Radical prostatectomy is a cornerstone curative treatment for localized prostate cancer. However, erectile dysfunction remains a common and distressing complication, affecting 25% to over 90% of patients depending on baseline function, comorbidities, and surgical technique. The impact extends beyond sexual health, affecting self-esteem, mental well-being, and interpersonal relationships. Penile rehabilitation emerged in the early 2000s as a proactive strategy to preserve penile tissue health, ensure proper oxygenation, speed functional recovery, and prevent penile length loss. Despite widespread use, there is currently no standardized, evidence-based rehabilitation protocol.

Current evidence supports several established rehabilitation modalities. Daily phosphodiesterase type 5 inhibitor (PDE5i) therapy, particularly sildenafil 100 mg or tadalafil 5 mg, is associated with better erectile function recovery than on-demand use, especially when started two weeks before surgery and continued long-term. Intracavernosal injection (ICI) therapy achieves success rates of 67%–94% in selected patients, though pain and poor adherence remain challenges. Vacuum erection devices help preserve penile length and improve International Index of Erectile Function (IIEF)-5 scores, particularly when combined with PDE5i. In contrast, emerging therapies such as low-intensity shockwave therapy, platelet-rich plasma, stem cell therapy, and nerve grafting remain investigational, with limited and inconsistent evidence.

A practical, evidence-based algorithm has been proposed to guide clinical decision-making (FIGURE 1). The algorithm stratifies patients into low-, intermediate-, and high-risk groups based on age, baseline erectile function, comorbidities, and nerve-sparing status. It provides clear recommendations: daily PDE5i for low-risk patients, PDE5i plus vacuum erection device (VED) for intermediate-risk patients, and VED plus ICI with early discussion of penile prosthesis for high-risk patients. The algorithm also emphasizes early counseling, regular follow-up every three months, and stepwise escalation of therapy.

Successful penile rehabilitation requires a structured framework from preoperative counseling and risk stratification to individualized treatment selection and long-term follow-up. Patient-centered care—including psychosocial support, partner involvement, and regular follow-up—is essential to improve adherence and outcomes.

The findings offer a clear answer to whether penile rehabilitation is fact or fiction: evidence supports its rationale, but standardized protocols are still needed. The work titled “Penile rehabilitation in men after radical robotic prostatectomy: Fact or fiction?” was published on UroPrecision (published on 14 January 2026).
DOI: 10.1002/uro2.70047