Preheat the oven to 375F and a large ovenproof skillet with a lid to medium-high heat. Add the sausage and cook for about 8 minutes, crumbling it as you go.
When the sausage is browned, crumbly, and cooked through, add the onion, garlic, oregano, and crushed red pepper flakes. Stir into the sausage for about 5 minutes to soften the onion. If the skillet seems dry, add a drizzle of olive oil.
When the onion is soft, add the vodka to the skillet. Stir to deglaze the pan, and allow the vodka to bubble for a few minutes and reduce in volume by half.
Add the canned tomatoes, water, salt, and sugar to the skillet. Turn the heat OFF and stir to combine. Cover the skillet, and place in the oven. Roast the sauce for thirty minutes to one hour, stirring every 20 minutes or so to ensure the sauce doesn't burn. During this time I cook and drain the pasta, reserving some of the cooking water, and get out parmesan, fresh herbs, bread, etc.
When the sauce has roasted, it should be dark in color with some of the moisture reduced. Remove it carefully from the oven and stir + taste + add a few pinches of salt. Add the pasta and cream to the sauce, stir to combine. If the sauce has reduced too much, add some splashes of the reserved pasta water to thin it out. Taste the dish one more time and add more salt if needed.
Serve immediately with parmesan, extra red pepper flakes, and anything else you'd like. Enjoy!