AMNIOX CORD Study – Radical Prostatectomy With and Without Cryopreserved Umbilical Cord Allograft

One hundred male patients who are scheduled for bilateral, nerve-sparing RARP that meet the eligibility criteria will be enrolled. These patients will be equally randomized (1:1) into two groups (n=50/group): one group will receive adjunctive CLARIX® CORD 1K (Amniox Medical, Inc., Miami, FL) during RARP, while the other group will undergo RARP without adjunctive CLARIX® CORD 1K. Subject stratification will be performed based on the surgeon that will be performing the RARP. All patients will be given the same routine preoperative, perioperative and postoperative evaluation and care aside from the CLARIX CORD 1K placement in the treatment group during RARP. RARP will be performed at Hackensack University Medical Center (30 Prospect Ave, Hackensack, NJ 07601) and follow up visits performed at Hackensack University Medical Group Urology (360 Essex Street, Suite 403, Hackensack, NJ 07601) or New Jersey Urology (255 W. Spring Valley Avenue Suite 101, Maywood, NJ 07607).

Two weeks prior to the RARP surgery, subjects are instructed to take low-dose oral phosphodiesterase type 5 inhibitors (i.e. 20 mg q.d. sildenafil citrate or 5 mg q.d. tadalafil) and perform standardized Kegel exercises (3x/day) which is our current standard care protocol. RARP surgery will be performed at Hackensack University Medical Center (Hackensack, NJ). The following are the key aspects of the RARP surgical technique which will be adhered to by all surgeons: 1) dissection of the bladder neck, seminal vesicles and vasa deferentia; 2) dissection of the neuroplexus from the posterior Denonvilliers' fascia and lateral prostatic fascia leaving the nerves intact; 3) division of the prostatic pedicles without cautery; 4) transection of the dorsal venous complex; and 5) urethrovesical anastomosis. More specifically, surgical technique includes exposing the prostate in the space of Retzius with the traditional anterior approach.

The prostatovesical tissue is dissected with monopolar electrocautery scissors with entry into the bladder proximal to the prostatovesical junction. The bladder neck is transected in the standard fashion followed by posterior dissection of the seminal vesicles and vasa deferentia.

Electrocautery is kept to a minimum when dissecting the seminal vesicles to avoid damage to the neuroplexus. (Note: each step hereafter must be performed by the PI or Sub-investigators, e.g. not a Resident Physician). A posterior surgical plane is then created between the rectum and prostate dorsally working from a medial to lateral direction and maintaining at least 1 layer of Denonvilliers' fascia on the rectal wall. The endopelvic fascia is then excised from lateral prostate and carried to capsule to create a plane of dissection immediately alongside the prostatic capsule and keeping the nerves attached laterally to the endopelvic fascia. Athermal division of each prostatic pedicle will be performed. Clips or suture may be placed on each pedicle at the discretion of the surgeon. The apex of the prostate is then dissected athermally sparing the neuroplexus. The dorsal vein complex is proximally transected with electrocautery while using the fourth arm to place traction on the prostate to define the space between the dorsal vein complex and the apex of the prostate. Apically, the prostate is divided from the urethra (paying special attention to the sphincter muscle and posterior lateral nerve bundle on each side) allowing the prostate to be removed. Once free, the prostate is placed in a collection bag and a drain is used for a certain period at the discretion of the surgeon.

Surgical site bleeding is managed using standard surgical techniques with sutures or cellulose polymer. If the patient is randomized to the treatment group, CLARIX CORD 1K is placed flat over the neuroplexis at the 5 and 7 clock position where the largest concentration of nerves exist. Sutures may be used to secure the CLARIX in place if necessary and cellulose polymer (Surgicel, Ethicon, Somerville, NJ) can be placed over the CLARIX CORD at the discretion of the physician.

At this point the bladder neck will be reconstructed as necessary to maintain a lumen of approximately 30 french. The vesicourethral anastomosis is performed using a V-lock barbed suture. The anastomosis will be tested by filling bladder to confirm the absence of leakage. If indicated, a bilateral pelvic lymph node dissection is performed (with clips at the discretion of the physician) using standard (borders along the external iliac artery and vein, obturator fossa, obturator nerve and pubic bone) or extended (borders additionally include internal iliac artery) technique at the discretion of the physician. Bleeding will be adequately managed. Postoperatively, all subjects are instructed to take low-dose oral phosphodiesterase type 5 inhibitors (i.e. 20 mg q.d. sildenafil citrate or 5 mg q.d. tadalafil) and perform standardized Kegel exercises (3x/day) following urethral catheter removal. When patients are sexually active, they may increase to full dosage of oral phosphodiesterase type 5 inhibitors up to twice a week. At 3 months after RARP, and if patients have severe or worse incontinence (defined as ICIQ score of >12) and desire additional treatment for urinary incontinence,[42] they will undergo pelvic floor therapy. Subjects will return for follow up visits at 6 weeks (±1 week), 3 months (±2 weeks), 6 months (±3 weeks) and 12 months (±4 weeks) when data will be collected.

Patient reported outcomes will be assessed including continence, potency, and satisfaction. Occurrence of adverse events, number of readmissions, and need for reintervention will also be recorded. Measurement of serum PSA levels will also be performed.