectile function and preservation of the neurovascular bundles. Despite these improvements in technique, erectile function returns in only 9–40% of patients [1–3]. The practice of early penile rehabilitation after RP seeks to improve on these rates, but the optimal rehabilitation regimen is yet to be established. Options currently available for patients with ED include oral pharmacotherapy, intraurethral prostaglandin E1, injection therapy, vacuum erection devices (VEDs), penile implants and vascular reconstruction. In a study of 30 patients, Montorsi et al. [4] assessed early prophylactic vasoactive intracavernosal injection therapy with alprostadil after RP, and reported a 67% incidence of return to spontaneous erectile function, compared with 20% with no treatment. This success rate has not been reproduced in more contemporary series, and the use of injectable agents is considered invasive and cumbersome by many patients. Phosphodiesterase-5 inhibitors (PDE-5i) offer a less invasive and more manageable alternative for penile rehabilitation after RP, but the utility of PDE-5i might be limited by the severity of cavernosal nerve injury after RP, which in turn inhibits initiation of the required erectile cascade for PDE-5i to be effective [5]. Another potential sequelae of RP is penile shortening. Apoptosis has been detected in rats after penile denervation [6], and the resulting fibrotic changes in the corporeal bodies after RP were recently evaluated and described, both of which could contribute to shortening [7]. Many authors have reported decreases in both penile length and circumference after RP. Fraiman et al. [8] reported a progressive loss in the mean values of flaccid length, erect length and circumference after RP, most of which occurred within the first 3–4 months. Munding et al. [9] showed that the stretched penile length decreased at 3 months after RP in 71% of their patients. Savoie et al. [10], in a prospective study evaluating penile length 3 months after RP, found a significant decrease in the flaccid, stretched and circumferential measurements of the penis.