This study aims at evaluating if placement of CLARIX® CORD 1K during robotic prostatectomy
decreases the time to achieve complete erectile and urinary function after the surgery. As
part of the study, the patient will be asked to answer various questions after the surgery
regarding sexual and urinary function.
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.
Inclusion Criteria:
1. Male aged between 30 and 70 years old
2. Primary diagnosis of organ confined prostate cancer
3. Scheduled to undergo bilateral, nerve-sparing RARP
4. Patient has ICIQ-SF score <6
5. Patient has no erectile dysfunction (defined as IIEF-6 score ≥ 26)
6. Patient is willing to return for all visits as defined in the protocol
7. Patient is willing to follow the instruction of the Investigator
8. Patient has provided written informed consent
Exclusion Criteria:
1. Previous history of pelvic radiation
2. Previous history of simple prostatectomy or transurethral prostate surgery
3. Previous history of systemic therapy for prostate cancer
4. Patient has neurogenic bladder
5. Body weight less than 50 kg (110 pounds) or a body mass index greater than 40 kg/m2
6. History of open pelvic surgery within 5 years except for hernia repair
7. Scheduled at the time of screening to undergo chemotherapy, radiation, hormone
therapy, or open surgery during the study period.
8. Any neurologic disorder or psychiatric disorder (e.g., Parkinson's Multiple Sclerosis,
etc.) that might confound postsurgical assessments
9. Received administration of an investigational drug within 30 days prior to study,
and/or has planned administration of another investigational product or procedure
during participation in this study
