GREENLIGHT HPS BPH FIBER OPTIC
Report
- Report Number
- 2937094-2014-00689
- Event Type
- Malfunction
- Date Received
- August 6, 2014
- Date of Event
- June 13, 2014
- Report Date
- June 24, 2014
- Manufacturer
- AMERICAN MEDICAL SYSTEMS, INC. (SAN JOSE)
- Product Code
- GEX
- PMA / PMN Number
- NA
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- OH, US
- Reporter Occupation
- OTHER
Narratives
(B)(4). THE FIBER CAP REMAINS ATTACHED AND EXHIBITS A DRILLED THROUGH CONDITION; THERE IS SOME WHITE UNKNOWN SUBSTANCE NOTED INSIDE THE FIBER CAP TIP; THE BEVEL SECTION IS MELTED; THE GLASS CAP EXHIBITS MILD DETRITUS ADHESION. BASED ON THE ANALYSIS, THE POTENTIAL FOR FORWARD FIRING MAY EXIST. PROBABLE ROOT CAUSE: BASED ON THE PRODUCT ANALYSIS RESULTS, THE PRODUCT COMPLAINT OF "BLOWN FIBER TIP" COLD NOT BE CONFIRMED; A CAP MELTED WAS OBSERVED; THE PROBABLE ROOT CAUSE OF THE FAILURE IS: HEAT ACCUMULATION. CAP WEAR WAS ACCELERATED DUE TO ANATOMICAL/PROCEDURAL FACTORS (TISSUE CONTACT AND TECHNIQUE) ENCOUNTERED DURING THE PROCEDURE WHICH WOULD LIMIT THE PERFORMANCE OF THE FIBER.
IT WAS REPORTED THAT TIP DAMAGE OCCURRED WHILE USING FOUR SURGICAL FIBERS DURING A PROSTATE PROCEDURE (AT 1,672 J, 2,447 J, 1,041 J, AND 4,157 JOULES OF USE RESPECTIVELY). THE PROCEDURE WAS COMPLETED USING A FIFTH SURGICAL FIBER. THERE WAS NO PATIENT INJURY REPORTED. THIS REPORT IS FOR THE THIRD SURGICAL FIBER USED.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 460818 | GREENLIGHT HPS BPH FIBER OPTIC | POWERED LASER SURGICAL INSTRUMENT | GEX | AMERICAN MEDICAL SYSTEMS, INC. (SAN JOSE) | 0010-2090 | 347H |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 |