inforMED
InjuryEZN

PERCUTANEOUS NEPHROSTOMY DILATOR

Received Jun 19, 2026

Report 9610711-2026-00197 · MDR key 25562672

Device

Generic name

Endoscopic-access Dilator, Single-use

Manufacturer

Coloplast A/s

Catalog number

RBC008

Product problems

  • Device Markings/Labelling Problem

Patient

NA · Unknown

  • Kidney injury

Narrative

Additional Manufacturer Narrative

THE INVESTIGATION IS NOT YET COMPLETE, A FOLLOW UP REPORT WILL BE SUBMITTED ON COMPLETION OF THE INVESTIGATION.

Description of Event or Problem

ACCORDING TO THE AVAILABLE INFORMATION, CONTAINED A SHAFT THAT WAS¿CONTRARY TO EXPECTATION¿TOO SHORT. ACCORDING TO THE CATALOG AND TECHNICAL DATA SHEET, A 21 CM LONG SPLIT SHAFT SHOULD HAVE BEEN INCLUDED. THE CUSTOMER STATES THAT, IN THE PAST, THEY HAD CONSISTENTLY RECEIVED THE SHORT VERSION OF THE RBC008. BECAUSE A 21 CM SHAFT WAS SUDDENLY INCLUDED, THE SENIOR PHYSICIAN INADVERTENTLY INJURED THE PATIENT'S KIDNEY (THOUGH LIKELY WITHOUT LASTING CONSEQUENCES). FURTHERMORE, THE CUSTOMER IS CONFUSED BY THE CHARRIÈRE SIZE "9" PRINTED ON THE LUER HUB, AS IT OUGHT TO BE AN 8 CH.