inforMED
MalfunctionFBO

INNER SHEATH ONLY

Received Dec 29, 2020 · Event occurred Nov 30, 2020

Report 9610617-2020-00147 · MDR key 11089238

Device

Generic name

Inner Sheath

Model number

27050CA

Lot number

US04

Product problems

  • Material Fragmentation
  • Material Integrity Problem
  • Material Fragmentation
  • Material Integrity Problem

Patient

Not reported

  • Foreign Body In Patient
  • Patient Problem/Medical Problem
  • Foreign Body In Patient
  • Patient Problem/Medical Problem

Narrative

Additional Manufacturer Narrative

THE ITEM IS FOUND THE CERAMIC BEAK IS BROKEN OFF THE END OF THE DISTAL SHAFT. THE SHAFT HAS A DENT APPROXIMATELY MIDWAY AND ANOTHER NEAR THE DISTAL END. THE DISTAL END OF THE SHEATH HAS A JAGGED EDGE WHERE THE BEAK HAD BROKEN OFF. THE SHEATH HAS STAINING ON THE INSIDE AND OUTSIDE. THE INSTRUMENT HAS GENERAL WEAR AND TEAR. THIS TYPE OF OCCURRENCE MOST LIKELY IS RELATED TO MECHANICAL FORCE.

Description of Event or Problem

ALLEGEDLY, WHILE PERFORMING A TRANSURETHRAL RESECTION OF PROSTATE (TURP), THE CERAMIC TIP BROKE OFF IN PATIENT'S URETHRA WHEN THE RESECTOSCOPE WAS BEING REMOVED FROM PATIENT. THIS CAUSED TRAUMA AND BLEEDING TO THE URETHRA. NO FURTHER INFORMATION IS AVAILABLE.