In the UK, primary care trusts are reviewing prescription guidelines and treatment recommendations for numerous conditions managed within the NHS. An assessment by the ‘Solutions for public health, UK (http://www.sph.nhs.uk/) has concluded that vacuum erection devices (VEDs) are a low priority in view of limited evidence and cost effectiveness .
The current incidence of erectile dysfunction (ED) after radical prostatectomy (RP) can range between 14 and 89% . The British Society for Sexual Medicine guidelines on erectile dysfunction management recommend phosphodiesterase-5 (PDE-5) inhibitors as well as a VED as first-line management for erectile dysfunction after RP. In the current literature, PDE-5 inhibitors are recommended because of their proven efficacy and cost effectiveness . By contrast, the limited evidence for VED effectiveness in large-scale trials has raised doubts over their use . Despite this ∼8000–10 000 VEDs are prescribed in the UK per year.
There is a lack of large-scale randomized controlled trials in the current literature to support the use of VED in erectile dysfunction after RP, but VEDs have a very high patient satisfaction rate of >80% . The use of VEDs in penile rehabilitation without constriction rings after RP results in a 60% improvement in spontaneous erections, as well as a significant improvement in International Index of Erectile Function (IIEF) scores used early postoperatively . Owing to a reduction in arterial inflow as well as venous flow, constriction rings are not recommended for use in penile rehabilitation [3, 4]. The study by Raina et al.  in 2006 showed that early use of a VED after RP resulted in 80% of patients successfully having intercourse, with a spousal satisfaction rate of 55%. Furthermore the mean IIEF-5 score improved from 4.8 before treatment to 16 after treatment at 9 months postoperatively. In that paper, 17% of patients had a return of natural erections sufficient for penetration, compared with only 11% without treatment . In addition, daily use of the VED has been found to prevent loss of penile length occurring secondary to atrophy after RP [3-5].
When used in combination therapy with PDE-5 inhibitors, VEDs have good success rates. Studies have shown that a VED used for 5–10 min a day with tadalafil three times a week has a success rate of 90% when using the IIEF-5 at 1 year, compared with 60% in those not using the VED . Another study showed that a VED combined with sildenafil after RP resulted in 30% of men reporting a return of spontaneous erections [4-6]. Patients on VEDs have also been found to have a reduction in the pain experienced with intracorporeal injections owing to improved tissue health, which was thought to be the result of penile tissue becoming used to filling and emptying .
We have calculated that the average cost of a VED device on prescription on the NHS is approximately £160 net of VAT. The average device life span of a VED device based on manufacturer specification is approximately 5 years. Patients on a VED device are advised to use a device atleast twice a week and may require two maintenance ring sets (3 rings per set) costing a total of £34. The combined dose of a VED device over five year is low at approximately £228 with VAT. When compared to the use of additional treatments for the post prostatectomy ED, the cost of patients on Caverject (Alprostadil Injections) at a dose of 40 micrograms / pack is £2589.50 (£21.58 per unit) over duration of 5 years.
In conclusion, there is convincing current evidence that VEDs are successful in the treatment of erectile dysfunction after RP, especially in combination with PDE-5 inhibitors, which appear to work synergistically to overcome the postoperative changes and to aid penile rehabilitation. Our calculations confirm that there is a cost benefit in prescribing VED when compared with additional adjuvant treatment options for erectile dysfunction after RP.