What is your approach to penile rehabilitation after radical prostatectomy for patients with moderate to good erectile function preop?

Although there is little strong data to support post-radical prostatectomy rehabilitation to actually recover better erectile function after surgery, I still employ this as it does make sense and may, at a minimum, preserve penile size and tissue quality. After surgery, most men do not have spontaneous nocturnal erectile activity. This was shown many years ago in a post-radical prostatectomy analysis trial, which I conducted. During that trial, it was found that it was several months before erectile activity recurred in men who ultimately developed satisfactory sexually induced erections. Without those nocturnal erections, there is relative hypoxia within the penis, and this theoretically can contribute to colonization of the cavernosal tis...

Having performed more than 8,000 nerve-sparing radical retropubic prostatectomies, my approach has been to recommend that patients begin intracavernosal injections at least twice per week, beginning one month after surgery and adding an oral phosphodiesterase-type-5 inhibitor once there is evidence of spontaneous tumescence. Many patients with moderate or good preoperative erectile function can eventually discontinue these measures; however, many continue to require them and, ironically, some who can "function" without them continue to take them simply because their erectile function with medication is better than it was preoperatively.

My approach to penile rehab in this scenario includes:

• daily tadalafil 5 mg,
• on-demand tadalafil 5-20 mg or sildenafil 20-100 mg,
• daily use of VED,
• intracavernosal injections as desired,
• optimizing lifestyle including diet, exercise, reducing sedentary activity, disease management (diabetes, HTN, etc.) with PCP.