A Phase 3, Multicenter, Prospective, Randomized, Open-label Study for Intraoperative Ureter(s) Visualization When Using ASP5354 With Near Infrared Fluorescence (NIR-F) Imaging in Participants Undergoing Minimally Invasive and Open Abdominopelvic Surgeries
Phase: PHASE3
Conditions: Intraoperative Ureter Visualization, Abdominolpelvic Surgery
Sponsor: Astellas Pharma Global Development, Inc.

Sponsor: APGD 
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Amendment 5 
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A Phase 3, Multicenter, Prospective, Randomized, Open-label 
Study for Intraoperative Ureter(s) Visualization When Using 
ASP5354 with Near-infrared Fluorescence (NIR-F) Imaging in 
Participants Undergoing Minimally Invasive and Open 
Abdominopelvic Surgeries 
 
ISN/Protocol 5354-CL-0301 
 
Amendment 5 [Nonsubstantial] 24 OCT 2024 
 
IND # 140758 
IND Grantor Center for Drug Evaluation and Research (CDER) 
Sponsor: 
Astellas Pharma Global Development Inc. 
Northbrook, IL 60062, US  
 
 
The information contained in this document is supplied as a background for clinical investigations. This document contains 
confidential information, which is the intellectual property of Astellas. By accepting or reviewing this document, you agree 
to hold this information in confidence and not copy or disclose it to others or use it for unauthorized purposes except (1) as 
otherwise agreed to in writing; (2) where required by applicable law; (3) where disclosure is directly related to the care and 
safety of the research participant; and (4) where disclosure of such information is made to a member of the investigator’s 
team who agrees to hold this information in confidence.  
 
 
 
 
 
 

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Table of Contents  
CONTACT DETAILS OF SPONSOR’S KEY PERSONNEL ································
······  8 
PROTOCOL AMENDMENT SUMMARY OF CHANGES ································
········  9 
1 
PROTOCOL SUMMARY ································
································
·······  11 
1.1 
Synopsis ································
································
························
 11 
1.2 
Study Schema ································
································
··················
 20 
1.3 
Schedules of Assessments ································
································
····  21 
1.3.1 
Sample Collection Schedule for Pharmacokinetics ································
· 24 
2 
INTRODUCTION ································
································
·················
 26 
2.1 
Study Rationale ································
································
················
 26 
2.2 
Background ································
································
····················
 27 
2.3 
Risk/Benefit Assessment ································
································
·····  27 
2.3.1 
Risk Assessment ································
································
·········  27 
2.3.2 
Benefit Assessment ································
································
·····  28 
2.3.3 
Overall Risk-Benefit Conclusion ································
······················
 28 
3 
OBJECTIVES, ENDPOINTS AND ESTIMANDS ································
·········  28 
3.1 
Primary Estimands ································
································
············
 31 
4 
STUDY DESIGN AND DOSE RATIONALE ································
················
 33 
4.1 
Overall Study Design ································
································
·········  33 
4.2 
Scientific Rationale for Study Design ································
······················
 33 
4.2.1 
Participant Input into Study Design ································
···················
 34 
4.3 
Dose Rationale ································
································
················
 34 
4.4 
Start and End of Study Definitions ································
··························
 37 
5 
STUDY POPULATION ································
································
··········
 37 
5.1 
Inclusion Criteria ································
································
··············
 37 
5.2 
Exclusion Criteria ································
································
·············
 38 
5.3 
Lifestyle Considerations ································
································
······  38 
5.4 
Screen Failures ································
································
················
 38 
5.4.1 
Rescreening ································
································
··············
 39 
6 
STUDY INTERVENTION AND CONCOMITANT THERAPY ························
 39 
6.1 
Study Intervention(s) Administered ································
·························
 39 
6.1.1 
Study Intervention Administration ································
····················
 40 

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6.2 
Preparation/Handling/Storage/Accountability ································
·············
 40 
6.2.1 
Packaging and Labeling ································
································
 40 
6.2.2 
Handling, Storage and Accountability ································
················
 41 
6.3 
Assignment to Study Intervention ································
···························
 41 
6.4 
Study Intervention Compliance ································
·····························
 41 
6.5 
Dose Modification ································
································
············
 41 
6.6 
Continued Access to Study Intervention After the End of the Study ···················
 41 
6.7 
Treatment of Overdose ································
································
·······  41 
6.8 
Prior and Concomitant Therapy ································
·····························
 42 
7 
STUDY PROCEDURES AND ASSESSMENTS ································
············
 42 
7.1 
Efficacy Assessments ································
································
·········  43 
7.1.1 
Primary and Secondary Efficacy Assessments································
·······  43 
7.1.1.1 
Ureter Conspicuity by 5-Point Likert Scale ································
····  43 
7.1.2 
Adults with Normal/Mild eGFR ································
·······················
 43 
7.1.3 
Adults with Moderate/Severe eGFR ································
··················
 44 
7.1.4 
Adolescents ································
································
··············
 44 
7.1.5 
BICR Ureter Conspicuity by 5-Point Likert Scale ································
··  44 
7.1.6 
Quantitative Assessment ································
································
 45 
7.2 
Safety Assessments ································
································
···········
 45 
7.2.1 
Laboratory Assessments ································
································
 45 
7.2.2 
Vital Signs, Height and Weight ································
························
 46 
7.2.3 
Physical Examination ································
································
···  46 
7.2.4 
Electrocardiogram and Cardiac Monitoring ································
··········
 46 
7.2.5 
Order of Assessments ································
································
···  46 
7.2.6 
Other Assessments ································
································
······  46 
7.2.6.1 
Visual Assessment of Urine Output ································
·············
 46 
7.3 
Adverse Events and Other Safety Aspects ································
·················
 47 
7.3.1 
Time Period and Frequency for Collecting Adverse Event and Serious 
Adverse Event Information································
·····························
 47 
7.3.1.1 
Adverse Device Effects ································
···························
 48 
7.3.2 
Method of Detecting Adverse Events and Serious Adverse Events ···············
 48 
7.3.3 
Follow-up of Adverse Events and Serious Adverse Events ························
 48 
7.3.4 
Regulatory Reporting Requirements for Serious Adverse Events/Adverse 
Device Effects/Medical Device Deficiencies ································
········  48 

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7.3.5 
Disease-related Events and/or Disease-related Outcomes Not Qualifying as 
Adverse Events or Serious Adverse Events ································
··········
 49 
7.3.6 
Adverse Events of Special Interest ································
····················
 49 
7.3.7 
Special Situations ································
································
········  49 
7.4 
Pharmacokinetics ································
································
··············
 50 
7.4.1 
Analysis of ASP5354 in Plasma ································
·······················
 50 
7.4.2 
Analysis of ASP5354 in Urine ································
·························
 50 
7.5 
Pharmacodynamics ································
································
···········
 50 
7.6 
Electronic Clinical Outcome Assessment ································
··················
 50 
7.7 
Total Amount of Blood ································
································
·······  50 
7.8 
Investigator Exit Interview ································
································
···  51 
8 
PARTICIPANT DISCONTINUATION ································
······················
 51 
8.1 
Discontinuation of Individual Participant(s) from Study Intervention ··················
 51 
8.2 
Discontinuation of Individual Participant(s) from Study ································
· 51 
8.3 
Lost to Follow-up ································
································
·············
 51 
9 
STATISTICAL CONSIDERATIONS ································
·························
 51 
9.1 
Statistical Hypotheses ································
································
········  51 
9.2 
Analysis Sets ································
································
···················
 53 
9.3 
Statistical Analyses ································
································
···········
 53 
9.3.1 
General Considerations ································
································
· 53 
9.3.2 
Primary Endpoint/Estimand(s) Analysis ································
··············
 54 
9.3.2.1 
Primary Analysis ································
································
···  54 
9.3.2.2 
Sensitivity Analysis ································
·······························
 55 
9.3.3 
Secondary Endpoints Analysis ································
·························
 55 
9.3.3.1 
Key Secondary Endpoints ································
························
 55 
9.3.3.2 
Additional Secondary Endpoints ································
·················
 57 
9.3.3.3 
Supplementary Analysis ································
··························
 58 
9.3.3.4 
Subgroup Analyses ································
································
 58 
9.3.4 
Exploratory Endpoints ································
································
··  58 
9.3.5 
Safety Analyses ································
································
··········
 58 
9.3.5.1 
Adverse Events································
································
·····  59 
9.3.5.2 
Laboratory Assessments ································
··························
 59 
9.3.5.3 
Vital Signs ································
································
··········
 59 
9.3.5.4 
Electrocardiogram and Cardiac Monitoring ································
····  59 

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9.3.6 
Other Analyses ································
································
···········
 60 
9.3.6.1 
Analysis of Pharmacokinetics ································
····················
 60 
9.3.6.2 
Analysis of Pharmacodynamics ································
··················
 60 
9.4 
Interim Analysis ································
································
···············
 60 
9.5 
Sample Size Determination ································
································
··  61 
9.5.1 
Adult Cohorts (Participants ≥ 18 Years of Age) ································
·····  61 
9.5.1.1 
Normal/Mild eGFR Cohort ································
·······················
 61 
9.5.1.2 
Moderate/Severe eGFR Cohort ································
··················
 61 
9.5.2 
Adolescent Cohort (Participants ≥ 12 and < 18 Years of Age) ····················
 61 
9.6 
Additional Conventions ································
································
······  62 
10 
SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS ································
································
·············
 63 
10.1 
Appendix 1 Ethical, Regulatory and Study Oversight Considerations ·················
 63 
10.1.1 
Regulatory and Ethical Considerations ································
···············
 63 
10.1.2 
Financial Disclosure ································
································
····  63 
10.1.3 
Informed Consent of Participants································
······················
 63 
10.1.3.1 
Informed Consent Process ································
························
 63 
10.1.3.2 
Supply of New and Important Information Influencing the 
Participant’s Consent and Revision of the Written Information ·············
 64 
10.1.4 
Recruitment Arrangements ································
·····························
 65 
10.1.5 
Data Protection ································
································
··········
 65 
10.1.6 
Committee(s) Structure ································
································
· 66 
10.1.6.1 
Blinded Independent Central Review Committee ·····························
 66 
10.1.7 
Dissemination of Clinical Study Data································
·················
 67 
10.1.7.1 
Disclosure of Study Information and Results ································
··  67 
10.1.7.2 
Access to Study Data ································
······························
 67 
10.1.8 
Data Quality Assurance ································
································
· 68 
10.1.9 
Source Documents ································
································
······  68 
10.1.10 
Study and Site Closure ································
································
··  70 
10.1.11 
Publication Policy ································
································
·······  70 
10.1.12 
Insurance of Participants and Others ································
··················
 70 
10.1.13 
Quality Assurance ································
································
·······  71 
10.2 
Appendix 2 Contraception Requirements ································
··················
 72 
10.3 
Appendix 3 Adverse Events/Adverse Device Effects: Definitions and 
Procedures for Recording, Evaluating, Follow-up and Reporting·······················
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10.3.1 
Definition of Adverse Events ································
··························
 76 
10.3.1.1 
Abnormal Laboratory Findings ································
··················
 76 
10.3.1.2 
Potential Cases of Drug-induced Liver Injury ································
··  77 
10.3.2 
Definition of Serious Adverse Events································
·················
 77 
10.3.3 
Adverse Device Effect (ADE) ································
·························
 78 
10.3.3.1 
Definition of ADE ································
································
· 78 
10.3.3.2 
Definition of Unanticipated adverse device effect (UADE) ··················
 78 
10.3.3.3 
Definitions of Technical Complaints and Device Deficiencies ··············
 78 
10.3.3.4 
Risks/Precautions ································
································
··  79 
10.3.4 
Assessment of Causality ································
································
 79 
10.3.5 
Assessment of Severity ································
································
· 81 
10.3.6 
Recording and Follow-up of AEs/SAEs and/or ADEs ······························
 81 
10.3.7 
Reporting Procedures for SAEs/ADEs/Medical Device Deficiencies ············
 82 
10.3.8 
Reporting Procedures for Pregnancy and Special Situations ·······················
 83 
10.3.8.1 
Contraceptive Guidance and Collection of Pregnancy Information ·········  83 
10.3.8.2 
Medication Error, Overdose and “Off-label Use” ·····························
 84 
10.3.8.3 
Misuse/Abuse ································
································
······  84 
10.3.8.4 
Occupational Exposure ································
···························
 84 
10.3.8.5 
(Suspicion of) Transmission of Infectious Agent ······························
 84 
10.3.8.6 
Suspected Drug-drug Interaction ································
················
 84 
10.3.9 
Supply of New Information Affecting the Conduct of the Study ··················
 85 
10.3.10 
Urgent Safety Measures ································
································
 85 
10.3.11 
Reporting Urgent Safety Measures ································
····················
 85 
10.4 
Appendix 4 Liver Safety Monitoring and Assessment ································
···  86 
10.5 
Appendix 5 List of Excluded Concomitant Medications ································
· 88 
10.6 
Appendix 6 Clinical Laboratory Assessments ································
·············
 89 
10.7 
Appendix 7 Assessment of Renal Function ································
················
 91 
10.7.1 
Adult Participants ································
································
·······  91 
10.7.2 
Adolescent Participants ································
································
· 91 
10.8 
Appendix 8 Ureter Conspicuity by 5-Point Likert Scale ································
· 92 
10.8.1 
Ureter Conspicuity by 5-Point Likert Scale ································
··········
 92 
10.8.1.1 
White Light Illustrative Examples ································
···············
 92 
10.8.1.2 
NIR-F Illustrative Examples ································
·····················
 94 
10.9 
Appendix 9 Clinical Study Continuity ································
······················
 96 
10.10 
Appendix 10 List of Abbreviations and Definition of Key Study Terms···············
 99 

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11 
REFERENCES ································
································
··················
 102 
12 
INVESTIGATOR’S SIGNATURE ································
··························
 103 
13 
COORDINATING INVESTIGATOR’S SIGNATURE ································
··  104 
14 
SPONSOR’S SIGNATURE ································
································
···  105 
 
List of In-text Tables 
Table 1 
Schedule of Assessments ································
································
·····  21 
Table 2 
Efficacy Assessment Schedule ································
······························
 24 
Table 3 
Sample Collection Schedule for Pharmacokinetics ································
·······  25 
Table 4 
Study Objectives and Endpoints ································
·····························
 28 
Table 5 
Study Intervention(s) Administered ································
·························
 39 
Table 6 
Study Arm(s) ································
································
··················
 40 
Table 7 
Grading Scale Defining the Severity of an Adverse Event ·······························
 81 
Table 8 
Moderate and Severe Liver Abnormalities ································
·················
 86 
Table 9 
Clinical Laboratory Tests ································
································
····  89 
Table 10 
Alternative Schedule of Assessments in Response to a Crisis ···························
 97 
 
List of In-text Figures 
Figure 1 
Fluorescence Intensity of the Index Ureter at Each Time Point During Surgery ······  35 
Figure 2 
Predicted Urine Pudexacianinium Concentration Data Versus the Intensity of 
Fluorescence (e.g., Likert Scale) From the Phase 2 Study ·······························
 36 
 

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CONTACT DETAILS OF SPONSOR’S KEY PERSONNEL 
24-hour Contact for 
Serious Adverse Events 
 
See [Section 10.3.7] 
Please fax or email the serious adverse events/special 
situations/adverse device effect worksheet to: 
Astellas Pharma Global Development Inc.  
Global Pharmacovigilance 
North America fax number: +1-888-396-3750 
North America alternate fax number: +1-847-317-1241 
International fax number: +44-800-471-5263 
Email: safety-us@astellas.com 
Medical Monitor/Study 
Physician 
 
 
Oncology Developmental Sciences, 
Astellas Pharma Global Development Inc., 
Northbrook, IL 60062, US 
 
 
Medical Monitor 
 
 
ICON Clinical Research 
Office: Av. Barranca del Muerto 329- 3rd floor CP. 03900 
Mexico City, Mexico  
 
 
 
PPD
PPD
PPD
PPD

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PROTOCOL AMENDMENT SUMMARY OF CHANGES 
DOCUMENT HISTORY 
Document 
Date 
Amendment 4 
11 JUL 2024 
Amendment 3 
04 APR 2024 
Amendment 2 
02 OCT 2023 
Amendment 1 
27 APR 2023 
Original Protocol 
08 NOV 2022 
Amendment 5 [Nonsubstantial] 24 OCT 2024 
This amendment is considered to be nonsubstantial based on the criteria set forth in Regulation (EU) No 536/2014 of the European Parliament because it 
neither significantly impacts the safety or physical/mental integrity of participants nor the scientific value of the study. 
Overall Rationale for the Amendment: 
The overall rationale for this amendment is to elevate the endpoint of frequency and percentage of participants with an improvement in ureter 
conspicuity under NIR-F vs WL from supplementary analysis to additional secondary endpoints. 
Summary of Changes 
Nonsubstantial Changes 
Section Number 
Description of Change 
Brief Rationale 
1.1, 3 (Table 4), 9.3.3.2 
Objectives and endpoints  
Elevation of supplementary analysis to additional secondary endpoints 
Addition of additional endpoint allowing for more substantial 
improvements under NIR-F vs WL 
The frequency and percentage of participants with 
average ureter conspicuity over all time points during 
surgery improved under NIR-F vs WL was elevated to 
additional secondary endpoints. This change was 
requested by FDA. 
A difference in ureter conspicuity under NIR-F vs WL 
of at least 3 and 4 points was added to assess 
improvements beyond 2 points.  
3.1, 4.2, 6.1 (Table 6), 7.1.1 
Clarification added for the order of conspicuity assessments 
The order of conspicuity assessment (WL followed by 
NIR-F) was added for clarification, based on comments 
received from FDA. 

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Section Number 
Description of Change 
Brief Rationale 
9.3.3.3 
Addition of supplementary analysis 
Since comparison to WL conspicuity assessment over all 
time points might be biased, a supplementary analysis 
comparing average ureter conspicuity over all NIR-F 
time points to ureter WL conspicuity score at the 30-min 
time point was added.  
 

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1 
PROTOCOL SUMMARY 
1.1 
Synopsis 
Title of Study:   
A Phase 3, Multicenter, Prospective, Randomized, Open-label Study for Intraoperative Ureter(s) 
Visualization When Using ASP5354 with Near-infrared Fluorescence (NIR-F) Imaging in 
Participants Undergoing Minimally Invasive and Open Abdominopelvic Surgeries 
Regulatory Agency Identifier Number(s):  
IND number: 140758 
WHO universal trial number: 1251 
Chemical Abstracts Service (CAS) Registry number: 2243793-22-6 
Unique Ingredient Identifier (UNII): D23R36L5QY 
Planned Study Period/Duration:  
From approximately 2Q2023 to 4Q2024 
Planned Total Number of Study Sites and Location(s):   
Approximately 6 sites in the US 
Rationale: 
ASP5354 (also known as pudexacianinium chloride) is a novel NIR-F imaging agent, under 
investigation for intraoperative anatomical identification/visualization of ureter(s) in participants 
undergoing minimally invasive and open abdominopelvic surgeries.  
Pudexacianinium chloride is a new chemical entity which has unique hydrophilic properties through 
conjugation with cyclodextrin. Unlike ICG, ASP5354 is iodine free. ASP5354 is administered 
intravenously and has a clinically distinct pharmacokinetic profile that allows for ASP5354 to be 
excreted into the urine through the kidneys. Photo-optically, ASP5354 is indistinguishable from ICG 
with an absorption of 780 nm and a fluorescence emission at 820 nm, allowing for the use of 
approved (ICG) NIR-F imaging technology. In this study, ASP5354 will be used with FDA-cleared 
imaging devices that have been approved for use with ICG for laparoscopic (Stryker 1688 Advanced 
Imaging Modalities device) and open surgical procedures (Stryker SPY-PHI). These devices provide 
both white light (WL) and NIR-F illumination modes. The NIR-F illumination/imaging technology 
when used with ASP5354 facilitates anatomic ureter visualization during minimally invasive and 
open abdominopelvic surgeries. 
This study is designed to evaluate the clinical utility of ASP5354 which enhances the conspicuity of 
the ureter with the use of an NIR-F imaging device. The benefit of enhanced conspicuity is to identify 
the ureter as soon as possible during the surgical procedures which is expected to help minimize the 
risk of iatrogenic ureteral injury (IUI) and associated complications. To date, there are no uniform 
prevention guidelines to avoid IUIs and no commercially available ureteral imaging agents. The 
European Association of Urology and American Society of Colon and Rectal Surgeons recommend 
either the use of ureteral stents and/or a cautious dissection with direct identification/visualization of 
the ureters during abdominopelvic procedures. Despite these recommendations, IUIs still occur and 
may not be evident until post-surgery. The European Association of Urology states that the best way 
to avoid IUIs is real-time ureter visualization. The use of ASP5354 with NIR-F imaging technologies 
is a promising technique that offers real-time ureter visualization for surgeons. 
ASP5354 has been studied in the following completed studies: 2 phase 1 studies in healthy 
participants and in 1 phase 2 study in participants undergoing laparoscopic or minimally invasive 
colorectal surgery. ASP5354 has also been studied in a completed phase 1 study in participants with 
mild, moderate and severe renal impairment compared with healthy controls. In addition to this phase 
3 study, another phase 3 study in adult participants undergoing minimally invasive and open 
abdominopelvic surgeries is being conducted. Clinical data to date shows ASP5354 has rapid renal 

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clearance without metabolism, and it is safe and well tolerated given as a single intravenous dose up 
to 24 mg. In the phase 2 study, enhanced conspicuity was observed in all 3 doses evaluated (0.3, 1 
and 3 mg).  
Doses of 1 mg and 3 mg provided visualization throughout the duration of the surgical procedure; 
however, at the 3 mg dose, fluorescent intensity was stronger and more consistent. At the 1 mg dose, 
the intensity of fluorescence was variable amongst the participants evaluated in the phase 2 study. 
The lower dose (0.3 mg) was determined to be inadequate for ureter visualization due to lower 
fluorescence intensity and shorter duration of visualization than doses of 1 mg and 3 mg. Given the 
ASP5354 safety profile, the highest dose of 3 mg was selected for the phase 3 program to provide 
optimal conspicuity of the ureter for the duration of surgery in all intended participants for the phase 
3 clinical program, including renally impaired participants. 
Using the PopPK model, plasma concentration data from the phase 2 study was used to predict urine 
ASP5354 concentration data. The relationship between simulated urine concentrations and the 
intensity of fluorescence from the Likert scale was evaluated for the 0.3, 1, and 3 mg doses. The 3 mg 
dose showed consistent efficacy with regards to intensity of fluorescence and was above the target 
urinary concentration for ureter visualization of 1 µg/mL, which was determined based on nonclinical 
ex vivo and in vivo minipig studies. In contrast, the 1 mg dose did not show consistency across the 
Likert scale regarding intensity of fluorescence and also depicted a high amount of variability even 
though it was above the target urinary concentration for ureter visualization of 1 µg/mL. Therefore, 
the 3 mg dose was selected for the phase 3 program. 
Based on the data from 2 phase 1 studies in healthy participants; 1 phase 1 study in participants with 
mild, moderate and severe renal impairment compared with healthy controls; 1 phase 2 study in 
participants undergoing laparoscopic or minimally invasive colorectal surgery; and to compensate for 
a potential decrease in urine concentration of ASP5354 in participants with renal impairment, a single 
3 mg dose is considered clinically relevant and safe. In addition, it should be adequate to evaluate the 
clinical utility of ASP5354 in this population. 
Study Objectives, Endpoints and Estimands: 
Objectives 
Endpoints 
Primary 
● 
Investigator’s blinded conspicuity assessment of 
the ureter at the first time point for adults with 
normal renal function or mild renal impairment 
● 
Intra-participant difference in ureter conspicuity 
for WL versus NIR-F at 30 (± 15) min after 
ASP5354 administration. Conspicuity will be 
scored individually for each illumination mode 
using the 5-Point Likert Scale 
Key Secondary 
● 
Investigator’s conspicuity assessment of the 
ureter when using ASP5354 with NIR-F for the 
duration of the surgical procedure for adults with 
normal renal function or mild renal impairment 
● 
Intra-participant comparison of ureter 
conspicuity scores for the WL 30 (± 15) min 
time point versus the average of all NIR-F time 
points 
● 
Intra-participant comparison of ureter 
conspicuity scores for the WL 30 (± 15) min 
time point versus the end of surgery time point 
score with NIR-F 
Additional Secondary 
● 
Support the investigator’s qualitative assessment 
of ureter conspicuity with a quantitative measure 
for all participants in all cohorts 
● 
Using recorded images, ureter conspicuity for 
WL and NIR-F illumination modes will be 
quantified by image analysis for all time points 
● 
Investigator’s conspicuity assessment of the 
● 
Descriptive summary of intra-participant 
difference in ureter conspicuity for WL versus 

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ureter at the first time point for adolescents 
NIR-F at 30 (± 15) min after ASP5354 
administration  
● 
Investigator’s conspicuity assessment of the 
ureter when using ASP5354 with NIR-F for the 
duration of the surgical procedure for 
adolescents 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the average of all NIR-F time points  
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the end of surgery time point score with 
NIR-F 
● 
Investigator’s conspicuity assessment of the 
ureter at the first time point for adults with 
moderate or severe renal impairment 
● 
Descriptive summary of intra-participant 
difference in ureter conspicuity for WL versus 
NIR-F at 30 (± 15) min after ASP5354 
administration 
● 
Investigator’s conspicuity assessment of the 
ureter when using ASP5354 with NIR-F for the 
duration of the surgical procedure for adults with 
moderate or severe renal impairment 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the average of all NIR-F time points 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the end of surgery time point score with 
NIR-F  
● 
Investigator’s conspicuity assessment of the 
ureter at the first time point for participants in all 
cohorts 
● 
Descriptive summary of intra-participant 
difference in ureter conspicuity for WL versus 
NIR-F at 30 (± 15) min after ASP5354 
administration 
● 
Investigator’s conspicuity assessment of the 
ureter when using ASP5354 with NIR-F for the 
duration of the surgical procedure for 
participants in all cohorts 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the average of all NIR-F time points 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the end of surgery time point score with 
NIR-F 
● 
Frequency and percentage of participants with 
average ureter conspicuity assessed by the 
investigator over all time points during surgery 
improved under NIR-F vs WL in all cohorts 
 
● 
BICR’s conspicuity assessment of the ureter at 
the first time point for adults with normal renal 
function or mild renal impairment 
● 
Frequency and percentage of participants with an 
average index ureter conspicuity over all NIR-F 
time points at least 1 point higher than the 
average index ureter conspicuity over all WL 
time points  
● 
Frequency and percentage of participants with an 
average index ureter conspicuity over all NIR-F 
time points at least 2, 3 or 4 points higher than 
the average index ureter conspicuity over all WL 
time points  
● 
Intra-participant difference in ureter conspicuity 
for WL versus NIR-F at 30 (± 15) min after 
ASP5354 administration 
● 
BICR’s conspicuity assessment of the ureter 
when using ASP5354 with NIR-F for the 
duration of the surgical procedure for adults with 
normal renal function or mild renal impairment 
● 
Intra-participant comparison of ureter 
conspicuity scores for the WL 30 (± 15) min 
time point versus the average of all NIR-F time 
points 
● 
Intra-participant comparison of ureter 
conspicuity scores for the WL 30 (± 15) min 
time point versus the end of surgery time point 
score with NIR-F 
● 
BICR’s conspicuity assessment of the ureter at 
● 
Descriptive summary of intra-participant 

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the first time point for adolescents 
difference in ureter conspicuity for WL versus 
NIR-F at 30 (± 15) min after ASP5354 
administration 
● 
BICR’s conspicuity assessment of the ureter 
when using ASP5354 with NIR-F for the 
duration of the surgical procedure for 
adolescents 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the average of all NIR-F time points 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the end of surgery time point score with 
NIR-F 
● 
BICR’s conspicuity assessment of the ureter at 
the first time point for adults with moderate or 
severe renal impairment 
● 
Descriptive summary of intra-participant 
difference in ureter conspicuity for WL versus 
NIR-F at 30 (± 15) min after ASP5354 
administration 
● 
BICR’s conspicuity assessment of the ureter 
when using ASP5354 with NIR-F for the 
duration of the surgical procedure for adults with 
moderate or severe renal impairment 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the average of all NIR-F time points 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the end of surgery time point score with 
NIR-F 
● 
BICR’s conspicuity assessment of the ureter at 
the first time point for participants in all cohorts 
● 
Descriptive summary of intra-participant 
difference in ureter conspicuity for WL versus 
NIR-F at 30 (± 15) min after ASP5354 
administration 
● 
BICR’s conspicuity assessment of the ureter 
when using ASP5354 with NIR-F for the 
duration of the surgical procedure for 
participants in all cohorts 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the average of all NIR-F time points 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the end of surgery time point score with 
NIR-F 
● 
Concordance between investigator’s 
intra-operative conspicuity assessment of the 
ureter and BICR assessment for adults with 
normal renal function or mild renal impairment 
● 
Intra-participant difference in ureter conspicuity 
for WL versus NIR-F at 30 (± 15) min after 
ASP5354 administration by each BICR reader 
● 
CCC, the inter-rater reliability between the 
investigators and BICR for the WL versus NIR-F 
at 30 (± 15) min after ASP5354 administration 
● 
Intra-participant difference in ureter conspicuity 
for WL at 30 (± 15) min versus the average of all 
NIR-F time points by each BICR reader 
● 
CCC, the inter-rater reliability between the 
investigators and BICR for the WL at 
30 (± 15) min time point versus the average of 
all NIR-F time points 
● 
Intra-participant difference in ureter conspicuity 
for WL at 30 (± 15) min versus the end of 
surgery time point score with NIR-F by each 
BICR reader 
● 
CCC, the inter-rater reliability between the 
investigators and BICR for the WL 
30 (± 15) min time point versus the end of 
surgery time point score with NIR-F  

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● 
Safety of ASP5354 
● 
Nature, frequency, severity and causality of 
TEAEs and serious TEAEs 
● 
Clinical laboratory tests (hematology, 
biochemistry and urinalysis) 
● 
Vital signs 
● 
Electrocardiograms/cardiac monitoring 
● 
Investigate the pharmacokinetics of ASP5354 
● 
Plasma and urine concentrations of ASP5354 
● 
Ae and Ae% 
Exploratory 
● 
To summarize the investigator’s conspicuity 
assessment with WL of the ureter at each time 
point 
● 
Descriptive summary of left and right ureter 
conspicuity scores for WL at each time point 
● 
Descriptive summary of index and non-index 
ureter conspicuity scores for WL at each time 
point 
● 
Concordance of conspicuity assessment of the 
ureter among BICR readers for participants with 
normal renal function or mild renal impairment 
● 
ICC, the inter-rater reliability among BICR 
readers on the intra-participant difference in 
ureter conspicuity for WL versus NIR-F at 
30 (± 15) min after ASP5354 administration 
● 
ICC, the inter-rater reliability among BICR 
readers on the scoring in ureter conspicuity for 
the WL and NIR-F at 30 (± 15) min after 
ASP5354 administration 
● 
ICC, the intra-rater reliability within each BICR 
reader on the intra-participant difference in 
ureter conspicuity for WL versus NIR-F at 
30 (± 15) min after ASP5354 administration 
● 
ICC, the intra-rater reliability within each BICR 
reader on the scoring in ureter conspicuity for 
the WL and NIR-F at 30 (± 15) min after 
ASP5354 administration 
Ae: amount of ASP5354 excreted into urine; Ae%: percentage of ASP5354 dose excreted into urine; 
BICR: blinded independent central review; CCC: concordance correlation coefficient; 
ICC: intraclass correlation coefficient; NIR-F: near-infrared fluorescence; TEAE: treatment-emergent 
adverse events; WL: white light 
Primary Estimands 
Population:  
Male and female participants ≥ 18 years of age with estimated glomerular filtration rate (eGFR) 
≥ 60 mL/min undergoing minimally invasive and open abdominopelvic surgeries. The population 
is further defined by the eligibility criteria. 
Treatment Regimen: 
The treatment regimen is ASP5354, 1 single intravenous dose of 3 mg (3 [three] 1 mg vials).  
Primary Endpoint:  
Intra-participant difference in ureter conspicuity for WL versus NIR-F at the 30-min time point 
after ASP5354 administration. The first assessment will always be under WL followed by NIR-F 

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assessment. Conspicuity will be scored individually for each illumination mode using the 5-Point 
Likert Scale (see [Section 10.8]). 
Intercurrent Events (ICEs) and Strategies: 
ICE1: Participants who have received the medications or therapy listed below within 48 hours prior 
to ASP5354 administration and/or before the completion of the surgical procedure: 
• 
ICG unless used for anastomotic evaluation after the ureters have been visualized or for 
lymphatic mapping where there is a clear anatomic separation of the ureters and the lymphatics 
• 
Other NIR-F imaging agents 
• 
Ureteral stent 
Composite strategy for ICE1: The assessment of ureter conspicuity after ICE1 will not be 
considered as relevant and will be handled as missing data. For participants that experience ICE1 
prior to the 30-min time point conspicuity assessment by the investigator, both conspicuity values 
at the 30-min time point with WL and NIR-F will be set as ‘1 = Not self-evident’ for the primary 
endpoint analysis. 
ICE2: Participants who are unable to have ureter conspicuity assessed by the investigator at the 
30-min time point for any reason. 
Treatment policy strategy for ICE2: The assessment of ureter conspicuity in the event of ICE2 will 
be imputed as follows. In the event that WL or NIR-F conspicuity is not assessed by the 
investigator at the 30-min time point, the first collected conspicuity assessment under the 
respective illumination mode will be used as the 30-min time point value. If a participant does not 
have any assessments under a respective illumination mode during the entire surgery, the 30-min 
time point value will be set as the 30-min value from the other illumination mode. If a participant 
does not have any assessments under either illumination mode during the entire surgery, both 
30-min time point values will be set as ‘1 = Not self-evident’. 
Population Level Summary:  
For participants randomized to WL/NIR-F, the score of the ureter conspicuity at the 30-min time 
point based on the 5-Point Likert Scale with NIR-F will be compared with the score of the ureter 
conspicuity at the 30-min time point based on the 5-Point Likert Scale with WL using absolute 
difference.  
Study Population:   
Male or female participants ≥ 12 years of age scheduled to undergo minimally invasive and open 
abdominopelvic surgery. 
Number of Participants:  
Approximately 107 participants (94 adults and 13 adolescents) will be enrolled. 
Adult Cohorts (Participants ≥ 18 years of age) 
• 
Normal/Mild eGFR Cohort: 
Approximately 84 adult participants with normal renal function or mild renal impairment 
(eGFR ≥ 60 mL/min) will be enrolled to receive ASP5354 and randomized to the WL/NIR-F 
arm or the WL-only arm. The allocation ratio of the randomization to WL/NIR-F versus 
WL-only will be specified in the study randomization specification document. 
• 
Moderate/Severe eGFR Cohort: 
Up to 10 participants with moderate or severe renal impairment (eGFR: ≥ 15 to < 60 mL/min) 
will be enrolled into the WL/NIR-F arm and receive ASP5354. All participants with moderate 
or severe renal impairment will be assessed with both WL and NIR-F during surgery 
(non-randomized cohort). In the event that the enrollment of participants with normal/mild 
renal impairment and adolescents is completed prior to enrolling 10 participants with 

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moderate/severe renal impairment, enrollment of participants in the moderate/severe eGFR 
cohort will end. Therefore, the final number of participants with moderate/severe renal 
impairment will be between 0 and 10. 
Adolescent Cohort (Participants ≥ 12 and < 18 years of age) 
Approximately 13 adolescent participants with normal renal function or mild renal impairment 
(eGFR ≥ 60 mL/min) will be enrolled and receive ASP5354 such that a minimum of 10 evaluable 
adolescent participants (at least 6 participants 12 to 14 years of age and at least 4 participants 
15 to 17 years of age) complete the study to allow collection of pharmacokinetic samples from at 
least 6 participants in age group ≥ 12 and < 15 years of age and at least 4 participants in age group 
≥ 15 and < 18 years of age. All adolescent participants will be assessed with both WL and NIR-F 
during surgery (non-randomized cohort). Assuming approximately 20% of participants might not 
facilitate derivation of plasma pharmacokinetic parameters, 13 adolescent participants would need 
to be enrolled. 
Study Design Overview:   
This is a phase 3, multicenter, prospective, randomized, open-label study to evaluate the clinical 
utility of ASP5354 with the use of an NIR-F imaging device in participants undergoing minimally 
invasive and open abdominopelvic surgeries. In order to achieve reasonably balanced enrollment 
across surgery types, the sponsor will monitor enrollment and may cap enrollment for a specific 
surgery type (i.e., gynecological or other abdominopelvic) during the study. 
This study is designed to evaluate the clinical utility of ASP5354 which enhances the conspicuity 
of the ureter with the use of an NIR-F imaging device. The investigator, at their discretion, will 
select ureter(s) of interest (i.e., right, left, or both) before surgery. If the selection is both, the 
investigator will further select 1 index ureter (i.e., right or left) at their discretion. The conspicuity 
of the ureter will be assessed by the investigator (5-Point Likert Scale) for the selected ureter(s) of 
interest during surgery for all participants. The investigator’s qualitative assessment of ureter 
conspicuity will be supported with a quantitative measure and blinded independent central review 
(BICR) assessment, which will be performed centrally using recorded images taken during the 
surgery. 
The study will enroll approximately 107 participants (84 adults with normal renal function or mild 
renal impairment [eGFR ≥ 60 mL/min], up to 10 adults with moderate or severe renal impairment 
[eGFR ≥ 15 to < 60 mL/min] and 13 adolescents with normal renal function or mild renal 
impairment [eGFR ≥ 60 mL/min]) who will receive a single intravenous 3 mg dose of ASP5354. 
The normal/mild eGFR cohort will be randomized to 2 arms: WL/NIR-F arm and WL-only arm. 
Randomization will be stratified by type of surgery (gynecological; other abdominopelvic). There 
is no randomization for adult participants with moderate/severe eGFR or adolescent participants 
and all of these participants will be evaluated with WL/NIR-F. Safety, tolerability and 
pharmacokinetics in the study population will also be assessed. 
Efficacy Assessments 
Adults with Normal/Mild eGFR: 
Each site with adult participants will designate an unblinded study member who will randomize 
participants via the study’s interactive response technology (IRT) system. Investigators will be 
blinded to the randomization assignment until after completion of the first ureter conspicuity 
assessment (by the study-specific 5-Point Likert Scale; hereafter, referred to as the 5-Point Likert 
Scale) performed with WL at 30-min after ASP5354 administration. This first WL assessment will 
be done when the investigator reaches the point in the surgery that visualization/identification of 
the ureter(s) is required.  
If the first assessment timeframe is missed (30 [± 15] min post-ASP5354 administration), the first 
conspicuity assessment for the study must be done while investigators remain blinded to the 

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participant’s randomization assignment. The time of the conspicuity assessment will be recorded at 
all time points. Following this assessment, the unblinded study member will provide the 
investigator with the randomization assignment of the participant. If the participant was 
randomized to the:  
• 
WL/NIR-F arm: the 30-min time point ureter conspicuity assessment will also be performed 
with NIR-F for the investigator-selected ureter(s) of interest (i.e., right, left or both). 
Thereafter, the investigator will assess the conspicuity of selected ureter(s) with WL and with 
NIR-F every 30 (± 15) min for the duration of the surgery, with the last assessment performed 
at the end of surgery time point. The first assessment will always be under WL followed by 
NIR-F assessment. 
Note: The end of surgery time point is defined as the last time point where the ureter can be 
captured in the surgical field before removal of laparoscopic instruments or before the 
beginning of closure of the abdomen for open surgeries. If a surgical approach is switched 
from laparoscopic to open during surgery, ureter conspicuity assessment must be performed 
until the end of the laparoscopic surgery part and can be continued until the end of the open 
surgery part at the investigator’s discretion. The actual end of surgery is defined as the moment 
when all the procedures related to the surgery/surgery part that the investigator planned for the 
study are concluded. 
• 
WL-only arm: only the 30-min time point after ASP5354 administration ureter conspicuity 
assessment will be performed with WL for the ureter(s) of interest (i.e., right, left or both). 
Note: no additional conspicuity assessments with WL will be needed at the subsequent time 
points  
Adults with Moderate/Severe eGFR: 
All moderate and severe eGFR participants will have conspicuity assessments performed with WL 
and NIR-F for all time points. The same conspicuity assessment procedures will be followed as 
described above for adults with normal/mild eGFR, except investigators will not be blinded at the 
first WL assessment time point. The WL-only arm does not apply to this cohort. 
Adolescents: 
Adolescent participants will have conspicuity assessments performed with WL and NIR-F for all 
time points. The same conspicuity assessment procedures will be followed as described above for 
adults with normal/mild eGFR, except investigators will not be blinded at the first WL assessment 
time point. The WL-only arm does not apply to this cohort. 
All Participants: 
All participants will have a safety follow-up assessment approximately 15 days after surgery. The 
anticipated duration of the study for each participant, including screening and follow-up visits, is 
between 5 to 53 days.  
Efficacy Evaluation 
For all participants, the investigator will perform the ureter conspicuity assessment by 5-Point 
Likert Scale: 
• 
The investigator will attempt to locate the ureter and score the ureter conspicuity using the 
5-Point Likert Scale by answering the question, “How conspicuous (easy to recognize/identify) 
is the ureter?”  
• 
When assessing the 5-Point Likert Score for ureter conspicuity, investigators should consider 
information, such as contrast, brightness (luminance) and/or fluorescence intensity. 
• 
Conspicuity (or “How conspicuous is the ureter?”) for this study is defined as “self-evident 
ureter location identification (jump out to capture your attention)”. 
WL/NIR-F Arm Participants Only:  

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• 
Using recorded images, ureter conspicuity for WL and NIR-F illumination modes will be 
quantified by image analysis for all time points. 
• 
The BICR will perform the ureter conspicuity assessment by 5-Point Likert Scale using 
recorded images taken during surgery at approximately the same timepoint as the investigator. 
Safety Evaluation 
Safety and tolerability will be assessed by adverse events (AEs), clinical laboratory evaluations 
(hematology, biochemistry and urinalysis), vital signs measurements, physical examinations and 
electrocardiograms (ECGs)/cardiac monitoring. 
Study Intervention Groups and Duration: 
Intervention Name 
ASP5354 (pudexacianinium chloride) 
Type 
drug 
Dose Formulation 
sterile powder for solution 
Unit Dose Strength 
each vial contains 1.3 mg of ASP5354 and must be reconstituted with 
1.2 mL sterile water for injection, to a concentration of 1 mg/mL 
Dosage Level 
single dose of 3 mg (3 vials of 1 mg)  
Route of Administration 
intravenous 
Use 
experimental 
 
 

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1.3 
Schedules of Assessments 
Table 1 
Schedule of Assessments  
Assessments 
Screening Period1 
Treatment Period 
Follow-up Period 
Visit number 
1 
2 
3 
Visit Label 
Screening 
Preoperative1 
Intraoperative 
Postoperative  
Follow-up 
Day 
-28 to -1 
1 
22 
153 
Window 
- 
- 
- 
- 
+ 2 
± 10 
Informed consent/assent4 
X 
 
 
 
 
 
Inclusion/exclusion criteria 
X 
 
 
 
 
 
Medical history and current conditions5 
X 
 
 
 
 
 
Demographics6 
X 
 
 
 
 
 
Physical examination7 
X 
X 
 
X8 
 
X 
Vital signs9 
X 
X 
 
X8 
 
X 
Clinical laboratory tests10 
X11 
X 
 
X12 
X 
X 
Height9 
X 
 
 
 
 
 
Weight9 
X 
 
 
 
 
X 
Pregnancy test13 
X11 
X 
 
 
 
 
ECG/cardiac monitoring14 
 
X 
X 
X8 
 
 
Randomization (normal/mild eGFR cohort only) 
 
X15 
 
 
 
 
ASP5354 dosing  
 
 
X 
 
 
 
Blood sampling for ASP5354 pharmacokinetics16 
 
 
See [Table 3] 
 
 
Urine sampling for ASP5354 pharmacokinetics17 
 
 
See [Table 3] 
 
 
 
Visual assessment of urine output18 
 
 
→ 
→ 
→ 
→ 
Efficacy assessments19 
 
 
See [Table 2] 
 
 
 
Record surgery 
 
 
X20 
 
 
 
Previous/concomitant medications 
X 
X 
X 
X 
X 
X21 
AE/SAE assessment 
X 
X 
X 
X 
X 
X21 
ADE assessment 
 
 
X 
 
 
 
ADE: adverse device effect; AE/SAE: adverse event/serious adverse event; ECG: electrocardiogram; eGFR: estimated glomerular filtration rate 

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1. The assessments scheduled for the screening period can be done on day 1 if all eligibility criteria can be confirmed before randomization for adults (normal/mild eGFR cohort) or 
can be confirmed before registering adults (moderate/severe eGFR cohort) and adolescent participants for ASP5354. If screening procedures are performed on day 1, physical 
examination, vital signs, clinical laboratory tests, pregnancy test (blood or urine), previous/concomitant medications and AE/SAE assessment will be done once.  
2. Only when participant stays in the hospital. 
3. If a participant discontinues early from the study after the study intervention administration, the follow-up visit procedures will be performed upon discontinuation. If a participant 
discontinues before the study intervention administration, the follow-up visit procedures will not be required. 
4. For adult participants ≥ 18 years of age, consent must be obtained prior to any study-related procedures. For adolescent participants ≥ 12 and < 18 years of age, in addition to 
consent from a participant’s parent or legal guardian, assent from an adolescent participant is obtained if required. 
5. Medical history includes all significant medical conditions that have occurred or are currently ongoing (including previous abdominopelvic surgical history and prior inflammatory 
disorders of interest [e.g., endometriosis]). 
6. Demographic information will be collected for all participants and will include age, sex, race and ethnicity. 
7. A full physical examination will be performed at screening (visit 1). Body systems to be evaluated include general appearance, skin, lymphatic, head and neck, ears, nose and 
throat, chest and lungs, cardiovascular, abdomen, extremities, musculoskeletal and neuromuscular. At visit 2 and the follow-up visit (visit 3), a symptom-directed physical 
examination will be performed. 
8. Physical examination, vital signs and ECG/cardiac monitoring will be completed on day 1 or day 2.  
9. All vital signs (blood pressure and pulse) will be measured with the participant in the sitting or supine position. Height will be collected at visit 1 and weight will be measured at 
visits 1 and 3 using standard institution practice and equipment. 
10. Clinical laboratory tests for the central laboratory include blood collection for hematology (complete blood count), biochemistry and urine samples for urinalysis. 
11. The results of these assessments have to be obtained prior to randomization for adults (normal/mild eGFR cohort) or registration of adults (moderate/severe eGFR cohort) and 
adolescent participants for ASP5354. If the results from the central laboratory are not yet available at time of randomization/registration, results from local laboratory within 28 
days before the surgery can be used. The participant will not be excluded from the study if central laboratory results from screening are exclusionary and are available only after 
randomization/registration. 
12. Clinical laboratory tests will be collected within 2-hours after the actual end time of surgery if participant is discharged on day of surgery (day 1). Otherwise, the test will be 
collected at postoperative day 2 (+ 2 days). 
13. Required only for women of childbearing potential (see [Section 10.2] for contraception requirements). The pregnancy test scheduled for the screening visit can be performed by 
either serum or urine. For the preoperative visit, serum or urine pregnancy test will be performed locally. If no result from screening visit is available at time of 
randomization/registration, the result of the blood or urine pregnancy test at preoperative visit must be confirmed before randomization/registration. 
14. A standard 12-lead ECG or the site's standard care of routine cardiac monitoring will be taken preoperatively prior to ASP5354 administration. After administration of ASP5354 
(within 10-min after ASP5354 administration) and the postoperative ECGs can be done as per the site’s standard of care routine cardiac monitoring.  
15. Randomization can also be done 1 business day prior to the surgery day if eligibility is confirmed prior to randomization depending on local pharmacy availability for early 
morning surgery cases. 
16. Blood samples for pharmacokinetics of ASP5354 will be collected from all participants. Blood samples will be collected according to [Table 3]. 
17. Urine samples for pharmacokinetics will be collected according to [Table 3]. Urine volume will be calculated from the weight of urine in the catheter bag. Urine volume will be 
recorded in milliliters. Details will be provided in a Laboratory Manual. 
18. Urine output will be visually assessed throughout the study. Visual observation abnormalities such as abnormal urine color (e.g., green color in the urine), if observed, will be 
recorded as an AE. 

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19. Investigator evaluation and blinded independent central review assessments for ureter conspicuity will be assessed intraoperatively and at the end of surgery time point (see 
[Table 2]).  
20. A video will be recorded during surgery (see [Table 2]). Additionally, the reason for surgery, surgery type, surgical duration, surgical device and time of the video for each time 
point will be collected. Recorded images will be used for the quantitative analysis and blinded independent central review assessments. 
21. If a participant experiences an AE/SAE/ADE or change in concomitant medications between Visit 2 and Visit 3, the participant should call the study site to inform of these 
changes. For participants who experience hypersensitivity reaction(s), an additional blood sample should be collected to determine histamine and tryptase concentration levels. The 
sample should be taken as soon as possible after the onset of the hypersensitivity reaction and sent to the central laboratory. 
 

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Table 3 
Sample Collection Schedule for Pharmacokinetics 
Blood Collection Schedule 
Procedure 
Time Point (after ASP5354 administration) 
PK Blood Collection 
Assessment Window for Blood Collection 
Intraoperative 
10 min1 
X 
± 5 min  
30 min1 
X 
± 15 min  
1 h2 
X 
± 15 min 
Every 1 hour until end of surgery time point3 
X 
± 15 min 
Postoperative 
-4 
X 
Within 2 hours after the actual end of surgery 
Urine Collection Schedule 
Procedure 
Time Interval (after ASP5354 administration) 
PK Urine Collection 
Assessment Window for  
Urine Catheter Bags Change5 
Intraoperative 
0- to 10 min 
X 
10 (± 5) min 
10- to 30 min 
X 
30 (± 15) min 
Every 30 min thereafter until end of surgery time point3 
X  
Every 30 (± 15) min  
Postoperative 
- 
- 
- 
PK: pharmacokinetics 
1. 
Even if surgery ends earlier than this time point, this time point would need to be collected. 
2. 
If surgery ends earlier than this time point, this time point would NOT need to be collected. 
3. 
The end of surgery time point is defined as the last time point where the ureter can be captured in the surgical field before removal of laparoscopic instruments or before the 
beginning of closure of the abdomen for open surgeries. Regardless of switching the surgical approach during surgery, blood and urine samples for PK should be collected until 
the end of surgery timepoint for the open surgery part according to [Table 3]. In any case, for the time points after “3 h time point” for blood, and after “2.5 h - 3 h time point” for 
urine, those time points would be optional. 
4. 
If the blood collection at 3 hours timepoint is obtained, this time point would be optional.   
5. 
The investigator or site study staff will change the urine catheter bags during the assessment window. 
 

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2 
INTRODUCTION 
2.1 
Study Rationale 
ASP5354 (also known as pudexacianinium chloride) is a novel near-infrared fluorescence 
(NIR-F) imaging agent under investigation for intraoperative anatomical 
identification/visualization of ureter(s) in participants undergoing minimally invasive and 
open abdominopelvic surgeries.  
Pudexacianinium chloride is a new chemical entity which has unique hydrophilic properties 
through conjugation with cyclodextrin. Unlike ICG, ASP5354 is iodine free. ASP5354 is 
administered intravenously and has a clinically distinct pharmacokinetic profile that allows 
for ASP5354 to be excreted into the urine through the kidneys. Photo-optically, ASP5354 is 
indistinguishable from ICG with an absorption of 780 nm and a fluorescence emission at 
820 nm, allowing for the use of approved (ICG) NIR-F imaging technology. In this study, 
ASP5354 will be used with FDA-cleared imaging devices that have been approved for use 
with ICG for laparoscopic (Stryker 1688 Advanced Imaging Modalities device) and open 
surgical procedures (Stryker SPY-PHI). These devices provide both white light (WL) and 
NIR-F illumination modes. The NIR-F illumination/imaging technology when used with 
ASP5354 facilitates anatomic ureter visualization during minimally invasive and open 
abdominopelvic surgeries. 
This study is designed to evaluate the clinical utility of ASP5354 which enhances the 
conspicuity of the ureter with the use of an NIR-F imaging device. The benefit of enhanced 
conspicuity is to identify the ureter as soon as possible during the surgical procedures, which 
is expected to help minimize the risk of iatrogenic ureteral injury (IUI) and associated 
complications. To date, there are no uniform prevention guidelines to avoid IUIs and no 
commercially available ureteral imaging agents. The European Association of Urology and 
American Society of Colon and Rectal Surgeons recommend either the use of ureteral stents 
and/or a cautious dissection with direct identification/visualization of the ureters during 
abdominopelvic procedures. Despite these recommendations, IUIs still occur and may not be 
evident until post-surgery. The European Association of Urology states that the best way to 
avoid IUIs is real-time ureter visualization. The use of ASP5354 with NIR-F imaging 
technologies is a promising technique that offers real-time ureter visualization for surgeons.  
ASP5354 has been studied in the following completed studies: 2 phase 1 studies in healthy 
participants and in 1 phase 2 study in participants undergoing laparoscopic or minimally 
invasive colorectal surgery. ASP5354 has also been studied in a completed phase 1 study in 
participants with mild, moderate or severe renal impairment compared with healthy controls. 
In addition to this phase 3 study, another phase 3 study in adult participants undergoing 
minimally invasive and open abdominopelvic surgeries is being conducted. Clinical data to 
date shows ASP5354 has rapid renal clearance without metabolism, and it is safe and well 
tolerated given as a single intravenous dose up to 24 mg. In the phase 2 study, enhanced 
conspicuity was observed in all 3 doses evaluated (0.3, 1 and 3 mg). Given the ASP5354 
safety profile, the highest dose of 3 mg was selected for the phase 3 program to provide 

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optimal conspicuity of the ureter for the duration of surgery in all intended participants for 
the phase 3 clinical program, including renally impaired participants. The physiologically 
based pharmacokinetic (PBPK) modeling and simulation suggests that lower urine ASP5354 
concentration levels are expected in moderate and severe renally impaired participants than in 
healthy participants with normal renal function. However, it was suggested that mean urine 
concentration would still exceed 1 μg/mL for 3 hours after a single intravenous 3 mg dose of 
ASP5354 in participants with moderate and severe renal impairment, which is the target urine 
concentration for ureter visualization based on nonclinical studies [Fushiki et al, 2023]. It is 
suggested that ureter conspicuity can be anticipated at a dose of 3 mg in participants with 
moderate and severe renal impairment as well. 
Based on the data from 2 phase 1 studies in healthy participants; 1 phase 1 study in 
participants with mild, moderate and severe renal impairment compared with healthy 
controls; 1 phase 2 study in participants undergoing laparoscopic or minimally invasive 
colorectal surgery; and to compensate for a potential decrease in urine concentration of 
ASP5354 in participants with renal impairment, a single 3 mg dose is considered clinically 
relevant and safe. In addition, it should be adequate to evaluate the clinical utility of 
ASP5354 in this population. 
2.2 
Background 
The available nonclinical and clinical data collected to date indicates that the use of ASP5354 
with NIR-F imaging technologies is a promising technique that offers noninvasive, real-time 
ureter visualization in participants undergoing minimally invasive and open abdominopelvic 
surgery. This is expected to help minimize the risk of IUI which is widely recognized as a 
“potentially devastating complication of modern surgery” [Burks & Santucci, 2014] 
associated with higher mortality, morbidity, longer length of hospital stays and increased 
healthcare cost [Halabi et al, 2014]. In a retrospective study of 53 096 hysterectomies in 
Norway, IUI was documented in 643 patients (1.2%). Of the 643 patients, 69 claims for 
compensation were received. In 77% of the claims patients required surgery to correct for IUI 
and 10% of these patients lost a kidney [Ravlo et al, 2022]. Numerous reports detail the 
seriousness of the IUI condition [Poza et al, 2022; Kaymak et al, 2021; Zhang et al, 2021].  
Refer to the Investigator’s Brochure (IB) for detailed information about the nonclinical and 
clinical data for ASP5354.  
2.3 
Risk/Benefit Assessment 
2.3.1 
Risk Assessment 
In the clinical studies completed to date, ASP5354 has been shown to be safe and well 
tolerated given as a single intravenous dose up to 24 mg. One of the most frequently reported 
adverse events (AEs) was green coloration of the urine. ASP5354 is excreted into the urine 
through the kidneys due to its hydrophilic nature. It is expected that all participants will have 
green coloration of the urine with ASP5354 administration. 

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ASP5354 is a new chemical entity administered intravenously. Unlike ICG, it does not 
contain iodine and no hypersensitivity reactions have been observed for ASP5354 in the 
clinical studies completed to date. In general, the ICG-related hypersensitivity has been 
attributed to iodine [Bjerregaard et al, 2013]. Although it remains a potential risk, the use of 
ASP5354 will be in surgical suites/operating rooms, which are fully equipped to manage a 
hypersensitivity reaction should it occur. 
2.3.2 
Benefit Assessment 
The benefit of ASP5354 is real-time visualization of the ureter in patients undergoing 
minimally invasive and open abdominopelvic surgeries with NIR-F optical devices currently 
in clinical practice, with the potential to identify intraoperative IUIs early or to minimize the 
risk of IUIs. 
2.3.3 
Overall Risk-Benefit Conclusion 
ASP5354 given at 3 mg as a single intravenous dose for use in minimally invasive and open 
abdominopelvic surgeries with NIR-F optical devices has a favorable overall risk-benefit 
profile.  
3 
OBJECTIVES, ENDPOINTS AND ESTIMANDS 
Table 4 
Study Objectives and Endpoints 
Objectives 
Endpoints 
Primary 
● 
Investigator’s blinded conspicuity assessment 
of the ureter at the first time point for adults 
with normal renal function or mild renal 
impairment 
● 
Intra-participant difference in ureter 
conspicuity for WL versus NIR-F at 
30 (± 15) min after ASP5354 administration. 
Conspicuity will be scored individually for 
each illumination mode using the 5-Point 
Likert Scale 
Key Secondary 
● 
Investigator’s conspicuity assessment of the 
ureter when using ASP5354 with NIR-F for the 
duration of the surgical procedure for adults 
with normal renal function or mild renal 
impairment 
● 
Intra-participant comparison of ureter 
conspicuity scores for the WL 30 (± 15) min 
time point versus the average of all NIR-F time 
points 
● 
Intra-participant comparison of ureter 
conspicuity scores for the WL 30 (± 15) min 
time point versus the end of surgery time point 
score with NIR-F 
Additional Secondary 
● 
Support the investigator’s qualitative 
assessment of ureter conspicuity with a 
quantitative measure for all participants in all 
cohorts 
● 
Using recorded images, ureter conspicuity for 
WL and NIR-F illumination modes will be 
quantified by image analysis for all time points 
● 
Investigator’s conspicuity assessment of the 
ureter at the first time point for adolescents 
● 
Descriptive summary of intra-participant 
difference in ureter conspicuity for WL versus 
NIR-F at 30 (± 15) min after ASP5354 
administration 

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Objectives 
Endpoints 
● 
Investigator’s conspicuity assessment of the 
ureter when using ASP5354 with NIR-F for the 
duration of the surgical procedure for 
adolescents 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the average of all NIR-F time points 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the end of surgery time point score with 
NIR-F 
● 
Investigator’s conspicuity assessment of the 
ureter at the first time point for adults with 
moderate or severe renal impairment 
● 
Descriptive summary of intra-participant 
difference in ureter conspicuity for WL versus 
NIR-F at 30 (± 15) min after ASP5354 
administration 
● 
Investigator’s conspicuity assessment of the 
ureter when using ASP5354 with NIR-F for the 
duration of the surgical procedure for adults 
with moderate or severe renal impairment 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the average of all NIR-F time points 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the end of surgery time point score with 
NIR-F 
● 
Investigator’s conspicuity assessment of the 
ureter at the first time point for participants in 
all cohorts 
● 
Descriptive summary of intra-participant 
difference in ureter conspicuity for WL versus 
NIR-F at 30 (± 15) min after ASP5354 
administration  
● 
Investigator’s conspicuity assessment of the 
ureter when using ASP5354 with NIR-F for the 
duration of the surgical procedure for 
participants in all cohorts 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the average of all NIR-F time points 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the end of surgery time point score with 
NIR-F  
● 
Frequency and percentage of participants with 
average ureter conspicuity assessed by the 
investigator over all time points during surgery 
improved under NIR-F vs WL in all cohorts 
● 
Frequency and percentage of participants with 
an average index ureter conspicuity over all 
NIR-F time points at least 1 point higher than 
the average index ureter conspicuity over all 
WL time points  
● 
Frequency and percentage of participants with 
an average index ureter conspicuity over all 
NIR-F time points at least 2, 3 or 4 points 
higher than the average index ureter 
conspicuity over all WL time points  
● 
BICR’s conspicuity assessment of the ureter at 
the first time point for adults with normal renal 
function or mild renal impairment 
● 
Intra-participant difference in ureter 
conspicuity for WL versus NIR-F at 
30 (± 15) min after ASP5354 administration 
● 
BICR’s conspicuity assessment of the ureter 
when using ASP5354 with NIR-F for the 
duration of the surgical procedure for adults 
with normal renal function or mild renal 
impairment 
● 
Intra-participant comparison of ureter 
conspicuity scores for the WL 30 (± 15) min 
time point versus the average of all NIR-F time 
points 
● 
Intra-participant comparison of ureter 
conspicuity scores for the WL 30 (± 15) min 
time point versus the end of surgery time point 
score with NIR-F 

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Objectives 
Endpoints 
● 
BICR’s conspicuity assessment of the ureter at 
the first time point for adolescents 
● 
Descriptive summary of intra-participant 
difference in ureter conspicuity for WL versus 
NIR-F at 30 (± 15) min after ASP5354 
administration 
● 
BICR’s conspicuity assessment of the ureter 
when using ASP5354 with NIR-F for the 
duration of the surgical procedure for 
adolescents 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the average of all NIR-F time points 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the end of surgery time point score with 
NIR-F 
● 
BICR’s conspicuity assessment of the ureter at 
the first time point for adults with moderate or 
severe renal impairment 
● 
Descriptive summary of intra-participant 
difference in ureter conspicuity for WL versus 
NIR-F at 30 (± 15) min after ASP5354 
administration 
● 
BICR’s conspicuity assessment of the ureter 
when using ASP5354 with NIR-F for the 
duration of the surgical procedure for adults 
with moderate or severe renal impairment 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the average of all NIR-F time points 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the end of surgery time point score with 
NIR-F 
● 
BICR’s conspicuity assessment of the ureter at 
the first time point for participants in all 
cohorts 
● 
Descriptive summary of intra-participant 
difference in ureter conspicuity for WL versus 
NIR-F at 30 (± 15) min after ASP5354 
administration 
● 
BICR’s conspicuity assessment of the ureter 
when using ASP5354 with NIR-F for the 
duration of the surgical procedure for 
participants in all cohorts 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the average of all NIR-F time points 
● 
Descriptive summary of ureter conspicuity 
scores for the WL 30 (± 15) min time point 
versus the end of surgery time point score with 
NIR-F 
● 
Concordance between investigator’s intra-
operative conspicuity assessment of the ureter 
and BICR assessment for adults with normal 
renal function or mild renal impairment 
● 
Intra-participant difference in ureter 
conspicuity for WL versus NIR-F at 
30 (± 15) min after ASP5354 administration by 
each BICR reader 
● 
CCC, the inter-rater reliability between the 
investigators and BICR for the WL versus NIR-
F at 30 (± 15) min after ASP5354 
administration 
● 
Intra-participant difference in ureter 
conspicuity for WL at 30 (± 15) min versus the 
average of all NIR-F time points by each BICR 
reader 
● 
CCC, the inter-rater reliability between the 
investigators and BICR for the WL at 
30 (± 15) min time point versus the average of 
all NIR-F time points 
● 
Intra-participant difference in ureter 
conspicuity for WL at 30 (± 15) min versus the 

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Objectives 
Endpoints 
end of surgery time point score with NIR-F by 
each BICR reader 
● 
CCC, the inter-rater reliability between the 
investigators and BICR for the WL 
30 (± 15) min time point versus the end of 
surgery time point score with NIR-F 
● 
Safety of ASP5354 
● 
Nature, frequency, severity and causality of 
TEAEs and serious TEAEs 
● 
Clinical laboratory tests (hematology, 
biochemistry and urinalysis) 
● 
Vital signs 
● 
Electrocardiograms/cardiac monitoring 
● 
Investigate the pharmacokinetics of ASP5354 
● 
Plasma and urine concentrations of ASP5354 
● 
Ae and Ae%  
Exploratory 
● 
To summarize the investigator’s conspicuity 
assessment with WL of the ureter at each time 
point 
● 
Descriptive summary of left and right ureter 
conspicuity scores for WL at each time point 
● 
Descriptive summary of index and non-index 
ureter conspicuity scores for WL at each time 
point 
● 
Concordance of conspicuity assessment of the 
ureter among BICR readers for participants 
with normal renal function or mild renal 
impairment 
● 
ICC, the inter-rater reliability among BICR 
readers on the intra-participant difference in 
ureter conspicuity for WL versus NIR-F at 
30 (± 15) min after ASP5354 administration 
● 
ICC, the inter-rater reliability among BICR 
readers on the scoring in ureter conspicuity for 
the WL and NIR-F at 30 (± 15) min after 
ASP5354 administration 
● 
ICC, the intra-rater reliability within each 
BICR reader on the intra-participant difference 
in ureter conspicuity for WL versus NIR-F at 
30 (± 15) min after ASP5354 administration 
● 
ICC, the intra-rater reliability within each 
BICR reader on the scoring in ureter 
conspicuity for the WL and NIR-F at 
30 (± 15) min after ASP5354 administration 
Ae: amount of ASP5354 excreted into urine; Ae%: percentage of ASP5354 dose excreted into urine; 
BICR: blinded independent central review; CCC: concordance correlation coefficient; 
ICC: intraclass correlation coefficient; NIR-F: near-infrared fluorescence; TEAE: treatment-emergent adverse 
events; WL: white light. 
3.1 
Primary Estimands 
Population: 
Male and female participants ≥ 18 years of age with eGFR ≥ 60 mL/min undergoing 
minimally invasive and open abdominopelvic surgeries. The population is further defined by 
the eligibility criteria. 

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Treatment Regimen: 
The treatment regimen is ASP5354, 1 single intravenous dose of 3 mg (3 [three] 1 mg vials). 
Primary Endpoint: 
Intra-participant difference in ureter conspicuity for WL versus NIR-F at the 30-min time 
point after ASP5354 administration. The first assessment will always be under WL followed 
by NIR-F assessment. Conspicuity will be scored individually for each illumination mode 
using the 5-Point Likert Scale. 
Intercurrent Events (ICEs) and Strategies: 
ICE1: Participants who have received the medications or therapy listed below within 
48 hours prior to ASP5354 administration and/or before the completion of the surgical 
procedure: 
● ICG, unless used for anastomotic evaluation after the ureters have been visualized or 
for lymphatic mapping where there is a clear anatomic separation of the ureters and 
the lymphatics 
● Other NIR-F imaging agents 
● Ureteral stent 
Composite strategy for ICE1: The assessment of ureter conspicuity after ICE1 will not be 
considered as relevant and will be handled as missing data. For participants that experience 
ICE1 prior to the 30-min time point conspicuity assessment by the investigator, both 
conspicuity values at the 30-min time point with WL and NIR-F will be set as 
‘1 = Not self-evident’ for the primary endpoint analysis. 
ICE2: Participants who are unable to have ureter conspicuity assessed by the investigator at 
the 30-min time point for any reason. 
Treatment policy strategy for ICE2: The assessment of ureter conspicuity in the event of 
ICE2 will be imputed as follows. In the event that WL or NIR-F conspicuity is not assessed 
by the investigator at the 30-min time point, the first collected conspicuity assessment under 
the respective illumination mode will be used as the 30-min time point value. If a participant 
does not have any assessments under a respective illumination mode during the entire 
surgery, the 30-min time point value will be set as the 30-min value from the other 
illumination mode. If a participant does not have any assessments under either illumination 
mode during the entire surgery, both 30-min time point values will be set as 
‘1 = Not self-evident’. 
Population Level Summary: 
For participants randomized to WL/NIR-F, the score of the ureter conspicuity at the 30-min 
time point based on the 5-Point Likert Scale with NIR-F will be compared with the score of 
the ureter conspicuity at the 30-min time point based on the 5-Point Likert Scale with WL 
using absolute difference.  

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4 
STUDY DESIGN AND DOSE RATIONALE 
4.1 
Overall Study Design 
This is a phase 3, multicenter, prospective, randomized, open-label study to evaluate the 
clinical utility of ASP5354 with the use of an NIR-F imaging device in participants 
undergoing minimally invasive and open abdominopelvic surgeries. In order to achieve 
reasonably balanced enrollment across surgery types the sponsor will monitor enrollment and 
may cap enrollment for a specific surgery type (i.e., gynecological or other abdominopelvic) 
during the study. This study will be conducted in approximately 6 clinical sites in the US.  
This study is designed to evaluate the clinical utility of ASP5354 which enhances the 
conspicuity of the ureter with the use of an NIR-F imaging device. The investigator, at their 
discretion, will select ureter(s) of interest (i.e., right, left, or both) before surgery. If the 
selection is both, the investigator will further select 1 index ureter (i.e., right or left) at their 
discretion. The conspicuity of the ureter will be assessed by the investigator (5-Point Likert 
Scale) for the selected ureter(s) of interest during surgery for all participants. The 
investigator’s qualitative assessment of ureter conspicuity will be supported with a 
quantitative measure and a BICR assessment, which will be performed centrally using 
recorded images taken during the surgery. 
The study will enroll approximately 107 participants (84 adults with normal renal function or 
mild renal impairment [eGFR ≥ 60 mL/min], up to 10 adults with moderate or severe renal 
impairment [eGFR ≥ 15 to < 60 mL/min] and 13 adolescents with normal renal function or 
mild renal impairment [eGFR ≥ 60 mL/min]) who will receive a single intravenous 3 mg 
dose of ASP5354. The normal/mild eGFR cohort will be randomized to 2 arms: WL/NIR-F 
and WL-only. Randomization will be stratified by type of surgery (gynecological; other 
abdominopelvic). There is no randomization for adult participants in the moderate/severe 
eGFR cohort or adolescent participants, and all of these participants will be evaluated with 
WL/NIR-F. Safety, tolerability and pharmacokinetics in the study population will also be 
assessed.  
For additional details on each cohort, please refer to [Sections 7.1.2, 7.1.3 and 7.1.4] for 
adults with normal/mild eGFR, adults with moderate/severe eGFR and adolescents, 
respectively.  
4.2 
Scientific Rationale for Study Design 
There are currently no approved imaging agents for ureter identification during open or 
minimally invasive abdominopelvic/pelvic surgeries. A multicenter, prospective, randomized 
and open-label study design was chosen to evaluate the intraoperative ureter conspicuity 
using NIR-F by the operating investigator after administration of ASP5354 compared with 
ureter conspicuity by WL within each study participant in the WL/NIR-F arm. To reduce the 
investigator’s bias, the WL-only arm is added to cast doubt in the investigator’s mind as to 
whether NIR-F illumination mode will be used for a given participant, which may enhance 
more consistent behavior (similar due diligence) for evaluation with WL versus NIR-F. 
Conspicuity assessments in the WL/NIR-F arm will be completed throughout surgery to 

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evaluate the clinical utility of ASP5354 in ureter visualization. In the WL/NIR-F arm, the 
first assessment will always be under WL followed by NIR-F assessment. Additionally, a 
confirmatory blinded independent central review (BICR) will be employed to independently 
read all WL and NIR-F images for all timepoints for all participants in the WL/NIR-F arm. 
ASP5354 has been studied in 2 phase 1 studies in healthy participants and in 1 phase 2 study 
in participants undergoing laparoscopic or minimally invasive colorectal surgery. ASP5354 
was shown to be safe and well tolerated at a single intravenous dose up to 24 mg in the US 
phase 1 safety and pharmacokinetic study in healthy participants (5354-CL-0001). No 
treatment-related serious or non-serious AEs were reported in this study. The Japanese phase 
1 study (5354-CL-0002) findings are consistent with those observed in the US phase 1 study. 
No safety issues were reported with no clinically significant changes in vital signs, 12-lead 
electrocardiogram (ECG), clinical laboratory evaluation or physical examination.  
ASP5354 has also been studied in a phase 1 study in participants with mild, moderate or 
severe renal impairment compared with healthy controls at a 3 mg dose:  
● 
No significant safety findings have been identified from clinical trial 5354-CL-0004 (A 
phase 1, open-label study to evaluate the pharmacokinetics, safety and tolerability of 
ASP5354 in participants with renal impairment compared to healthy participants with 
normal renal function). The safety data included a total of 7 non-serious treatment-
emergent adverse events (TEAEs) that were reported of the 28 participants enrolled. The 
TEAEs were single occurrences and included: anemia aggravated, sore throat, headache, 
flatulence, bloating, diarrhea and hyperbilirubinemia. 
● 
Only 2 of the non-serious TEAEs (headache grade 1 and hyperbilirubinemia grade 1) 
were considered related to ASP5354, which occurred in healthy participants with normal 
renal function: 
o The headache occurred on day 1 (day of ASP5354 administration) and resolved on 
day 3, as judged by the investigator. 
o The hyperbilirubinemia occurred on day 8 and resolved on day 14, as judged by the 
investigator. 
The inclusion of adolescents in a phase 3 study was proposed because ASP5354 has shown 
an acceptable safety and tolerability profile similar to ICG. Pharmacokinetic modeling and 
simulation has suggested that systemic exposure (Cmax and AUCinf) in adolescents (12 to 
< 18 years of age) is comparable to those in adults (≥ 18 years of age). Also, it is expected 
that adolescent participants will have similar efficacy/visualization when they have similar 
exposures of ASP5354 as adults. 
4.2.1 
Participant Input into Study Design  
There was no participant involvement in the design of the study.  
4.3 
Dose Rationale 
The dose selection for the phase 3 studies was based on data from the phase 2 dose-ranging 
study (5354-CL-0201) conducted in adult participants undergoing laparoscopic/minimally 

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invasive colorectal surgery. Single intravenous doses of ASP5354 (pudexacianinium 
chloride) 0.3, 1 and 3 mg were administered. ASP5354 was safe and well tolerated when 
administered as single intravenous ascending doses up to 3 mg. Doses of 1 mg and 3 mg 
provided visualization throughout the duration of the surgical procedure; however, at the 
3 mg dose, fluorescent intensity was stronger and more consistent. At the 1 mg dose, the 
intensity of fluorescence was variable [Figure 1] amongst the participants evaluated in the 
phase 2 study. The lower dose (0.3 mg) was determined to be inadequate for ureter 
visualization due to lower fluorescence intensity and shorter duration of visualization than 
doses of 1 mg and 3 mg. Given the ASP5354 safety profile described in [Section 4.2], the 
highest dose of 3 mg was selected for the phase 3 program to provide optimal conspicuity of 
the ureter for the duration of surgery in all intended participants for the phase 3 clinical 
program, including renally impaired participants.  
Figure 1 
Fluorescence Intensity of the Index Ureter at Each Time Point During 
Surgery 
 
Source: [Albert et al, 2023] 
Using the PopPK model, plasma concentration data from the phase 2 study was used to 
predict urine ASP5354 concentration data. The relationship between simulated urine 
concentrations and the intensity of fluorescence from the Likert scale was evaluated for the 
0.3, 1, and 3 mg doses. The 3 mg dose showed consistent efficacy with regards to intensity of 
fluorescence and was above the target urinary concentration for ureter visualization of 
1 µg/mL, which was determined based on nonclinical ex vivo and in vivo minipig studies 
[Fushiki et al, 2023] [Figure 2]. In contrast, the 1 mg dose did not show consistency across 
the Likert scale regarding intensity of fluorescence and also depicted a high amount of 
variability even though it was above the target urinary concentration for ureter visualization 
of 1 µg/mL. Therefore, the 3 mg dose was selected for the phase 3 program.  

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Figure 2 
Predicted Urine Pudexacianinium Concentration Data Versus the 
Intensity of Fluorescence (e.g., Likert Scale) From the Phase 2 Study 
 
Source: [5354-PK-0005 PKPD report] 
 
 
 

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4.4 
Start and End of Study Definitions  
First act of recruitment 
The study start date is the date on which the clinical study will be open for recruitment of 
participants. 
The first act of recruitment is the date the first participant signs the informed consent form 
(ICF) and will be the study start date. 
End of study 
The end of the study is defined as the last visit or assessment shown in Schedule of 
Assessments [Table 1] for the last participant in the study.  
A participant is considered to have completed the study if the participant has completed all 
periods of the study including the last assessment shown in the schedule of assessments. 
5 
STUDY POPULATION 
All screening assessments must be completed and reviewed to confirm the potential 
participant meets all eligibility criteria. Prospective approval of protocol deviations to 
eligibility criteria (also known as protocol waivers or exemptions) is not permitted.  
5.1 
Inclusion Criteria 
Participant is eligible for participation in the study if all of the following apply: 
1. Institutional Review Board (IRB)/Independent Ethics Committee (IEC) approved written 
informed consent and privacy language as per national regulations (e.g., Health 
Insurance Portability and Accountability Act [HIPAA] authorization for US study sites) 
must be obtained from the participant or participant’s parent or legal guardian, and if 
required, assent from adolescent participant (≥ 12 to < 18 years of age) prior to any 
study-related procedures (including withdrawal of prohibited medication, if applicable). 
2. Participant is ≥ 12 years of age at the time of signing an ICF.  
3. Participant is scheduled to undergo minimally invasive or open abdominopelvic surgery 
that may require ureter identification. 
4. Participant has normal renal function or has varying degrees of chronic kidney disease as 
defined by the National Kidney Foundation and calculated by individual eGFR using the 
modification of diet in renal disease (MDRD) formula for adults or the Schwartz formula 
for adolescents at the screening visit (see [Section 10.7]). 
● 
Adult normal/mild eGFR cohort: eGFR ≥ 60 mL/min 
● 
Adult moderate/severe eGFR cohort: eGFR ≥ 15 to < 60 mL/min 
● 
Adolescent cohort: eGFR ≥ 60 mL/min 
5. Female participant is not pregnant (see [Section 10.2]) and at least 1 of the following 
conditions apply: 
a. Not a woman of childbearing potential (WOCBP; see [Section 10.2]) 
b. WOCBP who agrees to follow the contraceptive guidance (see [Section 10.2]) from 
the time of informed consent through at least 30 days after study intervention 
administration. 

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6. Female participant must agree not to breastfeed starting at the administration of 
ASP5354 through 30 days after ASP5354 administration. 
7. Female participant must not donate ova starting at the administration of ASP5354 
through 30 days after ASP5354 administration. 
8. Male participant with female partner(s) of childbearing potential (including breastfeeding 
partner) must agree to use contraception (see [Section 10.2]) through at least 30 days 
after ASP5354 administration. 
9. Male participant must not donate sperm starting at the administration of ASP5354 
through 30 days after ASP5354 administration. 
10. Male participant with pregnant partner(s) must agree to remain abstinent or use a 
condom for the duration of the pregnancy from the start of ASP5354 administration 
through 30 days after ASP5354 administration. 
11. Participant (and/or participant’s parent or legal guardian) agrees not to participate in 
another interventional study involving unapproved study medications while participating 
in the present study. 
5.2 
Exclusion Criteria 
Participant will be excluded from participation in the study if any of the following apply: 
1. Participant has any physical or psychiatric condition, which, in the investigator’s 
opinion, makes the participant unsuitable for study participation. 
2. Participant is anticipated to require ureteral stenting during surgery.  
3. Participant has an active urinary tract infection requiring antibiotic therapy. 
4. Participant has moderate to severe cardiac disease that limits daily functioning (New 
York Heart Association Class III to IV) or other medical conditions that the investigator 
feels would impact safety or study compliance. 
5. Participant has any clinically relevant laboratory abnormality that could contraindicate 
surgery in the opinion of the investigator. 
6. Participant with body weight < 30 kg.  
7. Participant has a known or suspected hypersensitivity to ASP5354, ICG or any 
components of the formulation used. 
8. Participant has had previous exposure to ASP5354. 
9. Participant has been administered ICG or other NIR-F imaging agents within 48-hours 
prior to ASP5354 administration, with the exception of participants who receive ICG for 
lymphatic mapping before the surgery. 
10. Participant has received any investigational therapy within 28 days or 5 half-lives, 
whichever is longer, prior to randomization.  
11. Participant is on hemodialysis, hemodiafiltration or peritoneal dialysis 
5.3 
Lifestyle Considerations 
Not applicable. 
5.4 
Screen Failures 
A screen failure is defined as a potential participant who signed the ICF but did not meet 1 or 
more criteria required for participation in the study and was not enrolled/randomized.  

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For screen failures, the demographic data, date of signing the ICF, AEs up to the time of 
screen failure and reason for screen failure will be collected in the electronic case report form 
(eCRF). 
5.4.1 
Rescreening 
Results of screening assessments that do not meet the parameters required by the eligibility 
criteria (e.g., clinical laboratory tests, vital signs, physical examinations, etc.) may be 
repeated once within the 28-day screening period without the need to register the participant 
as a screen failure. If more than 28 days elapse from the date of signing the ICF, the 
participant must be documented as a screen failure. In order for a previously screen-failed 
participant to re-screen, a new ICF must be signed and the participant will be registered in the 
IRT with a new participant identification code assigned. Rescreening is only allowed once for 
an individual participant. 
6 
STUDY INTERVENTION AND CONCOMITANT THERAPY 
Study interventions are all pre-specified, investigational and non-investigational medicinal 
products, medical devices, vaccines and other interventions (e.g., surgical and behavioral) 
intended to be administered to the study participants during the study conduct.  
6.1 
Study Intervention(s) Administered 
Table 5 
Study Intervention(s) Administered 
Intervention Label 
ASP5354 
Intervention Name 
ASP5354 (pudexacianinium chloride) 
Type  
drug 
Dose Formulation 
sterile powder for solution 
Unit Dose Strength(s) 
each vial contains 1.3 mg of ASP5354 and must be reconstituted with 
1.2 mL sterile water for injection, to a concentration of 1 mg/mL 
Dosage Level(s) 
single dose of 3 mg (3 vials of 1 mg) 
Route of Administration 
intravenous 
Use 
experimental 
IMP and NIMP/AxMP 
IMP 
Sourcing 
Provided centrally by the sponsor 
Packaging and Labeling 
ASP5354 sterile lyophilized powder will be provided in 2R amber glass 
vials and stored according to the instructions on the label 
AxMP: auxiliary medicinal product; IMP: investigational medicinal product; NIMP: non-investigational 
medicinal product 
Refer to the pharmacy manual for detailed information regarding preparation, handling and 
storage of the study intervention.  

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Table 6 
Study Arm(s) 
Arm Title 
WL/NIR-F arm 
WL-only arm 
Arm Type 
experimental 
experimental 
Arm Description 
WL and NIR-F will be used to 
recognize/identify the ureter and conspicuity 
will be scored using the 5-Point Likert Scale. 
The time of the ureter conspicuity assessments 
will be documented. During surgery, ureter 
conspicuity assessment will be performed with 
WL and with NIR-F approximately every 
30 (± 15) min from the ASP5354 
administration with the last assessment 
performed at the end of surgery time point. The 
first assessment will always be under WL 
followed by NIR-F assessment. 
Only 1 conspicuity assessment for 
each ureter will be performed 
with WL at 30 (± 15) min from 
ASP5354 administration.  
Associated 
Intervention Labels 
ASP5354 
ASP5354 
NIR-F: near-infrared fluorescence; WL: white light 
6.1.1 
Study Intervention Administration 
All participants, adults and adolescents, will receive a single intravenous 3 mg dose (3 vials 
of 1 mg) of ASP5354 as an intravenous administration approximately 30 (± 15) min before 
the investigator expects to visualize the ureters. The time of ASP5354 administration will be 
documented.  
6.2 
Preparation/Handling/Storage/Accountability 
6.2.1 
Packaging and Labeling 
All study intervention used in this study will be prepared, packaged and labeled under the 
responsibility of qualified personnel at Astellas Pharma Global Development Inc. (APGD) or 
sponsor’s designee in accordance with APGD or sponsor’s designee standard operating 
procedures (SOPs), current Good Manufacturing Practice (GMP) guidelines, International 
Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use 
(ICH) Good Clinical Practice (GCP) guidelines and applicable local laws/regulations. 
Each carton and vial will bear a label conforming to regulatory guidelines, GMP and local 
laws and regulations that identifies the contents as investigational drug. The study sites will 
be provided cartons each containing vials of ASP5354. 
A qualified person of Astellas Pharma Europe BV or sponsor’s designee will perform the 
final release of the study intervention according to the requirements of the European Union 
(EU) Clinical Trials Regulation 536/2014, current GMP guidelines, ICH GCP guidelines and 
applicable local laws/regulations. 
Refer to the pharmacy manual for detailed information regarding packaging and labeling of 
the study intervention. 

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6.2.2 
Handling, Storage and Accountability 
● 
The investigator or designee must confirm appropriate conditions have been maintained 
during transit for all study intervention received and any discrepancies are reported and 
resolved before use of the study intervention. 
● 
Only participants enrolled in the study may receive study intervention and only 
authorized study site personnel may supply, prepare or administer study intervention. 
Only study intervention with appropriate expiry/retest dating may be dispensed. 
● 
All study intervention must be stored in a secure, environmentally-controlled and 
monitored (manual or automated) area in accordance with the labeled storage conditions 
and access must be limited to the investigator and authorized study site personnel. 
● 
The investigator, institution or the head of the medical institution (where applicable) or 
authorized site staff is responsible for accountability, reconciliation and record 
maintenance (i.e., receipt, reconciliation and final disposition records including 
Certificate of Destruction or equivalent).  
● 
The sponsor is responsible for providing further guidance and instruction on final 
disposition of used and unused study intervention in the pharmacy manual.  
Refer to the pharmacy manual for detailed information regarding handling, storage and 
accountability of the study intervention. 
6.3 
Assignment to Study Intervention 
Registration (adolescent and moderate/severe eGFR cohort[s])/randomization (normal/mild 
eGFR cohort only) and dispensation of study intervention will be performed via the 
interactive response technology (IRT) system. Each site with adult participants will designate 
an unblinded study member, who prior to initiation of surgery and treatment, will obtain the 
randomization assignment from the IRT system. Investigators will be blinded to the 
randomization assignment until after completion of the first ureter conspicuity assessment 
performed for the ureter(s) of interest with WL at the 30-min time point after ASP5354 
administration. Specific IRT procedures will be described in the respective study manual.  
6.4 
Study Intervention Compliance 
Not applicable. The exact date and time of study intervention administration will be 
documented and recorded in the source record and captured in the eCRF. 
6.5 
Dose Modification 
Not applicable. 
6.6 
Continued Access to Study Intervention After the End of the Study  
Not applicable. 
6.7 
Treatment of Overdose  
In the event of suspected ASP5354 overdose, the participant should receive symptomatic and 
supportive care and monitoring. The medical monitor /expert should be contacted as 
applicable. 

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Refer to [Section 10.3.8.2] for reporting requirements for suspected overdose or other 
medication error.  
6.8 
Prior and Concomitant Therapy 
The following concomitant medications listed below will not be allowed within 48 hours 
prior to ASP5354 administration through the completion of the surgical procedure: 
● 
ICG unless used for anastomotic evaluation after the ureters have been visualized or for 
lymphatic mapping where there is a clear anatomic separation of the ureters and the 
lymphatics 
● 
Other NIR-F imaging agents 
Participants anticipated to require ureteral stents during surgery are excluded from the study 
[Exclusion Criterion No.2]. Ureteral stents however may be used based on clinical judgment 
of the investigator during surgery. Diuretics should be avoided 48-hours prior to ASP5354 
administration until the completion of the surgical procedure but can be used based on 
clinical judgment of the anesthesiologist or investigator. 
A list of excluded concomitant medications is provided in [Section 10.5]. 
Concomitant and corrective treatments (medication and non-medication therapy) will be 
recorded in the eCRF. However, there is no need to record supplements, nutrients or 
intravenous solutions for hydration. 
7 
STUDY PROCEDURES AND ASSESSMENTS 
● 
Study procedures and their timing are summarized in the Schedules of Assessments 
[Table 1, Table 2 and Table 3]. Adherence to the study design requirements, including 
those specified in the Schedules of Assessments, is essential and required for study 
conduct. Prospective protocol waivers or exemptions are not allowed. 
● 
Any change, divergence or departure from the study design or procedures identified in 
the protocol is considered a protocol deviation. All deviations from the protocol are to be 
recorded. 
● 
All screening evaluations must be completed and reviewed to confirm that potential 
participants meet all eligibility criteria. The investigator will maintain a screening log to 
record details of all participants screened and to confirm eligibility or record reasons for 
screening failure, as applicable. 
● 
Procedures conducted as part of the participant’s routine clinical management (e.g., 
imaging, blood count) and obtained before signing of the ICF may be utilized for 
screening or baseline purposes provided the procedures met the protocol-specified 
criteria and were performed within the time frame defined in the Schedule of 
Assessments [Table 1]. 
● 
In the event of a significant study-continuity issue (e.g., caused by a pandemic), alternate 
strategies for participant visits, assessments, medication distribution and monitoring may 
be implemented by the sponsor or the investigator, as per local health authority/ethics 
requirements. These alternate strategies are described in [Section 10.9].  

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7.1 
Efficacy Assessments 
Planned time points for all efficacy assessments are provided in the Efficacy Assessment 
Schedule [Table 2]. 
7.1.1 
Primary and Secondary Efficacy Assessments 
7.1.1.1 Ureter Conspicuity by 5-Point Likert Scale 
The conspicuity of the ureter with WL or WL/NIR-F will be assessed by the investigator 
(5-Point Likert Scale) during surgery for all participants. The first assessment will always be 
under WL followed by NIR-F assessment.  
● 
The investigator will attempt to locate the ureter and score the ureter conspicuity using 
the 5-Point Likert Scale by answering the question, “How conspicuous (easy to 
recognize/identify) is the ureter?”  
● 
When assessing the 5-Point Likert Score for ureter conspicuity, investigators should 
consider information such as contrast, brightness (luminance) and/or fluorescence 
intensity. 
● 
Conspicuity (or “How conspicuous is the ureter?”) for this study is defined as 
“self-evident ureter location identification (jump out to capture your attention).”  
Conspicuity assessment will be scored using the 5-Point Likert Scale: 
Score 
Description of Ureter Conspicuity 
Ureter Location Identification 
1 
None 
Not self-evident 
2 
Poor 
Somewhat self-evident 
3 
Sufficient 
Sufficiently self-evident 
4 
Good 
Clearly self-evident 
5 
Excellent 
Extremely self-evident 
Refer to [Section 10.8] for more details regarding the conspicuity assessment by the 5-Point 
Likert Scale. 
Training on the use of fluorescence imaging systems used during surgery and training on the 
use of the 5-Point Likert Scale will be provided in a separate manual.  
7.1.2 
Adults with Normal/Mild eGFR 
Each site with adult participants will designate an unblinded study member who will 
randomize participants via the study’s IRT system. Investigators will be blinded to the 
randomization assignment until after completion of the first ureter conspicuity assessment (by 
the study-specific 5-Point Likert Scale; hereafter, referred to as the 5-Point Likert Scale) 
performed for ureter(s) of interest with WL at 30-min after ASP5354 administration. This 
first WL assessment will be done when the investigator reaches the point in the surgery that 
visualization/identification of the ureter(s) is required.  
If the first assessment timeframe is missed (30 [± 15] min post-ASP5354 administration), the 
first conspicuity assessment for the study must be done while investigators remain blinded to 

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the participant’s randomization assignment. The time of the conspicuity assessment will be 
recorded at all time points. Following this assessment, the unblinded study member will 
provide the investigator with the randomization assignment of the participant. If the 
participant was randomized to the:   
● 
WL/NIR-F arm: the 30-min time point ureter conspicuity assessment will also be 
performed with NIR-F for the investigator-selected ureter(s) of interest (i.e., right, left or 
both). Thereafter, the investigator will assess the conspicuity of selected ureter(s) with 
WL and with NIR-F every 30 (± 15) min for the duration of the surgery, with the last 
assessment performed at the end of surgery time point. 
Note: The end of surgery time point is defined as the last time point where the ureter can 
be captured in the surgical field before removal of laparoscopic instruments or before the 
beginning of closure of the abdomen for open surgeries. If a surgical approach is 
switched from laparoscopic to open during surgery, ureter conspicuity assessment must 
be performed until the end of the laparoscopic surgery part and can be continued until the 
end of the open surgery part at the investigator’s discretion. The actual end of surgery is 
defined as the moment when all the procedures related to the surgery/surgery part that 
the investigator planned for the study are concluded. 
● 
WL-only arm: only the 30-min time point after ASP5354 administration ureter 
conspicuity assessment will be performed with WL for the ureter(s) of interest (i.e., right, 
left or both).  
Note: no additional conspicuity assessments with WL will be needed at the subsequent 
time points. 
7.1.3 
Adults with Moderate/Severe eGFR 
All moderate and severe eGFR participants will have conspicuity assessments performed 
with WL and NIR-F for all time points. The same conspicuity assessment procedures will be 
followed for the moderate and severe eGFR participants as described in [Section 7.1.2], 
except investigators will not be blinded at the first WL assessment time point. The WL-only 
arm does not apply to this cohort. 
7.1.4 
Adolescents 
Adolescent participants will have conspicuity assessments performed with WL and NIR-F for 
all time points. The same conspicuity assessment procedures will be followed as described 
for adults with normal/mild eGFR (see [Section 7.1.2]), except investigators will not be 
blinded at the first WL assessment time point. The WL-only arm does not apply to this 
cohort. 
7.1.5 
BICR Ureter Conspicuity by 5-Point Likert Scale 
The conspicuity of the ureter with WL and WL/NIR-F will be assessed by BICR (5-Point 
Likert Scale) for all participants in the WL/NIR-F arm.  
The BICR assessment of the ureter with WL and WL/NIR-F will be performed 
retrospectively using recorded images of the surgeries in this study. The ureter conspicuity 
will be based on the recorded images, which will be blinded for all participant identifiers 

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(including, but not limited to, participant identification and demographic) and time points, 
and provided in a random sequence. The recorded images under WL and NIR-F will be 
separately prepared by using the videos during the surgery and timestamp information that 
the investigator will provide.  
The same conspicuity assessment procedures will be followed for all participants as 
described in [Section 7.1.1.1]. Additional details about the assessment will be provided in a 
separate manual. 
7.1.6 
Quantitative Assessment 
Quantitative assessment of ureter conspicuity will be performed by image analysis using 
recorded images. Contrast enhancement factor (CEF) is a measure of the degree to which 
color contrast is enhanced in areas in which ASP5354 fluorescence signal is present when 
compared to areas in which ASP5354 fluorescence signal is absent. The CEF value is utilized 
as a quantitative analog for the qualitative assessment of “conspicuity” by the surgeon. An 
independent vendor will perform the image analysis using WL and NIR-F images extracted 
from the video files for all time points specified in [Table 2]. The performer of this image 
analysis will not have access to or be provided with the qualitative assessment score data. A 
separate study image analysis charter/plan will describe details of the image analysis 
methodology and image analysis processes. 
Procedures and instructions for how to record, prepare, and submit the video files for the 
quantitative assessment will be described in the study’s Site Imaging Manual.  
7.2 
Safety Assessments 
Planned time points for all safety assessments are provided in the Schedule of Assessments 
[Table 1]. Protocol waivers or exemptions are not allowed. 
Procedures conducted as part of a participant’s clinical management (i.e., standard of care) 
obtained before signing the ICF may be utilized for screening or baseline purposes, provided 
the procedures met the protocol-specified criteria and were performed within the time frame, 
as defined in the Schedule of Assessments [Table 1]. 
All participants will have a safety follow-up assessment approximately 15 days after surgery. 
The anticipated duration of the study for each participant, including screening and follow-up 
visits, is between 5 to 53 days. 
7.2.1 
Laboratory Assessments 
● 
See [Section 10.6] for the list of clinical laboratory tests to be performed. 
● 
The investigator must review the laboratory report, document this review and record any 
clinically significant changes occurring during the study as an AE (see 
[Section 10.3.1.1]). The laboratory reports must be filed with the source documents.  
● 
Clinical significance of out-of-range laboratory findings is to be determined and 
documented by the investigator or sub-investigator who is a qualified physician. 
Abnormal laboratory findings associated with the underlying disease are not considered 

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clinically significant unless judged by the investigator to be more severe than expected 
for the participant’s condition. 
● 
A central laboratory is used, but local results are acceptable at screening for confirming 
eligibility. Even if local results are used at screening for confirming eligibility, central 
laboratory tests should be performed at screening for safety analysis. The sites will 
collect blood and urine samples both for local laboratory tests and Central laboratory 
tests when local results are used at screening for confirming eligibility. 
7.2.2 
Vital Signs, Height and Weight 
● 
All vital signs (blood pressure and pulse) will be measured with the participant in the 
sitting or supine position  
● 
Height and weight will be measured using standard institution practice and equipment.  
7.2.3 
Physical Examination  
A full physical examination will be performed at screening (visit 1). Body systems to be 
evaluated include general appearance, skin, lymphatic, head and neck, ears, nose and throat, 
chest and lungs, cardiovascular, abdomen, extremities, musculoskeletal and neuromuscular. 
At visit 2 and follow-up (visit 3), a symptom-directed physical examination will be 
performed.  
7.2.4 
Electrocardiogram and Cardiac Monitoring 
A standard 12-lead ECGs and/or cardiac monitoring will be taken as indicated in the 
Schedule of Assessments [Table 1].  
The original printout or an electronic copy of all scheduled and unscheduled ECG tracings 
should be maintained in the participant’s medical chart. The investigator will review, sign 
and date the 12-lead ECG after recording to ensure participant safety. The time of the 12-lead 
ECG, the interval measurements, as well as an overall conclusion will be documented. 
Results will be recorded as normal, abnormal not clinically significant or abnormal clinically 
significant. Any abnormal or clinically significant 12-lead ECG or cardiac monitoring 
abnormalities should be recorded as an AE. 
7.2.5 
Order of Assessments  
As a recommendation, the following order should be followed when more than 1 assessment 
is required at a scheduled time point.  
1. Vital signs 
2. ECG/cardiac monitoring 
3. Blood collection   
7.2.6 
Other Assessments 
7.2.6.1 Visual Assessment of Urine Output 
Urine output will be visually assessed throughout the study. Visual observation abnormalities 
such as abnormal urine color (e.g., green color in the urine), if observed, will be assessed and 
recorded as an AE in the eCRF as per [Sections 7.3 and 10.3]. 

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7.3 
Adverse Events and Other Safety Aspects 
The definitions of an AE or serious adverse event (SAE) and Adverse Device Effect (ADE) 
can be found in [Sections 10.3.1, 10.3.2 and 10.3.3], respectively. 
Adverse events will be reported by the participant (or, when appropriate, by a caregiver, 
surrogate, or the participant’s legally authorized representative [LAR]). 
The investigator and any qualified designees are responsible for detecting, documenting and 
recording events that meet the definition of an AE/SAE/ADE and remain responsible for 
following up AEs that are serious, considered related to the study intervention, or that caused 
the participant to discontinue the study intervention and/or study [see Section 10.3].  
The method of recording, evaluating, and assessing causality of AE/SAE/ADE and the 
procedures for completing and transmitting SAE/ADE reports are provided in [Section 10.3]. 
7.3.1 
Time Period and Frequency for Collecting Adverse Event and Serious Adverse 
Event Information 
All AEs and SAEs will be collected from the signing of the ICF until the follow-up visit at 
the time points specified in the Schedule of Assessments [Table 1] and reported in the eCRF. 
If the severity of an AE/SAE increases, an end date should be provided and the event should 
be relisted in the eCRF with the new National Cancer Institute Common Terminology 
Criteria for Adverse Events (NCI CTCAE) grade and new onset date. 
If the severity decreases, an end date should be provided and the AE/SAE should be relisted 
in the eCRF with the new NCI CTCAE grade and new onset date. The exception is ongoing 
pre-dose events that continue post-dose and improve post-dose. Such events should not be 
re-listed. 
If the severity of an SAE reduces, the details of the AE should be provided on the SAE 
worksheet for the medical assessor to be able to assess the course of the event. 
All SAEs will be recorded and reported to the sponsor or designee without undue delay but 
not later than within 24 hours of obtaining knowledge of the event, as indicated in 
[Section 10.3]. The investigator will submit any updated SAE data to the sponsor within 
24 hours of it being available. 
Investigators are not obligated to actively seek any AE or SAE after conclusion of the study 
participation. However, if the investigator becomes aware of any SAE with a suspected 
causal relationship to the study intervention, including a death, at any time after a participant 
has been discharged from the study, the investigator must promptly report the SAE to the 
sponsor. 
The Reference Safety Information that will be used to determine expectedness of an SAE for 
this study is in the IB.  

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7.3.1.1 Adverse Device Effects 
● 
ADEs are to be collected via the ADE worksheet and reported to the sponsor within 
24 hours of awareness (see [Section 10.3.3.1]). 
● 
Any complaint about a device must be reported regardless of whether the defect or 
deficiency had any effect on a participant or on study personnel (see [Section 10.3.3.3]). 
7.3.2 
Method of Detecting Adverse Events and Serious Adverse Events 
Care will be taken not to introduce bias when detecting AEs and/or SAEs. Open-ended and 
non-leading verbal questioning of the participant is the preferred method to inquire about AE 
occurrences. 
7.3.3 
Follow-up of Adverse Events and Serious Adverse Events 
After the initial AE/SAE report, the investigator is required to proactively follow each 
participant at subsequent visits/contacts. All SAEs and adverse events of special interest 
(AESIs) (as defined in [Section 7.3.6]) will be followed until resolution, stabilization, the 
event is otherwise explained or the participant is lost to follow-up (as defined in 
[Section 8.3]). Further information on follow-up procedures is provided in [Section 10.3].  
If after the protocol-defined AE collection period (see [Section 7.3.1]), an AE progresses to 
an SAE, or the investigator learns of any AE/SAE including death, where the investigator 
considers there is reasonable possibility it is related to the study intervention or study 
participation, the investigator must promptly notify the sponsor.  
7.3.4 
Regulatory Reporting Requirements for Serious Adverse Events/Adverse 
Device Effects/Medical Device Deficiencies 
● 
Prompt notification by the investigator to the sponsor of an SAE/ADE/medical device 
deficiency is essential so that legal obligations and ethical responsibilities towards the 
safety of participants and the safety of a study intervention under clinical investigation 
are met. 
● 
The sponsor has a legal responsibility to notify both the local regulatory authority and 
other regulatory agencies and/or device manufacturer about the safety of a study 
intervention under clinical investigation. The sponsor will comply with country-specific 
regulatory requirements relating to safety reporting to the regulatory authority, IRB/IEC 
and investigators. 
● 
Investigator safety reports must be prepared for Suspected Unexpected Serious Adverse 
Reactions (SUSARs) according to local regulatory requirements and sponsor policy and 
forwarded to investigators as necessary. 
● 
An investigator who receives an investigator safety report describing an SAE or other 
specific safety information (e.g., summary or listing of SAEs) from the sponsor will 
review and then file it along with the IB and will notify the IRB/IEC, if appropriate 
according to local requirements. 

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7.3.5 
Disease-related Events and/or Disease-related Outcomes Not Qualifying as 
Adverse Events or Serious Adverse Events 
Under this protocol, the following event(s) will not be considered as an AE/SAE and should 
not be reported to Astellas Safety: 
● 
Preplanned and elective hospital/clinical procedures/interventions or procedures for 
diagnostic, therapeutic or surgical procedures for a pre-existing condition that did not 
worsen during the course of the study. These procedures are collected in the eCRF. 
7.3.6 
Adverse Events of Special Interest 
Selected non-serious and serious AEs, also known as AESI, are to be collected via the SAE 
worksheet and reported to the sponsor within 24 hours of awareness.  
In this study, the following are considered AESI:  
● 
Hypersensitivity events (see [Section 2.3.1]) 
● 
IUI-associated events (see [Section 2.2]) 
7.3.7 
Special Situations  
Certain special situations observed in association with the study intervention, such as 
incorrect administration (e.g., wrong dose of study intervention) are reported as protocol 
deviations and/or may require special reporting, as described below. These special situations 
are not considered AEs but do require to be communicated to Astellas as per the timelines 
defined below. 
If a special situation is associated with, or results in, an AE, the AE is to be assessed 
separately from the special situation and captured as an AE in the eCRF. If the AE meets the 
definition of an SAE, the SAE is to be reported as described in [Section 10.3.7] and the 
details of the associated special situation are to be included in the clinical description on the 
special situation worksheet or pregnancy reporting form.  
The special situations are: 
● 
Pregnancy 
● 
Drug exposure via breast milk 
● 
Medication error, overdose and use outside protocol 
● 
Misuse/abuse 
● 
Occupational exposure 
● 
(Suspicion of) Transmission of infectious agent  
● 
Suspected drug-drug interaction 
Instructions and procedures for reporting special situations are provided in [Section 10.3.8].  

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7.4 
Pharmacokinetics 
7.4.1 
Analysis of ASP5354 in Plasma 
Blood samples for the analysis of ASP5354 in plasma will be collected as indicated in the 
Schedule of Assessments [Table 1] and Sample Collection Schedule for Pharmacokinetics 
[Table 3]. 
Blood samples will be collected via a peripherally or centrally placed intravenous cannula or 
by direct venipuncture in a suitable vein. Pharmacokinetic sample collection should not be 
taken from the same cannula used for the administration of ASP5354. Blood sampling, 
processing, storage and shipment instructions are provided in a Laboratory Manual.  
When deemed appropriate at a later date, plasma samples remaining after the 
pharmacokinetic analysis may be used for exploratory metabolic profiling or exploratory 
biomarker analysis after the study. These tests will be described in a separate report and will 
not be incorporated in the integrated clinical study report (CSR).  
7.4.2 
Analysis of ASP5354 in Urine 
Urine samples for the analysis of ASP5354 in urine will be collected at the intervals indicated 
in the Schedule of Assessments [Table 1] and Sample Collection Schedule for 
Pharmacokinetics [Table 3].  
A urethral catheter will be inserted before the administration of ASP5354 until the actual end 
of surgery. While the catheter is in place, each interval sample will be collected in a separate 
collection bag. Aliquots of urine samples will be collected from each collection bag. The time 
of ASP5354 administration, beginning of urine collection and exchange of collection bags 
will be recorded. Urine sampling, processing, storage and shipment instructions are provided 
in a Laboratory Manual.  
When deemed appropriate at a later date, urine samples remaining after the pharmacokinetic 
analysis may be used for exploratory metabolic profiling or exploratory biomarker analysis 
after the study. These tests will be described in a separate report and will not be incorporated 
in the integrated CSR.  
7.5 
Pharmacodynamics  
Pharmacodynamic variables will include the primary endpoint (Ureter[s] Conspicuity by the 
5-Point Likert Scale by the investigator) and the secondary efficacy endpoints (Quantitative 
assessment and Ureter[s] Conspicuity by the 5-Point Likert Scale by the BICR). 
See [Section 7.1.1] for primary and secondary efficacy assessments. 
7.6 
Electronic Clinical Outcome Assessment 
Not applicable. 
7.7 
Total Amount of Blood 
The total amount of blood collected from each participant will vary depending on the length 
of surgery. The average expected blood draw will be approximately 42.0 mL. If clinically 

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significant laboratory abnormalities are found, additional blood may be drawn for safety 
monitoring. Also, if a local laboratory is used to confirm the eligibility, additional blood will 
be taken for the central laboratory. 
7.8 
Investigator Exit Interview 
Exit interviews will be conducted with investigators who have completed more than 
1 procedure using ASP5354 with NIR-F. Additional details including investigator selection 
will be provided in a separate guidance document. The results of the exit interview will be 
summarized in a separate report from the CSR. 
8 
PARTICIPANT DISCONTINUATION 
Refer to [Section 10.1.10] regarding discontinuation of study sites or of the study as a whole.  
8.1 
Discontinuation of Individual Participant(s) from Study 
Intervention  
Not applicable.  
8.2 
Discontinuation of Individual Participant(s) from Study 
The participant is free to withdraw from the study for any reason and at any time without 
giving reason for doing so and without penalty or prejudice. The investigator is also free to 
terminate a participant’s involvement in the study at any time if the participant’s clinical 
condition warrants it.  
The reason for discontinuation from study must be documented in the participant’s medical 
records.  
8.3 
Lost to Follow-up 
Every reasonable effort is to be made to contact any participant lost to follow-up during the 
course of the study in order to complete study-related assessments and record outstanding 
data and retrieve study intervention. These contact attempts should be documented in the 
participant’s medical record.  
9 
STATISTICAL CONSIDERATIONS 
9.1 
Statistical Hypotheses 
The primary endpoint will be analyzed using a paired t-test. The following null and 
alternative hypotheses will be tested: 
● 
H0: The mean intra-participant difference between the ureter conspicuity at the 30-min 
time point with WL and the ureter conspicuity at the 30-min time point with NIR-F is 
equal to 0. 
● 
Ha: The mean intra-participant difference between the ureter conspicuity at the 30-min 
time point with WL and the ureter conspicuity at the 30-min time point with NIR-F is not 
equal to 0. 

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The difference (NIR-F - WL) in the ureter conspicuity between WL and NIR-F at the 30-min 
time point will be tested at a 2-sided significance level of 0.05. 
The first key secondary endpoint of the 30-min time point WL conspicuity score versus the 
mean NIR-F conspicuity score across all time points will be analyzed using a sign test which 
will test if the median of the intra-participant mean differences between the NIR-F score at 
each time point and the 30-min WL score is equal to 0. The following null and alternative 
hypotheses will be tested: 
● 
H0: The median of the intra-participant mean differences of the NIR-F score at each time 
point and the 30-min WL score is equal to 0. 
● 
Ha: The median of the intra-participant mean differences of the NIR-F score at each time 
point and the 30-min WL score is not equal to 0. 
The difference (NIR-F - WL) in the ureter conspicuity between WL at the 30-min time point 
and the mean conspicuity score across all time points with NIR-F will be tested at a 2-sided 
significance level of 0.05. 
The second key secondary endpoint of the 30-min time point after ASP5354 administration 
WL conspicuity score versus the end of surgery time point NIR-F conspicuity score will be 
analyzed using a paired t-test. The following null and alternative hypotheses will be tested: 
● 
H0: The mean intra-participant difference between the ureter conspicuity at the 30-min 
time point with WL and the ureter conspicuity at the end of surgery time point with 
NIR-F is equal to 0. 
● 
Ha: The mean intra-participant difference between the ureter conspicuity at the 30-min 
time point with WL and the ureter conspicuity at the end of surgery time point with 
NIR-F is not equal to 0. 
The difference (NIR-F - WL) in the ureter conspicuity between WL at the 30-min time point 
and the end of surgery time point with NIR-F will be tested at a 2-sided significance level of 
0.05. 
A fixed sequence testing procedure will be used to adjust for multiplicity and control the 
type I error rate. The hypothesis tests will be conducted in the following order.  
● 
H1: WL conspicuity at 30-min time point after ASP5354 administration versus NIR-F 
conspicuity at 30-min time point after ASP5354 administration 
● 
H2: WL conspicuity at 30-min time point after ASP5354 administration versus mean 
NIR-F conspicuity across all time points 
● 
H3: WL conspicuity at 30-min time point after ASP5354 administration versus NIR-F 
conspicuity at end of surgery time point 

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H2 will only be tested if the H1 P value is ≤ 0.05. H3 will only be tested if both the H1 and 
H2 P values are ≤ 0.05. A graphical representation of the testing procedure is given below. 
 
The values within the circles indicate the initial allocation of the 0.05 significance level. Therefore, at the initial 
test, the primary endpoint (H1) will be tested at the full significance level of 0.05 and the key secondary 
endpoints will not be tested. The values on the lines indicate the significance level from the prior step that is 
allocated to the next step if the null hypothesis is rejected. Therefore, if the null hypothesis for the primary 
endpoint is rejected, the first key secondary endpoint (H2) will be tested at the full significance level of 0.05. 
Subsequently, if the null hypothesis for the first key secondary endpoint is rejected, the second key secondary 
endpoint (H3) will be tested at the full significance level of 0.05. 
9.2 
Analysis Sets 
The allocation of participants to analysis sets will be determined prior to database hard-lock.   
The following populations are defined:  
Population 
Description 
Intent to Treat (ITT) 
All participants in the adult normal/mild eGFR cohort 
randomized to WL/NIR-F  
Modified Intent to Treat (mITT) 
All participants in any cohort in the WL/NIR-F arm 
Safety Analysis Set (SAF) 
All participants in any cohort who receive ASP5354. 
Pharmacokinetic Analysis Set 
(PKAS) 
All participants in any cohort who receive ASP5354 for which 
at least 1 plasma or urine concentration data are available with 
the time for dosing and sampling 
NIR-F: near-infrared fluorescence; WL: white light  
9.3 
Statistical Analyses 
A statistical analysis plan (SAP) will be written to provide details of the analyses, along with 
specifications for tables, listings and figures to be produced. Changes from the planned 
analyses in the final SAP that impact the statistical analyses will be justified in the CSR. The 
initial version of the SAP will be finalized before the first participant is screened. Any 
updates to the SAP will be approved prior to database lock. 
9.3.1 
General Considerations 
In general, data will be summarized with descriptive statistics for continuous endpoints, and 
frequency and percentage for categorical endpoints, unless otherwise specified. Percentages 
by categories will be based on the number of participants with no missing data (i.e., will add 
up to 100%). Baseline will be defined as the last non-missing observation prior to 
administration of study intervention, unless otherwise specified. 
Efficacy summaries for the primary and key secondary endpoints will be presented for all 
participants in the Intent to Treat (ITT) population which includes all participants in the adult 
normal/mild eGFR cohort randomized to WL/NIR-F. Efficacy data collected for adult 

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participants randomized to the WL-only arm will be listed only. Efficacy summaries for the 
adolescent and adult moderate/severe eGFR cohort will be presented as other secondary 
analyses.  
Unless otherwise specified, efficacy analyses will use data from one ureter for each 
participant based on selection by the investigator. If the investigator selects either the left or 
right ureter as the ureter of interest before surgery, then data from the selected ureter will be 
used in the efficacy analyses. If the investigator selects both ureters as ureters of interest, the 
index ureter selected by the investigator (either left or right) will be used in the efficacy 
analyses. 
Unless otherwise specified, all safety summaries will be presented by arm and for all 
participants in the Safety Analysis Set (SAF). More specifically, safety summaries will be 
presented for the following groups of participants unless otherwise specified: 
● 
All participants who receive ASP5354 
● 
Adult participants (≥ 18 years of age) 
● 
Adult participants randomized to the WL/NIR-F arm 
● 
Adult participants randomized to the WL-only arm  
● 
All participants enrolled/randomized to the WL/NIR-F arm 
● 
Adolescent participants (≥ 12 to < 18 years of age) 
● 
Moderate renal impairment participants (eGFR ≥ 30 to < 60 mL/min) 
● 
Severe renal impairment participants (eGFR ≥ 15 to < 30 mL/min) 
Additional subgroups for safety summaries may be considered based on feasibility. Details 
will be given in the SAP. 
9.3.2 
Primary Endpoint/Estimand(s) Analysis  
9.3.2.1 Primary Analysis  
The primary efficacy endpoint is the investigator’s blinded assessment of the intra-participant 
difference in ureter conspicuity for WL versus NIR-F at the 30-min time point after ASP5354 
administration based on a 5-Point Likert scale. The population used for the primary efficacy 
analysis will be the ITT population, which includes all participants in the adult normal/mild 
eGFR cohort randomized to the WL/NIR-F arm. Adolescents and moderate/severe renally 
impaired participants that are enrolled directly into the WL/NIR-F arm will not be included in 
the primary analysis. The primary endpoint will be analyzed using a paired t-test.  
Prior to the analysis, data will first be imputed as follows if participants experience either 
ICE1 or ICE2 (refer to primary estimands in [Section 3.1]):  
● 
Participants who experience ICE1 will have both their NIR-F and WL conspicuity 
assessments at the 30-min time point after ASP5354 administration imputed as 
‘1 = Not self-evident’ for the primary endpoint analysis. 
● 
Participants who experience ICE2 and do not have either a NIR-F or WL conspicuity 
assessment conducted at the 30-min time point after ASP5354 administration will have 
the first collected conspicuity assessment under the respective illumination mode used as 

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the 30-min time point value. If a participant does not have any assessments under a 
respective illumination mode during the entire surgery, the 30-min time point value will 
be set as the 30-min value from the other illumination mode. If a participant does not 
have any assessments under either illumination mode during the entire surgery, both 
30-min time point values will be set as ‘1 = Not self-evident’. 
Descriptive statistics will be used to summarize the ureter(s) conspicuity at the 30-min time 
point after ASP5354 administration with WL and the 30-min time point with NIR-F. 
Descriptive statistics for the differences between the ureter(s) conspicuity scores and 95% 
2-sided confidence interval for the mean difference and P value will be presented. 
9.3.2.2 Sensitivity Analysis  
A sensitivity analysis for the primary endpoint will be conducted. The same paired t-test as 
the primary analysis will be run with the assessments impacted by ICE1 or ICE2 left as 
missing. 
An additional sensitivity analysis for the primary endpoint will be conducted. The NIR-F and 
WL conspicuity assessments at the 30-min time point after ASP5354 administration will be 
compared using a Wilcoxon signed-rank test. This analysis will be conducted using the same 
data (with ICE1 and ICE2 imputation) as the primary analysis. 
Sensitivity analyses will be conducted on the ITT population. 
9.3.3 
Secondary Endpoints Analysis 
9.3.3.1 Key Secondary Endpoints 
The population used for the analysis of key secondary endpoints will be the ITT population 
which includes all participants in the adult normal/mild eGFR cohort randomized to 
WL/NIR-F. Adolescent and moderate/severe renally impaired participants that are enrolled 
directly into the WL/NIR-F arm will not be included in the analysis of the key secondary 
endpoints. 
The first key secondary endpoint of the 30-min WL conspicuity score versus the mean NIR-F 
conspicuity score across all time points will be analyzed using a sign test which will test if 
the median of the intra-participant mean differences between the NIR-F scores and 30-min 
WL scores is equal to 0. Prior to the analysis, the conspicuity scores will be windowed to 
time points every 30-min. Details of the windowing algorithm will be given in the SAP.  
The value used in the sign test for each participant will be derived as follows. The differences 
between the NIR-F scores at each time point and the 30-min WL score will be calculated for 
each participant. The mean of these differences will then be calculated for each participant. A 
sign test will be conducted using these mean differences to test if the median of the 
intra-participant mean differences between the NIR-F scores and 30-min WL scores is equal 
to 0. 
Prior to the sign test, data will first be imputed as follows if participants experience either 
ICE1 or ICE2:   

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● 
Participants who experience ICE1 will have both their NIR-F and WL conspicuity 
assessments at the 30-min time point after ASP5354 administration imputed as 
‘1 = Not self-evident’ for the analysis of key secondary endpoint no. 1. 
● 
Participants who experience ICE2 and do not have either an NIR-F or WL conspicuity 
assessment conducted at the 30-min time point after ASP5354 administration will have 
the first collected conspicuity assessment under the respective illumination mode used as 
the 30-min time point value. If a participant does not have any assessments under a 
respective illumination mode during the entire surgery, the 30-min time point value will 
be set as the 30-min value from the other illumination mode. If a participant does not 
have any assessments under either illumination mode during the entire surgery, both 
30-min time point values will be set as ‘1 = Not self-evident’.  
Additionally, the following imputation rules will be applied to NIR-F conspicuity scores at 
other time points after 30-min prior to the sign test. 
● 
Participants who experience ICE1 will have NIR-F conspicuity scores at time points 
after ICE1 set as their WL conspicuity assessment at the 30-min time point. 
● 
Participants who are unable to have NIR-F conspicuity scores assessed by the 
investigator at time points after the 30-min time point will have such NIR-F scores left as 
missing. 
If a participant does not have a conspicuity assessment at a time point due to the surgery 
ending before the time point, the time point will be left as missing prior to the sign test. 
Additional details will be given in the SAP.  
The following results will be presented for comparisons between WL and NIR-F: 
● 
Frequency and percentage of participants with a positive mean difference, negative mean 
difference and mean difference of 0 
● 
Summary statistics of the mean differences between 30-min WL and NIR-F time points  
The mean difference will be used to obtain a 2-sided P value to test if the median of the mean 
differences is equal to 0. 
The second key secondary endpoint of the 30-min time point after ASP5354 administration 
WL conspicuity score versus the end of surgery time point NIR-F conspicuity score will be 
analyzed using a paired t-test. 
Descriptive statistics will be used to summarize the ureter conspicuity at the 30-min time 
point after ASP5354 administration with WL and the end of surgery time point with NIR-F. 
The same imputation algorithm described in the analysis of the first key secondary endpoint 
will be applied to the data prior to setting the end of surgery NIR-F value for each participant. 
Descriptive statistics for the differences between the ureter conspicuity scores and 95% 
2-sided confidence interval for the mean difference and P value will be presented. 

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9.3.3.2 Additional Secondary Endpoints 
To quantify ureter conspicuity, CEF data will be summarized using descriptive statistics by 
time point for participants in the mITT population.  
The correlation between the CEF assessments and conspicuity values will be investigated. 
Additional details will be given in the SAP. 
The analysis of the primary and key secondary endpoints will be repeated using the following 
groups of participants. P-values will not be presented. Additional details will be given in the 
SAP. 
● 
Adolescents 
● 
Adults with moderate renal impairment (eGFR ≥ 30 to < 60 mL/min) 
● 
Adults with severe renal impairment (eGFR ≥ 15 to < 30 mL/min) 
● 
mITT population 
To further characterize the difference of ureter conspicuity under NIR-F vs WL, the 
frequency and percentage of participants with an average ureter conspicuity assessed by the 
investigator over all NIR-F time points during surgery at least 1 point higher than the average 
ureter conspicuity over all WL time points during surgery will be presented. The same 
analysis will be repeated using a difference of 2, 3 and 4 points. These analyses will be 
carried out in all cohorts. 
The qualitative assessment of index ureter(s) conspicuity scored on a 5-point Likert Scale 
under WL and NIR-F (1 = None, 2 = Poor, 3 = Sufficient, 4 = Good and 5 = Excellent) 
performed by a BICR will be summarized descriptively at all time points post-ASP5354 
administration. The analysis of the primary and key secondary endpoints will be repeated 
using the BICR data. This analysis, as well as the descriptive statistics, will be presented 
within adolescents, adults with moderate renal impairment, adults with severe renal 
impairment, the ITT population and the mITT population.  
The concordance analysis between BICR readers and investigators will be conducted for the 
ITT population. The hypothesis testing for the primary and key secondary endpoints will be 
repeated for each separate BICR reader. This will be the primary measure of concordance 
between the BICR readers and investigator data. A high concordance between the 
2 assessments is considered if 2 of 3 BICR readers yield a P value of ≤ 0.05. 
The concordance correlation coefficient measuring the agreement between investigator and 
BICR Likert conspicuity scores will be presented for the following values for each separate 
BICR reader.  
● 
Difference between NIR-F and WL at the 30-min time point 
● 
Mean difference between NIR-F across all time points and WL at the 30-min time point 
● 
Difference between NIR-F at the end of surgery time point and WL at the 30-min time 
point 
Additional details will be provided in the SAP. 

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9.3.3.3 Supplementary Analysis 
Descriptive statistics for the number of NIR-F conspicuity time points for each participant 
during surgery will be presented. 
The frequency and percentage of participants with an average ureter conspicuity assessed by 
the investigator over all NIR-F time points during surgery at least 1 point higher than the 
ureter WL conspicuity score at the 30-min time point will be presented. The analysis will also 
be repeated using a difference of at least 2, 3 and 4 points. These analyses will be carried out 
in all cohorts. 
9.3.3.4 Subgroup Analyses 
The primary endpoint, key secondary endpoints and color contrast quantitative assessment 
will be summarized using descriptive statistics within the following subgroups within the ITT 
population: 
● 
Body mass index (underweight or normal [< 25 kg/m2]; overweight [≥ 25 to < 30 kg/m2]; 
obese [≥ 30 kg/m2]) 
● 
Participants with prior pelvic or abdominal surgery (yes; no) 
● 
Participants with prior inflammatory disorders of interest (yes; no) 
● 
Type of surgery (gynecological; other abdominopelvic) 
● 
Type of surgery (minimally invasive and open) 
Additional details will be provided in the SAP. 
9.3.4 
Exploratory Endpoints 
Descriptive statistics will be used to summarize the ureter conspicuity by time point under 
WL for both the left and right ureters of participants in the ITT population. Also, the same 
descriptive statistics summary will be applied for the ureter conspicuity under WL for both 
index and non-index ureters in the ITT population. 
Inter- and intra-rater reliability within the BICR readers will be measured using the 
assessments at the 30-min time point for the ITT population and will be assessed using an 
ICC with a 95% CI.  
Inter-rater reliability of the differences between the 30-min WL and 30-min NIR-F values as 
well as the raw values under WL and NIR-F will be assessed. 
Intra-rater reliability of the repeat readings of the 30-min WL and 30-min NIR-F images will 
also be assessed. Intra-rater reliability of the differences between the 30-min WL and 30-min 
NIR-F values will also be assessed. ICC will be calculated using Shrout-Fleiss formulae for 
estimation of inter- and intra-rater reliability (agreement) (ICC, as defined in [Qin et al, 
2019]) and details will be provided in the SAP. 
9.3.5 
Safety Analyses 
Safety analyses will be conducted using the SAF, unless otherwise specified. No hypothesis 
testing will be performed. 

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9.3.5.1 Adverse Events  
Adverse events will be coded using Medical Dictionary for Regulatory Activities and graded 
using the NCI CTCAE, version 5.0. 
A TEAE is defined as an AE observed after administration of the study intervention and up to 
the follow-up period. A study intervention-related TEAE is defined as any TEAE with a 
causal relationship assessed as “yes” by the investigator. 
The number and percentage of participants with TEAEs, study intervention-related TEAEs, 
serious TEAEs and study intervention-related serious TEAEs will be summarized by System 
Organ Class and Preferred Term within the groups listed in [Section 9.3.1]. The number and 
percentage of TEAEs by toxicity grade will be summarized. The worst toxicity grade will be 
summarized if the same AE is recorded more than once for a participant. 
Hypersensitivity and IUI-associated events will be considered AESIs. The frequency and 
percentage of participants with each type of AESI will be summarized within the groups 
listed in [Section 9.3.1]. 95% Clopper-Pearson confidence intervals for the proportion of 
participants with each type of AESI will be presented. 
The frequency and percentage of participants with green coloration of urine will be 
summarized within the groups listed in [Section 9.3.1]. 
Adverse event data will be listed. 
9.3.5.2 Laboratory Assessments 
For quantitative clinical laboratory measurements (hematology, biochemistry, urinalysis), 
descriptive statistics will be used to summarize results and change from baseline by the 
groups listed in [Section 9.3.1] and time point. 
Shift from baseline to post-baseline worst grade based on NCI CTCAE (version 5.0) until the 
follow-up period in laboratory tests will be tabulated. 
Laboratory data will be listed.  
9.3.5.3 Vital Signs  
Descriptive statistics will be used to summarize vital signs results and changes from baseline 
by the groups listed in [Section 9.3.1] and time point. 
The frequency and percentage of participants with potentially clinically significant vital signs 
at baseline and the worst post-baseline result for each participant will be summarized by the 
groups listed in [Section 9.3.1]. Additional details will be given in the SAP. 
Vital signs data will be listed. 
9.3.5.4 Electrocardiogram and Cardiac Monitoring 
The frequency and percentage of participants with normal and abnormal ECG results for the 
overall interpretation will be summarized by the groups listed in [Section 9.3.1]. A shift 

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analysis table showing shift in overall interpretation from baseline to each time point will be 
provided. 
Standard 12-lead ECG interpretations will be listed. 
9.3.6 
Other Analyses 
9.3.6.1 Analysis of Pharmacokinetics   
The analysis of pharmacokinetics will be reported by the following 5 groups of participants. 
● 
Adults with normal/mild eGFR (eGFR ≥ 60 mL/min): WL/NIR-F arm 
● 
Adults with normal/mild eGFR (eGFR ≥ 60 mL/min): WL-only arm 
● 
Adults with moderate renal impairment (eGFR ≥ 30 to < 60 mL/min): WL/NIR-F arm 
● 
Adult with severe renal impairment (eGFR ≥ 15 to < 30 mL/min): WL/NIR-F arm 
● 
Adolescent cohort (eGFR ≥ 60 mL/min): WL/NIR-F arm  
For ASP5354 in plasma, descriptive statistics will be used to summarize plasma 
concentrations for ASP5354 by time point. Individual overlay (spaghetti) and mean plasma 
concentration‑time profiles (linear and semi‑logarithmic scale) will be produced. 
For ASP5354 in urine, descriptive statistics will be used to summarize urine concentrations 
for ASP5354, urine volume, amount excreted into urine (Ae), and cumulative amount 
excreted into urine by time interval. 
Individual overlay (spaghetti) and mean cumulative amount of ASP5354 excreted into 
urine-time profiles will be produced.  
Ae and percentage of ASP5354 dose excreted into urine (Ae%) during surgery will be 
summarized.  
Pharmacokinetic data will be listed. 
Plasma and urine concentration data of ASP5354 will be subjected to population 
pharmacokinetic analysis and the similarity of pharmacokinetic profiles will be investigated 
by comparing adults and adolescents.  
Details of the population analyses will be described in a separate analysis plan and a separate 
report. 
9.3.6.2 Analysis of Pharmacodynamics 
The relationship between ureter visualization (5-Point Likert Scale score by the investigator 
and BICR, CEF, etc.) and pharmacokinetics will be evaluated by a population 
pharmacokinetic/pharmacodynamic approach and compared between adults and adolescents. 
Details of the population analyses will be described in a separate analysis plan and a separate 
report. 
9.4 
Interim Analysis  
Not applicable. 

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9.5 
Sample Size Determination 
Only adult participants with normal/mild renal impairment randomized to WL/NIR-F will be 
included in the analysis of the primary and key secondary endpoints. Adolescent participants 
and participants with moderate/severe renal impairment will be included in other secondary 
analyses. Screen failures and participants who are not randomized or enrolled will not be 
evaluated. 
9.5.1 
Adult Cohorts (Participants ≥ 18 Years of Age) 
9.5.1.1 Normal/Mild eGFR Cohort 
The sample size calculation is based on the primary efficacy endpoint. When assuming the 
difference in the mean score of the averaged ureter conspicuity score at the 30-min time point 
after ASP5354 administration with NIR-F compared with WL is 1.0 with a common standard 
deviation of 2.0 and the correlation is 0.2, 84 adult participants randomized to either 
WL/NIR-F or WL-only at the selected allocation ratio will provide enough participants in the 
WL/NIR-F arm for 90% power to demonstrate a statistically significant difference from 0 at a 
2-sided significance level of 0.05 using the paired t-test. The allocation ratio of the 
randomization to WL/NIR-F versus WL-only will be specified in the study randomization 
specification document. The randomization will be stratified by type of surgery 
(gynecological; other abdominopelvic).  
9.5.1.2 Moderate/Severe eGFR Cohort 
Up to 10 participants with moderate or severe renal impairment (eGFR: ≥ 15 to 
< 60 mL/min) will be enrolled into the WL/NIR-F arm and receive ASP5354. All participants 
with moderate or severe renal impairment will be assessed with both WL and NIR-F during 
surgery (non-randomized cohort). In the event that the enrollment of participants with 
normal/mild renal impairment and adolescents is completed prior to enrolling 10 participants 
with moderate/severe renal impairment, enrollment of participants in the moderate/severe 
eGFR cohort will end. Therefore, the final number of participants with moderate/severe renal 
impairment will be between 0 and 10. 
9.5.2 
Adolescent Cohort (Participants ≥ 12 and < 18 Years of Age) 
Approximately 13 adolescent participants with normal renal function or mild renal 
impairment (eGFR ≥ 60 mL/min) will be enrolled and receive ASP5354 such that a minimum 
of 10 evaluable adolescent participants (at least 6 for 12 to 14 years of age and at least 4 for 
15 to 17 years of age) complete the study to allow collection of pharmacokinetic samples 
from at least 6 participants in age group ≥ 12 and < 15 years of age and at least 4 participants 
in age group ≥ 15 and < 18 years of age. All adolescent participants will be assessed with 
both WL and NIR-F during surgery (non-randomized cohort). Assuming approximately 20% 
of participants might not facilitate derivation of plasma pharmacokinetic parameters, 
13 adolescent participants would need to be enrolled.   
To achieve the precise estimate of important plasma pharmacokinetic parameters 
(CL: clearance and Vd: volume of distribution) of ASP5354, prospectively the study has at 

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least 80% power to target a 95% 2-sided confidence interval within 60% and 140% of the 
geometric mean estimates of CL and Vd estimated by non-compartment analysis assuming an 
underlying interparticipant %CV up to 42% for both parameters [Wang et al, 2012].  
The data from this study is intended to confirm the similarity of pharmacokinetic and 
pharmacodynamic profiles between adolescents and adults and to characterize the efficacy 
and supportive safety in the target adolescent population under surgery. The plasma 
concentration of ASP5354 and the urine concentration of ASP5354 as a surrogate marker of 
urinary visualization intensity will be used to support dose selection for adolescents with the 
age of 0 to less than 12 using the physiologically based pharmacokinetics model and 
population pharmacokinetic model. In addition, the mean ratio of color components of ureter 
(CEF) during surgery and the time course of CEF will be compared between adolescents and 
adults. Considering the simple pharmacokinetic and pharmacodynamic profiles of ASP5354 
(intravenous bolus administration, almost completely renally cleared, no metabolism, no need 
for pharmacological response with the aim being to achieve sufficient concentration in the 
ureters to be detectable by NIR-F during the surgery), the number of participants planned is 
considered appropriate to confirm the similarity of pharmacokinetic and pharmacodynamic 
profiles by graphical exploration and model development. 
9.6 
Additional Conventions 
Missing conspicuity scores will be imputed per the algorithm described in [Section 9.3.2.1]. 
Otherwise, no imputation of missing data will be done with the exception of missing start and 
stop dates of AEs and concomitant medications. 

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10 
SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS 
10.1 
Appendix 1 
Ethical, Regulatory and Study Oversight 
Considerations 
10.1.1 Regulatory and Ethical Considerations 
● 
This study will be conducted in accordance with the protocol and with the following: 
o Consensus ethical principles derived from international guidelines including the 
Declaration of Helsinki and Council for International Organizations of Medical 
Sciences international ethical guidelines 
o Applicable ICH GCP guidelines 
o Applicable laws and regulations 
● 
The protocol, ICF, IB, and other relevant documents (e.g., advertisements) must be 
submitted to an IRB/IEC by the investigator and reviewed and approved by the IRB/IEC 
before the study is initiated. 
● 
Any amendments to the protocol will require IRB/IEC approval before implementation 
of changes made to the study design, except for changes necessary to eliminate an 
immediate hazard to study participants. 
● 
The investigator will be responsible for the following: 
o Providing written summaries of the status of the study to the IRB/IEC annually or 
more frequently in accordance with the requirements, policies, and procedures 
established by the IRB/IEC 
o Notifying the IRB/IEC of SAEs or other significant safety findings as required by 
IRB/IEC procedures 
o Providing oversight of the conduct of the study at the site and adherence to 
requirements of 21 Code of Federal Regulations (CFR), ICH guidelines, the 
IRB/IEC, European regulation 536/2014 for clinical studies (if applicable), and all 
other applicable local regulations 
10.1.2 Financial Disclosure 
Investigators and sub-investigators will provide the sponsor with sufficient, accurate financial 
information as requested to allow the sponsor to submit complete and accurate financial 
certification or disclosure statements to the appropriate regulatory authorities. Investigators 
are responsible for providing information on financial interests during the course of the study 
and for 1 year after completion of the study.  
10.1.3 Informed Consent of Participants 
10.1.3.1 Informed Consent Process 
● 
The investigator or the investigator’s representative will explain the nature of the study 
to the potential participant or their LAR (if applicable; defined as an individual, judicial 
or other body authorized under applicable law to consent on behalf of a prospective 
participant to the participant’s participation in the procedure[s] involved in research 
(45 CFR 46.102[c])) and answer all questions regarding the study.  

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● 
The information provided shall be provided in writing and shall: 
o Enable the participant or their LAR (if applicable) to understand:  
▪ The nature, objectives, benefits, implications, risks and inconveniences of the 
clinical study 
▪ The conditions under which the clinical study is to be conducted, including the 
expected duration of the participant’s participation in the clinical study 
▪ The possible treatment alternatives, including the follow-up measures if the 
participation of the participant in the clinical study is discontinued 
o Be kept comprehensive, concise, clear, relevant, and understandable to a layperson 
o Be provided in a prior interview with an appropriately qualified member of the study 
team. Special attention shall be paid to the information needs of specific patient 
populations and of individual participants, as well as to the methods used to give the 
information. Care should be taken to verify that the participant has understood the 
information. 
o Include information about the applicable damage compensation system 
o Include the study international study number (ISN) number and information about 
the future availability of the clinical study results in terms understandable to a 
layperson 
● 
Potential participants must be informed that their participation is voluntary and shall 
have their protective rights and guarantees explained. In particular their right to refuse to 
participate and the right to withdraw from the clinical study at any time without any 
resulting detriment and without having to provide any justification shall be explained.  
● 
Participants or their LAR will be required to sign a statement of informed consent that 
meets the requirements of 21 CFR 50, EU CTR 536/2014 (including Article 29), local 
regulations, ICH GCP guidelines, the Declaration of Helsinki, HIPAA requirements, 
where applicable, and the IRB/IEC or study center. 
● 
If the participant is a minor, their assent, in order to participate in a clinical study, shall 
also be obtained. 
● 
The medical record must include a statement that written informed consent was obtained 
before the participant was enrolled in the study and the date the written consent was 
obtained. The authorized person obtaining the informed consent must also sign the ICF. 
● 
In case of an update to the ICF during the study, participants must be reconsented to the 
most current version of the ICF(s) during their participation in the study. 
● 
A copy of the ICF(s) must be provided to the participant or their LAR (if applicable). 
10.1.3.2 Supply of New and Important Information Influencing the Participant’s 
Consent and Revision of the Written Information 
● 
The investigator or the investigator’s representative will immediately inform the 
participant verbally whenever new information becomes available that may be relevant 
to the participant’s consent or may influence the participant’s willingness to continue 
participating in the study (e.g., report of serious adverse drug reaction). The 
communication must be documented in the participant’s medical records and whether the 
participant is willing to remain in the study or not must be confirmed and documented.  

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● 
The investigator must update the participant’s ICF and submit it for approval to the 
IRB/IEC. The investigator or the investigator’s representative must obtain written 
informed consent from the participant on all updated ICFs throughout their participation 
in the study. The investigator or the investigator’s designee must reconsent participants 
with the updated ICF even if relevant information was provided verbally. The 
investigator or the investigator’s representative who obtained the written informed 
consent and the participant should sign and date the ICF. A copy of the signed ICF will 
be given to the participant and the original will be placed in the participant’s medical 
record. An entry must be made in the participant’s records documenting the reconsent 
process. 
10.1.4 Recruitment Arrangements 
The activated sites will screen participants via mechanisms currently in place at each site, and 
review prospective participants’ medical history against the study eligibility criteria. 
If necessary, the sites and the sponsor will take the following study-specific recruitment 
strategies. 
● 
Site database/medical records search 
● 
Doctor to doctor letter 
● 
Participant referrals 
● 
Sponsor call with investigators 
10.1.5 Data Protection 
The sponsor will use the personal data collected from participants in order to run the study 
and to use and publish the results of the study. The personal data of participants will be used 
throughout the development program of the investigational study intervention (e.g., to 
develop a product, obtain permission to market the product, monitor its safety and obtain 
coverage by health insurance and reimbursement schemes).  
Astellas relies on the permission (or “consent”) in order to use the data of participants and 
their permission is obtained by signing the ICF. 
The investigator and/or the site personnel will record information from the medical file of 
study participants in the eCRF and in an external (electronic) data file (e.g., central laboratory 
data). These study records will identify the participants with a code instead of their name or 
other personal data. Only the investigator and the site personnel can match the code with the 
name of the study participant, which will be retained in the medical file at the site only. 
Non-medical personnel acting on behalf of Astellas and being bound by a duty of 
confidentiality, as well as health authorities and/or IRB/IECs, may also be given access to 
this data at the site only to verify that the study is carried-out in compliance with legal and 
quality requirements.  

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The sponsor collects personal data from the participants during the study that may be used 
for:   
● 
Submission to government regulatory authorities and IRB/IEC  
● 
Use in reports or public scientific presentations, and  
● 
Use in research, now or in the future 
However, the identity of participants will not be revealed if study participants’ personal data 
are shared for these purposes. 
The personal data of participants may be shared with: 
● 
Astellas and its present or future affiliates 
● 
Research, collaboration and licensing partners and/or service providers (such as 
laboratories conducting tests on behalf of Astellas) and authorized representatives of 
Astellas 
● 
Study monitors appointed by Astellas or Astellas’s service providers, and   
● 
Auditors/inspectors appointed by Astellas or Astellas’s service providers or by health 
and regulatory authorities for GCP inspections. 
The sponsor will inform the participants about their privacy rights and how to exercise them 
under the ICF which participants will sign in order to participate in the study. The sponsor 
will provide the investigator and study staff with a privacy notice explaining how their 
personal data will be used and how to exercise their privacy rights.  
The sponsor will comply and process personal data in accordance with all applicable privacy 
laws and regulations. 
The contract between sponsor and study sites specifies responsibilities of the parties related 
to data protection, including handling of data security breaches and respective 
communication and cooperation of the parties. 
Information technology systems used to collect, process, and store study-related data are 
secured by technical and organizational security measures designed to protect such data 
against accidental or unlawful loss, alteration or unauthorized disclosure or access. 
10.1.6 Committee(s) Structure 
10.1.6.1 Blinded Independent Central Review Committee 
A blinded committee will independently read all WL and NIR-F images for all timepoints for 
all participants in the WL/NIR-F arm. The committee members will be experienced surgeons 
not associated with the study and will have no clinical information regarding the participants. 
Each BICR reader will score conspicuity for all pre-defined time points separately using a 
5-point Likert scale.  
A charter will be prepared to define specific procedures for BICR reader training and 
replacement of BICR readers. 

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10.1.7 Dissemination of Clinical Study Data 
ICH E3 guidelines recommend and EU Clinical Trial Regulation 536/2014 requires that a 
final CSR that forms part of a marketing authorization application, be signed by the 
representative for the coordinating investigator(s) or the principal investigator(s). The 
representative for the coordinating investigator(s) or the principal investigator(s) will have 
the responsibility to review the final study results to confirm to the best of their knowledge it 
accurately describes the conduct and results of the study. The representative for the 
coordinating investigator(s) or the principal investigator(s) will be selected from the 
participating investigators by the sponsor prior to database lock.  
10.1.7.1 Disclosure of Study Information and Results   
Astellas complies with relevant laws, regulatory requirements and industry guidance for 
registration of clinical studies, posting of clinical study information, and disclosure of clinical 
study results.  
Astellas commits to registering all interventional clinical studies sponsored by Astellas that 
seek to evaluate the safety and/or efficacy profile of an Astellas owned or in-licensed 
product. Clinical studies sponsored by Astellas that are covered under Astellas policy are 
registered on a publicly accessible clinical study registry (e.g., www.clinicaltrials.gov). In 
addition, other Astellas-sponsored studies are registered on national registries, if required by 
local/regional laws or regulations. 
Astellas commits to disclosing summary results in Astellas clinical study websites for all 
phase 1 to 4 interventional clinical studies for products sponsored by Astellas, conducted in 
the target patient population, with Astellas products that have health authority approval. In 
addition, summary results for other Astellas-sponsored studies are disclosed on national 
registries, if required by local/regional laws or regulations. 
Summary of end of study results will be available only after all data have been obtained from 
all participating countries/sites. Statistical analyses of end of study results are conducted 
when all relevant data are available.  
10.1.7.2 Access to Study Data  
Subject to compliance with the applicable laws and regulations relevant to protection of 
personal data, Astellas provides a platform (www.clinicalstudydatarequest.com) where 
researchers may request access to participant level data, study level data and protocols from 
Astellas-sponsored clinical studies conducted in patients that are completed after 
01 JAN 2010. 
Access to this data is granted for products and indications approved in any country after the 
request has been reviewed and approved by an independent panel of experts (“Scientific 
Review Board”) based on scientific merit and the qualifications of the researcher. Access is 
given by Astellas after review and approval by the Scientific Review Board and execution of 
a data sharing agreement. 

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Before participant-level data are shared, it is anonymized to respect the rights of the clinical 
study participants to privacy and to protection of their personal health information. 
10.1.8 Data Quality Assurance 
● 
All participant data relating to the study will be recorded in the eCRF unless transmitted 
to the sponsor or designee electronically in an external data file (e.g., central laboratory 
data). The investigator is responsible for verifying that data entries in the eCRF are 
accurate and correct by physically or electronically signing the eCRF.  
● 
Guidance on completion of eCRFs will be provided in a separate eCRF Completion 
Guideline.  
● 
The investigator must permit study-related monitoring, audits, IRB/IEC review, and 
regulatory agency inspections and provide direct access to source data documents. 
● 
Monitoring details describing strategy, including definition of study critical data items 
and processes (e.g., risk-based initiatives in operations and quality such as risk 
management and mitigation strategies and analytical risk-based monitoring), methods, 
responsibilities and requirements, including handling of noncompliance issues and 
monitoring techniques (central, remote or on-site monitoring) are provided in the 
Monitoring Plan. 
● 
The sponsor or designee is responsible for the data management of this study including 
quality checking of the data. 
● 
The sponsor assumes accountability for actions delegated to other individuals (e.g., 
contract research organizations [CRO(s)]). 
● 
Records and documents, including signed ICFs, pertaining to the conduct of this study 
must be retained by the investigator according to ICH or applicable local regulatory 
requirements, whichever is longer, after study completion. No records may be destroyed 
during the retention period without the written approval of the sponsor. No records may 
be transferred to another location or party without written notification to the sponsor. 
10.1.9 Source Documents 
● 
Source data must be available at the study site to document the existence of the 
participants and to substantiate the integrity of study data collected. Source data must 
include the original documents relating to the study, as well as the medical treatment and 
medical history of the participant.  
● 
The investigator must maintain accurate documentation (source data) that supports the 
information entered in the eCRF. 
● 
The investigator is responsible for ensuring the source data are attributable, legible, 
contemporaneous, original, accurate and complete whether the data are handwritten on 
paper or entered electronically. If source data are created (first entered), modified, 
maintained, archived, retrieved or transmitted electronically via computerized systems 
(and/or other kind of electronic devices) as part of regulated study activities, such 
systems must be compliant with all applicable laws and regulations governing use of 
electronic records and/or electronic signatures. Such systems may include, but are not 
limited to, electronic medical/health records, protocol-related assessments, AE tracking, 
electronic clinical outcome assessment and/or drug accountability.  

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● 
Paper records from electronic systems used in place of electronic format must be 
certified copies. A certified copy must be an exact copy and must have all the same 
attributes and information as the original. Certified copies must include signature and 
date of the individual completing the certification. Certified copies must be a complete 
and chronological set of study records (including notes, attachments, and audit trail 
information, if applicable). All printed records must be kept in the participant file and be 
available for archiving.  
● 
The sponsor or designee will perform ongoing source data review to confirm that the 
safety and rights of participants are being protected; and that the study is being 
conducted in accordance with the currently approved protocol and any other study 
agreements, ICH GCP, and all applicable regulatory requirements.  
● 
The documents of the blinded independent review committee (minutes and charters and 
others) and judgement committee outside the study sites (minutes and charters and 
others) shall be retained by the sponsor. 

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10.1.10 Study and Site Closure 
The sponsor or designee reserves the right to close the study site or terminate the study at any 
time for any reason at the sole discretion of the sponsor. Study sites will be closed upon study 
completion. A study site is considered closed when all required documents and study supplies 
have been collected and a study site closure visit has been performed. 
The investigator may initiate study site closure at any time, provided there is reasonable 
cause and sufficient notice is given in advance of the intended termination. 
Reasons for the early closure of a study site by the sponsor or investigator may include but 
are not limited to: 
For study termination: 
● 
Discontinuation of further investigational study intervention development 
For site termination: 
● 
Failure of the investigator to comply with the protocol, the requirements of the IRB/IEC 
or local health authorities, the sponsor’s procedures or GCP guidelines 
● 
Inadequate or no recruitment (evaluated after a reasonable amount of time) of 
participants by the investigator 
● 
Total number of participants enrolled earlier than expected 
If the study is prematurely terminated or suspended, the sponsor or designee shall promptly 
inform the investigators, the IECs/IRBs, the regulatory authorities, and any CRO(s) used in 
the study of the reason for termination or suspension, as specified by the applicable 
regulatory requirements. The investigator shall promptly inform the participant and should 
assure appropriate participant therapy and/or follow-up. 
10.1.11 Publication Policy 
● 
The results of this study may be published or presented at scientific meetings. If this is 
foreseen, the investigator agrees to submit all manuscripts or abstracts to the sponsor 
before submission. This allows the sponsor to protect proprietary information and to 
provide comments. 
● 
The sponsor will comply with the requirements for publication of study results. In 
accordance with standard editorial and ethical practice, the sponsor will generally 
support publication of multicenter studies only in their entirety and not as individual site 
data. In this case, a coordinating investigator will be designated by mutual agreement. 
● 
Authorship will be determined by mutual agreement and in line with International 
Committee of Medical Journal Editors authorship requirements. 
Publication of the study results is discussed in the study agreement. 
10.1.12 Insurance of Participants and Others  
The sponsor has covered this study by means of an insurance of the study according to 
national requirements. The name and address of the relevant insurance company, the 

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certificate of insurance, the policy number and the sum insured are provided in the 
investigator’s file.  
10.1.13 Quality Assurance 
The sponsor is implementing and maintaining quality assurance (QA) and quality control 
(QC) systems with written SOPs to ensure that studies are conducted and data are generated, 
documented, recorded, and reported in compliance with the protocol, GCP and applicable 
regulatory requirement(s). Where applicable, the QA and QC systems and written SOPs of 
the CRO will be applied. 
The sponsor or sponsor’s designee may arrange to audit the study at any or all study sites and 
facilities. The audit may include on-site review of regulatory documents, eCRFs and source 
documents. Direct access to these documents will be required by the auditors.  

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10.2 
Appendix 2 
Contraception Requirements 
WOCBP who are eligible for participation in the study, including those who choose complete 
abstinence, must have pregnancy tests as specified in the Schedule of Assessments [Table 1]. 
Pregnancy test results must confirm that the participant is not pregnant.  
WOMEN OF CHILDBEARING POTENTIAL DEFINITIONS AND METHODS OF 
CONTRACEPTION DEFINITIONS 
A female is considered fertile (i.e., WOCBP) following menarche and until becoming 
postmenopausal unless permanently sterile.  
Females in the following categories are not considered WOCBP 
● 
Premenarchal 
● 
Premenopausal with 1 of the following (i.e., permanently sterile): 
o Documented hysterectomy 
o Documented bilateral salpingectomy 
o Documented bilateral oophorectomy 
● 
Postmenopausal 
A postmenopausal state is defined as at least 12 months after last menstrual bleeding without 
an alternative medical cause.  
In case the last menstrual bleeding cannot be clearly determined, confirmation with more 
than 1 follicle-stimulating hormone (FSH) measurement of at least > 40 IU/L (or higher per 
local institutional guidelines) is required.  
Females on hormone replacement therapy (HRT) and whose menopausal status is in doubt 
will be required to use 1 of the nonestrogen hormonal highly effective contraception methods 
if they wish to continue their HRT during the study. Otherwise, they must discontinue HRT 
to allow confirmation of postmenopausal status by repeated FSH measurements before study 
enrollment. 
Documentation of any of these categories can come from the study site personnel’s review of 
the female participant’s medical records, medical examination or medical history interview. 
CONTRACEPTION GUIDANCE FOR FEMALE PARTICIPANTS OF 
CHILDBEARING POTENTIAL 
Female participants of childbearing potential are eligible for participation in the study if they 
agree to use one of the highly effective methods of contraception listed below from the time 
of signing the ICF and until the end of relevant systemic exposure, defined as 30 days after 
the final study intervention administration.a 

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Highly effective methods of contraception (failure rate of < 1% per year when used 
consistently and correctly)b:  
● 
Combined (estrogen- and progestogen-containing) hormonal contraception associated 
with inhibition of ovulation 
o Oral 
o Intravaginal 
o Transdermal 
● 
Progestogen-only hormonal contraception associated with inhibition of ovulation 
o Oral 
o Injectable 
o Implantable 
● 
Other combined (estrogen- and progesterone-containing) methods 
o Vaginal ring 
o Injectable 
o Implantable 
o Intrauterine hormone-releasing system or intrauterine device 
● 
Bilateral tubal occlusion or bilateral tubal ligation 
● 
Vasectomized partner 
A vasectomized partner is a highly effective contraception method provided that the 
partner is the sole male sexual partner of the WOCBP and the absence of sperm has been 
confirmed. If not, an additional highly effective method of contraception should be used. 
a Local laws and regulations may require use of alternative and/or additional contraception 
methods. 
b Typical use failure rates may differ from those when used consistently and correctly. Use 
should be consistent with local regulations regarding the use of contraceptive methods for 
participants participating in clinical studies. 
CONTRACEPTION GUIDANCE FOR MALE PARTICIPANTS WITH PARTNER(S) 
OF CHILDBEARING POTENTIAL. 
Male participants with female partners of childbearing potential are eligible for participation 
in the study if they agree to the following during treatment and until the end of relevant 
systemic exposure defined as 30 days after study intervention administration.a 
● 
Inform any and all partner(s) of their participation in a clinical study and the need to 
comply with contraception instructions as directed by the investigator 
● 
Use a condom 
● 
Female partners of male participants who have not undergone a vasectomy with the 
absence of sperm confirmed or a bilateral orchiectomy should consider use of effective 
methods of contraception 
a Local laws and regulations may require use of alternative and/or additional contraception 
methods. 

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Contraception for Pediatric Male Participants of Reproductive Potential 
Male children/adolescents in the following categories are not considered of reproductive 
potential: 
1. Tanner stage 1 development 
2. Documented surgically sterile  
Documentation from the site personnel’s review of the male participant’s medical records, 
medical examination, and medical history interview is necessary.  
Contraception guidance for male children/adolescents of reproductive potential: 
● 
Male children/adolescents of reproductive potential (Tanner Stage 2 and above) 
receiving nongenotoxic agents should use a condom through at least 30 days after study 
intervention administration.  
● 
Male participants should inform their female partners that they are participating in a 
clinical study and effective methods of contraception should be used.  
● 
Female partners of male participants who have not undergone bilateral orchiectomy 
should consider use of effective methods of contraception through at least 30 days after 
study intervention administration.  
Contraception for Pediatric Female Participants of Childbearing Potential 
Female children/adolescents in the following categories are not considered of 
childbearing potential: 
1. Premenarchal  
2. Documented surgically sterile (hysterectomy, bilateral salpingectomy, bilateral 
oophorectomy) 
Documentation from the site personnel’s review of the female participant’s medical records, 
medical exam, and medical history interview is necessary. 
Contraception guidance for female children/adolescents of childbearing potential: 
● 
Female children/adolescents of childbearing potential receiving nongenotoxic agents 
should use effective contraception during treatment through at least 30 days after 
ASP5354 administration. 
● 
Pregnancy testing for female children/adolescents of childbearing potential 
o At screening and preoperative visits 
One of the highly effective methods of contraception listed below is required at the time of 
informed consent and until the end of relevant systemic exposure as defined above. 

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Highly Effective Birth Control Methods-failure rate < 1%/year 
1. Combined estrogen- and progesterone-containing hormonal contraception  
a. Oral 
b. Intravaginal 
c. Transdermal (e.g., Patch) 
d. Injectable (e.g., Cyclofem, Mesigyna) 
2. Progestogen-only hormonal contraception  
a. Oral 
b. Injectable (e.g., depot-medroxyprogesterone acetate intramuscular or subcutaneous) 
c. Implantable (e.g., Norplant) 
3. IUD 
4. IUS 
5. Bilateral tubal occlusion 
6. Vasectomized male partner 
7. True abstinence* 
*True abstinence: When this is in line with the preferred and usual lifestyle of the participant. 
Periodic abstinence (such as calendar, ovulation, symptothermal, post-ovulation methods) 
and withdrawal are not acceptable methods of contraception. Sexual abstinence is considered 
a highly effective method only if defined as refraining from heterosexual intercourse during 
the entire period of risk associated with the study intervention. It is not necessary to use any 
other method of contraception when complete abstinence is elected. 

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10.3 
Appendix 3 
Adverse Events/Adverse Device Effects: 
Definitions and Procedures for Recording, Evaluating, Follow-up 
and Reporting 
10.3.1 Definition of Adverse Events 
AE Definition: 
An AE is any untoward medical occurrence in a patient or clinical study participant, 
temporally associated with the use of study intervention, whether or not considered related to 
the study intervention. 
NOTE: An AE can therefore be any unfavorable and unintended sign (including an abnormal 
laboratory finding), symptom, or disease (new or exacerbated) temporally associated with the 
use of study intervention. This includes events related to the (study) procedures. 
Events Meeting the AE Definition 
● 
Any abnormal laboratory test results (hematology, biochemistry, or urinalysis) or other 
safety assessments (e.g., ECG, radiological scans, vital signs measurements), including 
those that worsen from baseline, considered clinically significant in the medical and 
scientific judgment of the investigator (i.e., not related to progression of underlying 
disease). 
● 
Exacerbation of a chronic or intermittent pre-existing condition including either an 
increase in frequency and/or intensity of the condition. 
● 
New conditions detected or diagnosed after study intervention administration even 
though it may have been present before the start of the study. 
Events NOT Meeting the AE Definition 
● 
Any clinically significant abnormal laboratory findings or other abnormal safety 
assessments which are associated with the underlying disease, unless judged by the 
investigator to be more severe than expected for the participant’s condition. 
● 
The disease/disorder being studied or expected progression, signs, or symptoms of the 
disease/disorder being studied, unless more severe than expected for the participant’s 
condition. 
● 
Medical or surgical procedure (e.g., endoscopy, appendectomy): the condition that leads 
to the procedure is the AE. 
● 
Situations in which an untoward medical occurrence did not occur (social and/or 
convenience admission to a hospital). 
● 
Anticipated day-to-day fluctuations of pre-existing disease(s) or condition(s) present or 
detected at the start of the study that do not worsen. 
10.3.1.1 Abnormal Laboratory Findings 
Any abnormal laboratory test result (e.g., hematology, biochemistry or urinalysis) or other 
safety assessment (e.g., vital signs, physical examination, or ECGs), including those that 
worsen from baseline, that is considered to be clinically significant in the medical and 

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scientific judgment of the investigator and not related to underlying disease, is to be reported 
as an AE/SAE.  
Any clinically significant abnormal laboratory finding or other abnormal safety assessment, 
which is associated with the underlying disease, does not require reporting as an AE/SAE, 
unless judged by the investigator to be more severe than expected for the participant’s 
condition. 
Repeating an abnormal laboratory test or other safety assessment, in the absence of any of the 
above criteria, does not constitute an AE. Any abnormal test result that is determined to be an 
error does not require reporting as an AE. 
10.3.1.2 Potential Cases of Drug-induced Liver Injury 
Refer to [Section 10.4] for detailed instructions on drug-induced liver injury (DILI). 
Abnormal values in aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT) 
concurrent or with abnormal elevations in total bilirubin (TBL) that meet the criteria outlined 
in [Section 10.4], in the absence of other causes of liver injury, are considered potential cases 
of DILI (potential Hy’s Law cases) and are always to be considered important medical events 
and reported per [Section 10.3.7].  
10.3.2 Definition of Serious Adverse Events 
An SAE is defined as any untoward medical occurrence that, at any dose: 
● 
Results in death 
● 
Is life-threatening 
The term “life-threatening” in the definition of “serious” refers to an event in which the 
participant was at risk of death at the time of the event. It does not refer to an event, which 
hypothetically might have caused death, if it were more severe. 
● 
Requires inpatient hospitalization or prolongation of existing hospitalization 
o 
In general, hospitalization signifies that the participant has been detained (usually 
involving at least an overnight stay) at the hospital or emergency ward for 
observation and/or treatment that would not have been appropriate in the physician’s 
office or outpatient setting. Complications that occur during hospitalization are AEs. 
If a complication prolongs hospitalization or fulfills any other serious criteria, the 
event is serious. When in doubt as to whether “hospitalization” occurred or was 
necessary, the AE should be considered serious. 
o 
Hospitalization for elective treatment of a pre-existing condition that did not worsen 
from baseline is not considered an AE. 
● 
Results in persistent or significant disability/incapacity 
o 
The term disability means a substantial disruption of a person’s ability to conduct 
normal life functions. 
o 
This definition is not intended to include experiences of relatively minor medical 
significance such as uncomplicated headache, nausea, vomiting, diarrhea, influenza, 

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and accidental trauma (e.g., sprained ankle), which may interfere with or prevent 
everyday life functions but do not constitute a substantial disruption. 
● 
Is a congenital anomaly/birth defect 
● 
Other situations: 
o 
Medical or scientific judgment should be exercised in deciding whether SAE 
reporting is appropriate in other situations such as important medical events that 
may not be immediately life-threatening or result in death or hospitalization but may 
jeopardize the participant or may require medical or surgical intervention to prevent 
1 of the other outcomes listed in the above definition. These events should usually 
be considered serious. 
o 
Examples of such events include invasive or malignant cancers, intensive treatment 
in an emergency room or at home for allergic bronchospasm, blood dyscrasias or 
convulsions that do not result in hospitalization, or development of drug dependency 
or drug abuse. 
If an event is not an AE per definition in [Section 10.3.1], then it cannot be an SAE even if 
serious conditions are met (e.g., hospitalization for signs/symptoms of the disease under 
study, death due to progression of disease).  
10.3.3 Adverse Device Effect (ADE) 
10.3.3.1 Definition of ADE 
● 
Any adverse event related to the use of device (includes all hardware components). 
o Includes any event that is a result of a user error or intentional misuse. 
10.3.3.2 Definition of Unanticipated adverse device effect (UADE)  
● 
UADE is any serious adverse effect on health or safety, any life-threatening problem or 
death caused by, or associated with a device, if that effect, problem, or death was not 
previously identified in nature, severity, or degree of incidence in the application; or any 
other unanticipated serious problem associated with a device that relates to the rights, 
safety, or welfare of participants. Note the reporting of UADEs should follow reporting 
requirements for SAEs/serious adverse device effects.  
10.3.3.3 Definitions of Technical Complaints and Device Deficiencies 
● 
Device Complaint: A quality complaint received in writing, electronically, or orally that 
alleges deficiencies related to the identity, quality, durability, reliability, safety, 
effectiveness, or performance of a device product. (In this definition, "effectiveness" 
refers to the actual function of the device, not to how the participant responds to the 
action of the device. 
● 
Device Deficiency: Inadequacy of a medical device with respect to its identity, quality, 
durability, reliability, safety or performance. Device deficiencies include malfunctions, 
use errors and inadequate labelling. 

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10.3.3.4 Risks/Precautions 
Refer to the SPY Portable Handheld Imager (SPY-PHI) and 1688 Advanced Imaging 
Modalities (AIM) 4k Platform Manuals for a full description of the risks and precautions 
associated with all components of the SPY-PHI and 1688 AIM systems, respectively. The 
entirety of the Operator Manuals should be read before using the device(s). Failure to follow 
the instructions and warnings in the manual may result in unsafe operation of the system 
and/or injury to the subject or operator. 
10.3.4 Assessment of Causality 
● 
The investigator is obligated to assess the relationship between study intervention, 
imaging device(s), study procedures and each occurrence of each AE/SAE/ADE. 
● 
A “reasonable possibility” of a relationship conveys that there are facts, evidence, and/or 
arguments to suggest a causal relationship, rather than a relationship cannot be ruled out. 
● 
The investigator will use clinical judgment to determine the relationship. 
● 
Alternative causes, such as underlying disease(s), concomitant therapy, and other risk 
factors, as well as the temporal relationship of the event to study intervention 
administration will be considered and investigated. 
● 
The investigator will also consult the IB and/or product information, for marketed 
products, in the assessment. 
● 
For each AE/SAE/ADE, the investigator must document in the medical notes that they 
have reviewed the AE/SAE/ADE and has provided an assessment of causality. 
● 
There may be situations in which an SAE/ADE has occurred and the investigator has 
minimal information to include in the initial report to the sponsor. However, it is very 
important that the investigator always make an assessment of causality for every event 
before the initial transmission of the SAE/ADE data to the sponsor. 
● 
The investigator may change their opinion of causality in light of follow-up information 
and send a SAE/ADE follow-up report with the updated causality assessment. 
● 
The causality assessment between study intervention is 1 of the criteria used when 
determining regulatory reporting requirements. 
Following a review of the relevant data, the causal relationship between the study 
intervention and each AE/SAE/ADE will be assessed by answering “yes” or “no” to the 
question “Do you consider that there is a reasonable possibility that the event may have been 
caused by the study intervention?” 
When making an assessment of causality, the following factors are to be considered when 
deciding if there is evidence and/or arguments to suggest there is a “reasonable possibility” 
that an AE/SAE/ADE may have been caused by the study intervention (rather than a 
relationship cannot be ruled out) or if there is evidence to reasonably deny a causal 
relationship: 
● 
Has the participant been administered study intervention?  
● 
Plausibility (i.e., could the event have been caused by the suspect study intervention? 
Consider biologic and/or pharmacologic mechanism, half-life, literature evidence, drug 
class, preclinical and study data, etc.) 

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● 
Dechallenge/rechallenge:  
o Dechallenge: Did the AE/SAE/ADE resolve or improve after only stopping the dose 
of the suspect study intervention without any treatment? 
o Rechallenge: Did the AE/SAE/ADE reoccur if the suspected study intervention was 
reintroduced after having been stopped?  
● 
Laboratory or other test results: a specific laboratory investigation supports the 
assessment of the relationship between the AE/SAE/ADE and the study intervention 
(e.g., based on values pre-, during and post-treatment) 
● 
Available alternative explanations independent of study intervention exposure, such as 
other concomitant interventions, device malfunctions, medical history, concurrent or 
underlying disease, risk factors including medical and family history, season, location, 
etc., and strength of the alternative explanation  
● 
Temporal relationship between exposure to the study intervention and AE/SAE/ADE 
onset and/or resolution. Did the AE/SAE/ADE occur in a reasonable temporal 
relationship to the administration of the study intervention?  
● 
Finally, judging which are more likely based on all the above contents, factors of 
reasonable possibility or confounding factors, comprehensive judgment of plausibility 
will be provided.  
There may be situations in which an SAE/ADE has occurred and the investigator has 
minimal information to include in the initial report to the sponsor. While it is very important 
that the investigator always assesses causality for every event before the initial transmission 
of the SAE data to the sponsor, the initial report should be submitted without delay (i.e., 
within 24 hours of awareness). With limited or insufficient information about the event to 
make an informed medical judgment and in absence of any indication or evidence to establish 
a causal relationship, a causality assessment of “no” is to be considered. In such instance, the 
investigator is expected to obtain additional information regarding the event as soon as 
possible and to re-evaluate the causality upon receipt of additional information. The 
medically qualified investigator may revise their assessment of causality in light of new 
information regarding the SAE/ADE and shall send an SAE/ADE follow-up report and 
update the eCRF with the new information and updated causality assessment.  
Device Relatedness 
Events will be classified as device related if they meet the following criteria: 
● 
Not Related: Any reaction that does not follow a reasonable temporal sequence from 
administration of the device or surgical procedure, or study intervention AND that is 
likely to have been produced by the subject’s clinical state or other modes of therapy 
administered to the subject. 
● 
Related: A reaction that follows or may follow a reasonable temporal sequence from 
administration of the device, surgical procedure, or study intervention AND that follows 
a known response pattern to the suspected device/surgical procedure/study intervention. 

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10.3.5 Assessment of Severity  
Adverse events, including abnormal clinical laboratory values, will be graded using the NCI 
CTCAE guidelines, version 5.0. The items that are not stipulated in the NCI CTCAE 
version 5.0 will be assessed according to the criteria below and entered into the eCRF: 
Table 7 
Grading Scale Defining the Severity of an Adverse Event 
Grade 
Assessment Standard 
1 - Mild 
Asymptomatic or mild symptoms, clinical or diagnostic observations only; 
intervention not indicated 
2 - Moderate 
Minimal local or noninvasive intervention indicated; limiting age-appropriate 
instrumental ADL1 
3 - Severe 
Medically significant but not immediately life-threatening, hospitalization or 
prolonged hospitalization indicated; disabling; limiting self-care ADL2 
4 - Life-threatening 
Life-threatening consequences, urgent intervention indicated 
5 - Death 
Death related to AE 
ADL: activities of daily living; AE: adverse event 
1 
Instrumental ADL refers to preparing meals, shopping for groceries or clothes, using the telephone, 
managing money, etc. 
2 
Self-care ADL refers to bathing, dressing and undressing, feeding self, using the toilet, taking 
medications and not bedridden. 
10.3.6 Recording and Follow-up of AEs/SAEs and/or ADEs 
AE, SAE and ADE Recording 
● 
When an AE/SAE/ADE occurs, it is the responsibility of the investigator to review all 
documentation (e.g., hospital progress notes, laboratory reports, and diagnostics reports) 
related to the event. 
● 
The investigator will then record all relevant AE/SAE/ADE information in the eCRF. 
● 
It is not acceptable for the investigator to send photocopies of the participant’s medical 
records to the sponsor in lieu of completion of the eCRF. 
● 
There may be instances when copies of medical records for certain cases are requested 
by the sponsor. In this case, all participant identifiers, with the exception of the 
participant number, will be redacted on the copies of the medical records before 
submission to the sponsor. 
● 
The investigator will attempt to establish a diagnosis of the event based on signs, 
symptoms, and/or other clinical information. Whenever possible, the diagnosis (not the 
individual signs/symptoms) will be documented as the AE/SAE/ADE. 
Follow-up of AEs/SAEs/ADEs 
● 
The investigator is obligated to perform or arrange for the conduct of supplemental 
measurements and/or evaluations as medically indicated or as requested by the sponsor 
to elucidate the nature and/or causality of the AE/SAE/ADE as fully as possible. This 
may include additional laboratory tests or investigations, histopathological examinations, 
or consultation with other healthcare professionals. 

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● 
If a participant dies during participation in the study or during a recognized follow-up 
period, the investigator will provide the sponsor with a copy of any postmortem findings 
including histopathology. 
● 
New or updated information will be recorded in the originally completed eCRF. 
● 
The investigator will submit any updated SAE or ADE data to the sponsor within 
24 hours of receipt of the information. 
10.3.7 Reporting Procedures for SAEs/ADEs/Medical Device Deficiencies 
The investigator must complete and submit an SAE or ADE worksheet containing all 
information that is required by local and/or regional regulations to the sponsor by fax or 
email immediately (no later than within 24 hours of obtaining knowledge of the event).  
The SAE or ADE worksheet must be signed by a medically qualified investigator (as 
identified on delegation of authority log). Signature confirms accuracy and completeness of 
the SAE/ADE data, as well as the investigator causality assessment including the explanation 
for the causality assessment.  
For contact details, see [Contact Details of Sponsor’s Key Personnel]. Fax or email the 
SAE/special situations or the ADE worksheet to:   
Astellas Pharma Global Development Inc. 
Global Pharmacovigilance  
North America fax number: +1-888-396-3750 
North America alternate fax number: +1-847-317-1241 
International fax: +44-800-471-5263 
Email: safety-us@astellas.com 
If there are any questions, or if clarification is needed regarding the SAE/ADE/medical 
device deficiency, please contact the sponsor’s medical monitor/study physician or their 
designee [Contact Details of Sponsor’s Key Personnel].  
Follow-up information for the event should be sent promptly (as soon as available, but no 
longer than within 7 days of the initial notification). 
Full details of the SAE/ADE/medical device deficiency should be recorded on the medical 
records and SAE/special situation or ADE worksheet.  
The following minimum information is required: 
● 
International study number/study number  
● 
Participant number, sex and age 
● 
Date of report 
● 
Description of the SAE/ADE/medical device deficiency (event and seriousness criteria)  
● 
Causal relationship to the study intervention (including reason) 
● 
Drug provided (if any)  
The sponsor or sponsor’s designee will medically evaluate the SAE/ADE/medical device 
deficiency and determine if the report meets the requirements for expedited reporting based 
on seriousness, causality, and expectedness of the events (e.g., SUSAR reporting) according 

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to current local/regional regulatory requirements. The sponsor or sponsor’s designee will 
submit expedited safety reports to competent authorities and concerned ethics committee per 
current local regulations, and will inform the investigator of such regulatory reports as 
required. Investigators must submit safety reports as required by their IRB/IEC within 
timelines set by regional regulations (e.g., European Medicines Agency, Food and Drug 
Administration [FDA]) where required. Documentation of the submission to and receipt by 
the IRB/IEC of expedited safety reports should be retained by the study site. In the US, FDA 
expedited IND reporting guidelines will be followed. 
The sponsor or sponsor’s designee will also evaluate any ADEs/medical device deficiencies 
and determine if the report meets the requirements for expedited reporting. 
The sponsor will notify all investigators responsible for ongoing clinical studies with the 
study intervention of all SUSARs, which require submission per local requirements 
(IRB/IEC). 
Investigators should provide written documentation of IRB/IEC notification for each report to 
the sponsor. 
The investigator may contact the sponsor’s medical monitor/study physician for any other 
problem related to the rights, safety or well-being of the participant. 
10.3.8 Reporting Procedures for Pregnancy and Special Situations 
10.3.8.1 Contraceptive Guidance and Collection of Pregnancy Information 
● 
Details of all pregnancies in female participants and, if indicated, female partners of male 
participants will be collected after the start of study intervention and until 30 days after 
the study intervention administration. 
● 
If a pregnancy is reported, the investigator will record pregnancy information on the 
appropriate form and submit it to the sponsor within 24 hours of learning of the female 
participant or female partner of male participant (after obtaining the necessary signed 
informed consent from the female partner) pregnancy. 
● 
While pregnancy itself is not considered to be an AE or SAE, any pregnancy 
complication or elective termination of a pregnancy for medical reasons will be reported 
as an AE or SAE. 
● 
Abnormal pregnancy outcomes (e.g., spontaneous abortion, fetal death, stillbirth, 
congenital anomalies, ectopic pregnancy) are considered SAEs and will be reported as 
such. 
● 
The participant/pregnant female partner will be followed to determine the outcome of the 
pregnancy. The investigator will collect follow-up information on the 
participant/pregnant female partner and the neonate and the information will be 
forwarded to the sponsor. 
● 
Any pregnancy-related SAE reported after the participant’s last study visit, considered 
reasonably related to the study intervention by the investigator, will be reported to the 
sponsor as described in [Section 10.3.7]. While the investigator is not obligated to 
actively seek this information in former study participants/pregnant female partners, they 
may learn of pregnancy-related SAE through spontaneous reporting. 

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● 
Any female participant who becomes pregnant while participating in the study will be 
withdrawn from the study. 
10.3.8.2 Medication Error, Overdose and “Off-label Use” 
If a medication error (defined as an unintended failure in the treatment process that leads to, 
or has the potential to lead to, harm to the participant), overdose or “off-label use” (i.e., use 
outside of the target disease defined in the protocol) is suspected, the investigator must 
forward the special situation worksheet to the sponsor by fax or email immediately (within 
24 hours of awareness). Any associated AEs/SAEs are to be reported in the eCRF. If the AE 
meets the definition of an SAE, the SAE is also to be reported as described in 
[Section 10.3.7] together with the details of the medication error, overdose and/or “off-label 
use.” 
10.3.8.3 Misuse/Abuse 
Definition of misuse: Situations where the study intervention is/are intentionally and 
inappropriately used not in accordance with the intended use as defined in the protocol. 
Definition of abuse: Persistent or sporadic, intentional excessive use of medicinal products 
which is accompanied by harmful physical or psychological effects. 
If misuse or abuse of the study intervention is suspected, the investigator must forward the 
special situation worksheet to the sponsor by fax or email immediately (within 24 hours of 
awareness). Any associated AEs/SAEs are to be reported in the eCRF. If the AE meets the 
definition of an SAE, the SAE is also to be reported as described in [Section 10.3.7] together 
with details of the misuse or abuse of the study intervention. 
10.3.8.4 Occupational Exposure 
If occupational exposure (e.g., inadvertent exposure to the study intervention of study site 
personnel while preparing it for administration to the participant) to the study intervention 
occurs, the investigator must forward the special situation worksheet to the sponsor by fax or 
email immediately (within 24 hours of awareness). Any associated AEs/SAEs occurring to 
the individual associated with or resulting from the special situation are to be reported on the 
special situations worksheet. 
10.3.8.5 (Suspicion of) Transmission of Infectious Agent 
If transmission of an infectious agent associated with the study intervention is suspected, the 
investigator must forward the special situation worksheet to the sponsor by fax or email 
immediately (within 24 hours of awareness) and any associated AEs/SAEs are to be reported 
in the eCRF. If the AE meets the definition of an SAE, the SAE is also to be reported as 
described in [Section 10.3.7] together with the details of the suspected transmission of 
infectious agent.  
10.3.8.6 Suspected Drug-drug Interaction 
If a drug-drug interaction associated with the study intervention is suspected, the investigator 
must forward the special situation worksheet to the sponsor by fax or email immediately 

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(within 24 hours of awareness). Any associated AEs/SAEs are to be reported in the eCRF. If 
the AE meets the definition of an SAE, the SAE is also to be reported as described in 
[Section 10.3.7] together with details of the suspected drug-drug interaction. 
10.3.9 Supply of New Information Affecting the Conduct of the Study 
When new information becomes available that is necessary to allow for proper conduct of the 
study, the sponsor will inform all investigators involved in the study, as well as the 
appropriate regulatory authorities. Investigators should inform the IRB/IEC of such 
information when needed.  
The investigator will also inform the participants, who will be required to sign an updated 
ICF in order to continue in the study. 
10.3.10 Urgent Safety Measures  
An urgent safety measure (USM) is an intervention that is not defined by the protocol and 
can be put in place with immediate effect without needing to gain prior approval by the 
sponsor, relevant competent authorities, IRB/IEC, where applicable, in order to protect 
participants from any immediate hazard to their health and/or safety. Either the investigator 
or the sponsor can initiate a USM. The cause of a USM can be safety-, product- or 
procedure-related.  
10.3.11 Reporting Urgent Safety Measures 
In the event of a potential USM, the investigator must contact the study physician (within 
24 hours of awareness). Full details of the potential USM are to be recorded in the 
participant’s medical records. The sponsor may request additional information related to the 
event to support their evaluation.  
If the event is confirmed to be a USM, the sponsor will take appropriate action to ensure the 
safety and welfare of the participants. These actions may include, but are not limited to, a 
change in study procedures or study intervention, halting further enrollment in the study, or 
stopping the study in its entirety. The sponsor or sponsor’s designee will notify the relevant 
competent authorities and concerned ethics committee within the timelines required per 
current local regulations, and will inform the investigators, as required. When required, 
investigators must notify their IRB/IEC within timelines set by regional regulations. 

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10.4 
Appendix 4 
Liver Safety Monitoring and Assessment 
The purpose of this appendix is to provide guidance for the monitoring DILI during the 
course of the study. It should be noted that this section does not specify the end of study 
analyses of liver enzymes. The end of study liver enzymes analyses will be described in the 
SAP.  
Testing for Liver Abnormalities 
Conduct the following for any participant enrolled in a study receiving active study 
intervention with an increase of serum aminotransferase (AT) to > 3 × upper limit of normal 
(ULN) (to > 5 x ULN in participants with liver metastases) or total bilirubin (TBL) > 2 × 
ULN  
● 
Repeat testing for liver enzymes (including at least ALP, ALT, AST, TBL, and INR) 
within 72 hours of notification of the test results. For studies for which a central 
laboratory is used, alerts will be generated by the central laboratory regarding moderate 
or severe liver abnormality to inform the investigator and study team.  
● 
Participants should be asked if they have any symptoms suggestive of hepatobiliary 
dysfunction. 
Definition of Liver Abnormalities 
Confirmed abnormalities will be characterized as moderate and severe where ULN is as 
shown below.  
Table 8 
Moderate and Severe Liver Abnormalities 
 
ALT or AST 
 
TBL 
Moderate 
> 3 × ULN (in participants without liver metastases), 
> 5 × ULN (in participants with liver metastases) 
or 
> 2 × ULN 
Severe 
> 3 × ULN 
and† 
> 2 × ULN 
ALT: alanine aminotransferase; AST: aspartate aminotransferase; TBL: total bilirubin; ULN: upper limit of 
normal 
†Samples taken simultaneously or within maximum 24 hours. 
In addition, the participant should be considered to have severe hepatic abnormalities if any 
of the following apply:  
● 
ALT or AST > 8 × ULN 
● 
ALT or AST > 5 × ULN for more than 2 weeks (in the absence of liver metastases) 
● 
ALT or AST > 3 × ULN and† TBL > 2 × ULN or INR > 1.5 (if INR testing is 
applicable/evaluated) 
● 
ALT or AST > 5 × ULN and† (TBL > 2 × ULN in participants with liver metastases) 
● 
ALT or AST > 3 × ULN with the appearance of fatigue, nausea, vomiting, right upper 
quadrant pain or tenderness, fever, rash and/or eosinophilia (> 5%)  
† Samples taken simultaneously or within a maximum of 24 hours. 

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The investigator may determine that abnormal liver function results, other than as described 
above, may qualify as moderate or severe abnormalities and require additional monitoring 
and follow-up.  
Follow-up Procedures for Moderate or Severe Abnormalities 
● 
Follow participants with confirmed moderate or severe abnormal liver function by repeat 
testing 2 to 3 times weekly, and then weekly or less frequently if abnormalities stabilize 
or the study intervention has been discontinued and the participant is asymptomatic.  
● 
Complete the LA-CRF 
● 
Thoroughly characterize moderate or severe abnormalities in hepatic functions by 
obtaining appropriate expert consultations, detailed pertinent history, physical 
examination and clinical laboratory tests. 
o Obtain a more detailed history of symptoms and prior or concurrent diseases. 
Symptoms and new onset diseases are to be recorded as “AEs” within the eCRF. 
Illnesses and conditions such as hypotensive events, and decompensated cardiac 
disease that may lead to secondary liver abnormalities should be noted. Nonalcoholic 
steatohepatitis is seen in obese hyperlipoproteinemic and/or diabetic participants and 
may be associated with fluctuating AT levels. The investigator should ensure that the 
medical history form captures any illness that predates study enrollment that may be 
relevant in assessing hepatic function.  
o Obtain a history of concomitant drug use (including nonprescription medication, 
complementary and alternative medications), alcohol use, recreational drug use and 
special diets. Medications are to be entered in the eCRF. Information on alcohol, 
other substance use and diet should be entered on the LA-CRF or an appropriate 
document. 
o Obtain a history of exposure to environmental chemical agents. 
o Based on the participant’s history, other testing may be appropriate including:  
▪ Acute viral hepatitis (A, B, C, D, E or other infectious agents such as 
cytomegalovirus, Epstein–Barr virus) 
▪ Ultrasound or other imaging to assess biliary tract disease 
▪ Other clinical laboratory tests, including INR and direct bilirubin 
o Consider gastroenterology or hepatology consultations. 
o Submit results for any additional testing and possible etiology on the LA-CRF or an 
appropriate document. 
Severe hepatic liver function abnormalities as defined above, in the absence of another 
etiology may be considered an important medical event and may be reported as an SAE. The 
sponsor should be contacted and informed of all participants for whom severe hepatic liver 
function abnormalities possibly attributable to study intervention are observed. 
Study Intervention Discontinuation 
Since this is a single dose study, treatment discontinuation is not applicable. 

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10.5 
Appendix 5 
List of Excluded Concomitant Medications 
Please note that this is not an exhaustive list. Investigators should verify the participant’s 
concomitant medications for all prohibited and restricted drug classes. 
Prohibited Medications 
From 48 hours prior to the ASP5354 administration until the completion of the surgical 
procedure.  
Class 
Drug 
ICG1 
Indocyanine green 
Other NIR-F imaging 
agent 
Methylene blue 
Other agents which emit fluorescence when excited by NIR-F 
spectrum 
ICG: indocyanine green; NIR-F: near-infrared fluorescence 
1. 
ICG unless used for anastomotic evaluation after the ureters have been visualized or for lymphatic 
mapping where there is a clear anatomic separation of the ureters and the lymphatics.  
 

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10.6 
Appendix 6 
Clinical Laboratory Assessments 
Laboratory tests will be performed according to the Schedule of Assessments [Table 1] and 
sent to a central laboratory for analysis.  
Table 9 
Clinical Laboratory Tests 
Panel/Assessments 
Parameters to be Analyzed 
Hematology 
Hemoglobin 
Hematocrit 
Erythrocytes 
Leukocytes 
Differential leukocytes 
Platelets 
Biochemistry 
Albumin  
Alanine aminotransferase 
Alkaline phosphatase 
Aspartate aminotransferase 
Blood urea nitrogen 
Calcium 
Chloride 
Creatinine 
Creatine kinase 
Estimated glomerular filtration rate 
Gamma-glutamyl transferase 
Glucose 
Inorganic phosphorus 
Lactate dehydrogenase 
Magnesium 
Potassium 
Sodium  
Total bilirubin 
Total cholesterol 
Total protein 
Triglycerides 
Uric acid 
Allergic reactions 
Histamine and tryptase (only in participants with hypersensitivity reaction) 
Urinalysis 
Urine, dipstick as 
applicable (if protein, 
blood, leukocytes or 
nitrites are abnormal, 
microscopy will be 
performed) 
Protein 
Glucose 
pH 
Blood 
Leukocytes 
Urobilinogen 
Bilirubin 
Ketones 
Nitrite 
Color 
Microscopy (if needed) 
Casts 
Crystals 
Epithelial cells 
Leucocytes 

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Panel/Assessments 
Parameters to be Analyzed 
Erythrocytes 
Bacteria 
Pregnancy 
Human chorionic gonadotropin (female participants of childbearing potential only) 

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10.7 
Appendix 7 
Assessment of Renal Function 
10.7.1 Adult Participants 
Individual eGFR (mL/min): 
= eGFR (mL/min/1.73 m2) (by MDRD) × BSA/1.73 
● 
Formula for eGFR from the MDRD [Levey et al, 2006]: 
eGFR (mL/min per 1.73 m2) = 175 × (Scr, std)-1.154 × (age)-0.203 × (0.742 if female) 
× (1.212 if African American) 
● 
Formula for BSA calculated by Du Bois Formula [Du Bois & Du Bois, 1916]: 
BSA (m2) = 0.007184 × weight (kg)0.425 × height (cm)0.725 
 
BSA = body surface area; eGFR: estimated glomerular filtration rate; MDRD: modification of diet in renal 
disease; Scr, std: serum creatinine (mg/dL) measured with a standardized assay 
10.7.2 Adolescent Participants 
Individual eGFR (mL/min): 
= eGFR (mL/min/1.73 m2) (by Schwartz formula) × BSA/1.73 
● 
Formula for eGFR from the Schwartz formula [Schwartz et al, 2009]: 
eGFR (mL/min per 1.73 m2) = 0.413 × (height [cm] / Scr, std [mg/dL]) 
● 
Formula for BSA calculated by Du Bois Formula [Du Bois & Du Bois, 1916]: 
BSA (m2) = 0.007184 × weight (kg)0.425 × height (cm)0.725 
 
BSA = body surface area; eGFR: estimated glomerular filtration rate; Scr, std: serum creatinine (mg/dL) measured 
with a standardized assay 
 

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10.8 
Appendix 8 
Ureter Conspicuity by 5-Point Likert Scale 
Primary and Secondary Efficacy Assessments  
10.8.1 Ureter Conspicuity by 5-Point Likert Scale  
The conspicuity of the ureter with WL or WL/NIR-F will be assessed by the investigator 
(5-Point Likert Scale) during surgery for all participants.  
● 
The investigator will attempt to locate the ureter and score the ureter conspicuity using 
the 5-Point Likert scale by answering the question, “How conspicuous (easy to 
recognize/identify) is the ureter?”   
● 
When assessing the 5-Point Likert Score for ureter conspicuity, investigators should 
consider information such as contrast, brightness (luminance), and/or fluorescence 
intensity. 
● 
Conspicuity (or “How conspicuous is the ureter?”) for this study is defined as 
“self-evident ureter location identification (jump out to capture your attention)”.  
Conspicuity assessment will be scored using the 5-Point Likert Scale below for WL 
[Section 10.8.1.1] and NIR-F [Section 10.8.1.2]:  
10.8.1.1 White Light Illustrative Examples  
Score 
Description 
of Ureter 
Conspicuity 
Ureter 
Location 
Identification 
Illustrative Example of Images 
1 
None 
Not 
self-evident 
 
2 
Poor 
Somewhat 
self-evident 
 
 

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Score 
Description 
of Ureter 
Conspicuity 
Ureter 
Location 
Identification 
Illustrative Example of Images 
3 
Sufficient 
Sufficiently 
self-evident  
 
 
4 
Good 
Clearly self-
evident  
 
5 
Excellent 
Extremely 
self-evident 
 
 
 
 

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10.8.1.2 NIR-F Illustrative Examples 
Score 
Description 
of Ureter 
Conspicuity 
Ureter 
Location 
Identification 
Illustrative Example of Images 
1 
None 
Not 
self-evident 
 
 
2 
Poor 
Somewhat 
self-evident 
 
 
 
 
3 
Sufficient 
Sufficiently 
self-evident  
 
 
 
 

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Score 
Description 
of Ureter 
Conspicuity 
Ureter 
Location 
Identification 
Illustrative Example of Images 
4 
Good 
Clearly 
self-evident  
 
 
 
 
5 
Excellent 
Extremely 
self-evident 
 
 
 
 
 
 

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10.9 
Appendix 9 
Clinical Study Continuity 
INTRODUCTION 
The purpose of this appendix is to provide acceptable alternate methods to assess safety and 
efficacy parameters, as appropriate, in the event the clinical study is interrupted at the 
country, state, site or participant level during any crisis (e.g., natural disaster, pandemic). 
BENEFIT-RISK RATIONALE 
Maintaining the safety of clinical study participants and delivering continuity of care in the 
clinical study setting is paramount during any crisis. The site is expected to follow the 
protocol and associated Schedule of Assessments [Table 1] unless the site principal 
investigator discusses the need with the Astellas medical monitor to implement the alternate 
measures.  
The approach outlined within this appendix defines which assessments are required to 
maintain a favorable benefit/risk to the participant, to maintain overall study integrity and to 
provide acceptable alternate methods to complete the study-required assessments and 
procedures if study activities are unable to be performed as described in [Section 7] due to a 
crisis.  
INFORMED CONSENT 
Participants who need to follow any or all of the alternate measures outlined in this appendix 
will be required to provide informed consent, which explicitly informs them of the nature of 
and rationale for these changes, and gain their agreement to continue participation in the 
study prior to the implementation of any of these changes. In the event the urgency of 
implementing the alternate measures does not allow for the participant to provide written 
consent prior to implementation, the principal investigator or designee will obtain oral 
agreement from the participant followed by written documentation as soon as is feasible. A 
separate addendum to the study ICF will be provided to document the participant’s consent to 
the changes.  
PARTICIPANT PROCEDURES ASSESSMENT 
Sites with participants who are currently enrolled into this clinical study may consider 
implementing the alternate methods outlined below if 1 or more of the following conditions 
are met due to the crisis: 
● 
Regional or local travel has been restricted, inclusive of mandatory shelter in place 
measures, which makes participant travel to/from the study site nearly impossible. 
● 
Site facilities have been closed for clinical study conduct.  
● 
Site has been restricted to treating patients with conditions outside of the scope of the 
study. 
● 
Site personnel have temporarily relocated the conduct of the study to a location that 
place a burden on the participant with respect to time and travel. 
● 
Participant(s) have temporarily relocated from the current study site to an alternate study 
site to avoid placing a burden on the participant with respect to travel. 

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● 
Participant(s) have temporarily relocated from their home location and the new distances 
from the site would cause undue burden with respect to time and travel. 
● 
Participant has risk factors for which traveling to the site poses an additional risk to the 
participant’s health and safety. 
Adherence to the original protocol as reflected in the Schedule of Assessments [Table 1] is 
expected, where plausible, in the case of a crisis. The alternate measures as noted in 
[Table 10] below are only permissible in the event of a crisis, and after discussing the need 
with the Astellas medical monitor to implement the alternate measures. This is to allow for 
continuity of receiving study intervention and maintaining critical safety and efficacy 
assessments for participants in the study at a time of crisis. 
If 1 or more of the alternate measures noted below is implemented for a participant, the site 
should document in the participant’s source document the justification for implementing the 
alternate measure and the actual alternate measures that were implemented, along with the 
corresponding time point(s).  
Table 10 
Alternative Schedule of Assessments in Response to a Crisis 
Assessments 
Treatment Period 
Follow-up 
Period 
Alternate Approaches 
Visit Number 
2 
3 
Visit Label 
Postoperative 
Follow-up 
Day 
1 
21 
152 
Window 
- 
+ 2 
± 10 
Physical examination3 
X4 
 
X 
Can be obtained at local clinic 
Vital signs5 
X4 
 
X 
Can be obtained at local clinic 
Clinical laboratory tests6 
X4 
X 
X 
Visit collection of samples at local 
facility acceptable if results can be 
made available to investigator’s 
site. 
Weight5 
 
 
X 
Can be obtained at local clinic 
Previous/concomitant 
medications 
X 
X 
X7 
Remote/virtual/telemedicine visits 
allowed 
AE/SAE assessment 
X 
X 
X7 
Remote/virtual/telemedicine visits 
allowed 
AE: adverse event; ECG: electrocardiogram; SAE: Serious adverse event 
1. 
Only when participant stays in the hospital. 
2 
If a participant discontinues early from the study after the study intervention administration, the follow-up 
visit procedures will be performed upon discontinuation 
3. 
At visit 2 and the follow-up visit (visit 3), a symptom-directed physical examination will be performed. 
4. 
Physical examination, vital signs and ECG/cardiac monitoring will be completed within 2-hours after 
surgery. Clinical laboratory tests will be collected within 2 hours after surgery if participant is discharged 
on day of surgery (day 1) or on day 2, if participant remained hospitalized. 
5. 
All vital signs will be measured with the participant in the sitting or supine position. Weight will be 
measured using standard institution practice and equipment. 
6 
Clinical laboratory tests for the central laboratory include blood collection for hematology (complete 
blood count), biochemistry and urine samples for urinalysis.  
7. 
If a participant experiences an AE/SAE or change in concomitant medications between Visit 2 and Visit 3, 
the participant should call the study site to inform of these changes. For participants who experience 
hypersensitivity reaction(s), an additional blood sample should be collected to determine histamine and 
tryptase concentration levels. The sample should be taken at a local laboratory as soon as possible after the 
onset of the hypersensitivity reaction. 

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STUDY INTERVENTION SUPPLY 
If any of the conditions outlined above in the Participants Procedures Assessment are met, 
1 or all of the following mitigating strategies will be employed, as needed, to ensure 
continuity of study intervention supply to the participants:   
● 
Increase stock of study intervention on-site to reduce number of shipments required, if 
site space will allow.  
DATA COLLECTION REQUIREMENTS 
Additional data may be collected in order to indicate how participation in the study may have 
been affected by a crisis and to accommodate data collection resulting from alternate 
measures implemented to manage the conduct of the study and participant safety.  
● 
Critical assessments for safety and efficacy based on study endpoints to be identified as 
missing or altered (performed virtually, at alternative locations, out of window or other 
modifications) due to the crisis.  

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10.10 Appendix 10 
List of Abbreviations and Definition of Key Study 
Terms 
List of Abbreviations 
Abbreviations 
Description of abbreviations 
ADE 
adverse device effect 
AE 
adverse event 
Ae 
amount of ASP5354 excreted into urine 
Ae% 
percentage of ASP5354 dose excreted into urine 
AESI 
adverse event of special interest 
ALT 
alanine aminotransferase 
APGD 
Astellas Pharma Global Development Inc. 
AST 
aspartate aminotransferase 
AT 
aminotransferases 
BICR 
blinded independent central review 
BSA 
body surface area 
CEF 
contrast enhancement factor 
CFR 
Code of Federal Regulations 
CRO 
contract research organization 
CSR 
clinical study report 
DILI 
drug-induced liver injury 
ECG 
electrocardiogram 
eCRF 
electronic case report form 
eGFR 
estimated glomerular filtration rate 
EU CTR 
European Union Clinical Trial Regulation 
FSH 
follicle-stimulating hormone 
GCP 
Good Clinical Practice 
GMP 
Good Manufacturing Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
HRT 
hormone replacement therapy 
IB 
Investigator’s Brochure 
ICC 
intraclass correlation coefficient 
ICE 
intercurrent event 
ICF 
informed consent form 
ICG 
indocyanine green 
ICH  
International Council for Harmonisation of Technical Requirements for 
Pharmaceuticals for Human Use 
IEC 
Independent Ethics Committee 
IND 
investigational new drug 
INR 
international normalized ratio 
IRB 
Institutional Review Board 
IRT 
interactive response technology 
ISN 
international study number 
ITT 
Intent to Treat 

Sponsor: APGD 
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Abbreviations 
Description of abbreviations 
IUI 
iatrogenic ureteral injury 
LA-CRF 
liver abnormality case report form 
LAR 
legally authorized representative 
MDRD 
modification of diet in renal disease  
mITT 
Modified Intent to Treat 
NCI CTCAE 
National Cancer Institute Common Terminology Criteria for Adverse Events 
NIR-F 
near-infrared fluorescence 
PBPK 
physiologically based pharmacokinetic 
PK 
pharmacokinetics 
PopPK 
population pharmacokinetics 
QA 
quality assurance 
QC 
quality control 
SAE 
serious adverse event 
SAF 
Safety Analysis Set 
SAP 
statistical analysis plan 
SOP 
standard operating procedure 
SUSAR 
suspected unexpected serious adverse reaction 
TBL 
total bilirubin 
TEAE 
treatment-emergent adverse event 
UADE 
unanticipated adverse device effect 
ULN 
upper limit of normal 
USM 
urgent safety measure 
WL 
white light 
WOCBP 
woman of childbearing potential 

Sponsor: APGD 
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Definition of Key Study Terms 
Terms 
Definition of Terms 
Baseline  
Assessments of participants as they enter a study before they receive any 
treatment.  
Blinded 
independent central 
review 
A committee that consists of experienced surgeons not associated with the 
study with no clinical information regarding the participants. The reviewers 
will review recorded images to evaluate ureter conspicuity. 
Conspicuity 
Self-evident ureter location identification (jump out to capture your 
attention). 
Endpoint  
Variable that pertains to the efficacy or safety evaluations of a study. 
Note: Not all endpoints are themselves assessments since certain endpoints 
might apply to populations or emerge from analysis of results. That is, 
endpoints might be facts about assessments (e.g., prolongation of survival). 
Enroll 
To register or enter a participant into a study.  
Randomization 
The process of assigning participants to dose groups using an element of 
chance to determine assignments in order to reduce bias. 
Screen failure 
Potential participant who signed the ICF, but did not meet one or more 
criteria required for participation in the study and was not enrolled. 
Screening 
A process of active consideration of potential participants for enrollment in a 
study. Note: Once a participant has signed ICF, the protocol applies to the 
participant. 
Screening period 
Period of time before entering the investigational period, usually from the 
time when a participant signs the consent form until just before the test 
product or comparative drug (sometimes without randomization) is given to 
a participant.  
Study period 
Period of time from the first study site initiation date to the last study site 
completing the study. 
Variable 
Any quantity that varies; any attribute, phenomenon or event that can have 
different qualitative or quantitative values. 

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11 
REFERENCES 
Albert M, Delgado-Herrera L, Paruch J, Gerritsen-van Schieveen P, Kishimoto T, Takusagawa S, 
et al. Pudexacianinium (ASP5354) chloride for ureter visualization in participants undergoing 
laparoscopic, minimally invasive colorectal surgery. Surg Endosc. 2023;37:7336-47. 
Bjerregaard J, Pandia MP, Jaffe RA. Occurrence of severe hypotension after indocyanine green 
injection during the intraoperative period. A A Case Rep. 2013;1:26-30. 
Burks FN, Santucci RA. Management of iatrogenic ureteral injury. Ther Adv Urol. 2014;6:115-24. 
Du Bois D, Du Bois EF. A formula to estimate the approximate surface area if height and weight be 
known. Arch Intern Med. 1916;17:863-71. 
Fushiki H, Yoshikawa T, Matsuda T, Sato T, Suwa A. Preclinical development and validation of 
ASP5354: A near-infrared fluorescent agent for intraoperative ureter visualization. Mol 
Imaging Biol. 2023;25:74-84. 
Halabi WJ, Jafari MD, Nguyen VQ, Carmichael JC, Mills S, Pigazzi A, et al. Ureteral injuries in 
colorectal surgery: an analysis of trends, outcomes, and risk factors over a 10-year period in the 
United States. Dis Colon Rectum. 2014;57:179-86. 
Kaymak Ş, Özer MT, Demirbaş S, Kaya E, Kozak O. Renal autotransplantation due to iatrogenic 
ureter injury: A case report. Ulus Travma Acil Cerrahi Derg. 2021;27:260-4. 
Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendriksen S, et al. Using standardized 
serum creatinine values in the modification of diet in renal disease study equation for 
estimating glomerular filtration rate. Ann Intern Med. 2006;145:247-54. 
Poza A, Marzullo L, García G, Reig C. Reparación de lesiones ureterales complejas: presentación de 
tres casos clínicos y análisis de las diferentes opciones terapéuticas [Surgical repair of complex 
ureteral injuries: three clinical cases and analysis of different technical approaches]. Arch Esp 
Urol. 2022;75:77-81. 
Qin S, Nelson L, McLeod L, Eremenco S, Coons SJ. Assessing test-retest reliability of 
patient-reported outcome measures using intraclass correlation coefficients: recommendations 
for selecting and documenting the analytical formula. Qual Life Res. 2019;28:1029-33. 
Ravlo M, Moen MH, Bukholm IRK, Lieng M, Vanky E. Ureteric injuries during hysterectomy-A 
Norwegian retrospective study of occurrence and claims for compensation over an 11-year 
period. Acta Obstet Gynecol Scand. 2022;101:68-76. 
Schwartz GJ, Munoz A, Schneider MF, Mak RH, Kaskel F, Warady BA, et al. New equations to 
estimate GFR in children with CKD, J Amer Soc Nephrol. 2009;20:629-37. 
Wang Y, Jadhav PR, Lala M, Gobburu JV. Clarification on precision criteria to derive sample size 
when designing pediatric pharmacokinetic studies. J Clin Pharmacol. 2012;52:1601-6. 
Zhang Z, Chen D, Deng L, Li W, Wang X, Zhang Y et al. Iatrogenic ureteral injury during 
retroperitoneal laparoscopy for large renal cysts: What we learned and a review of the 
literature. J Xray Sci Technol. 2021;29:185-96. 

Sponsor: APGD 
ISN/Protocol 5354-CL-0301 
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Clinical Study Protocol 
24 OCT 2024 
Amendment 5 
Astellas 
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12 
INVESTIGATOR’S SIGNATURE 
A Phase 3, Multicenter, Prospective, Randomized, Open-label Study for Intraoperative 
Ureter(s) Visualization When Using ASP5354 with Near-infrared Fluorescence (NIR-F) 
Imaging in Participants Undergoing Minimally Invasive and Open Abdominopelvic 
Surgeries 
ISN/Protocol 5354-CL-0301, Amendment 5 [Nonsubstantial] 
24 OCT 2024 
I have read all pages of this protocol for which Astellas is the sponsor. I agree to conduct 
the study as outlined in the protocol and to comply with all the terms and conditions set out 
therein. I confirm that I will conduct the study in accordance with International Council for 
Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) 
Good Clinical Practice (GCP) guidelines and applicable local regulations. I will also 
ensure that sub-investigator(s) and other relevant members of my personnel have access to 
copies of this protocol and the ICH GCP guidelines to enable them to work in accordance 
with the provisions of these documents. 
Principal Investigator: 
Signature: 
 
 
 
 
Date (DD MMM YYYY) 
Printed Name:  
  
<Insert name and qualification of the investigator> 
Address of 
study site: 
 
 
 
 
 
 
 
 
 

Sponsor: APGD 
ISN/Protocol 5354-CL-0301 
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24 OCT 2024 
Amendment 5 
Astellas 
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13 
COORDINATING INVESTIGATOR’S SIGNATURE 
A Phase 3, Multicenter, Prospective, Randomized, Open-label Study for Intraoperative 
Ureter(s) Visualization When Using ASP5354 with Near-infrared Fluorescence (NIR-F) 
Imaging in Participants Undergoing Minimally Invasive and Open Abdominopelvic 
Surgeries 
ISN/Protocol 5354-CL-0301, Amendment 5 [Nonsubstantial] 
24 OCT 2024 
I have read all pages of this protocol for which Astellas is the sponsor. I agree that it 
contains all the information required to conduct this study. 
Coordinating Investigator: 
Signature: 
 
 
 
 
Date (DD MMM YYYY) 
Printed 
Name: 
 
  
<Insert name and qualification of the coordinating investigator> 
Address: 
 
 
 
 
 
 
 
 
 

Sponsor: APGD 
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Clinical Study Protocol 
24 OCT 2024 
Amendment 5 
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14 
SPONSOR’S SIGNATURE 
Required sponsor signatures as required by ICH GCP 4.5.1 are located in the first attachment 
Attachment 1 
Electronic Sponsor Signatures 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Global Protocol Format V11.0