MAUDE Adverse Event Report: AMERICAN MEDICAL SYSTEMS, INC. AMS ELEVATE ANTERIOR PROLAPSE REPAIR SYSTEM; MESH, SURGICAL, POLYMERIC

Catalog Number 720093-01

Device Problem Insufficient Information (3190)

Patient Problems Death (1802); Incontinence (1928); Laceration(s) (1946); Pain (1994); Scarring (2061); Injury (2348); Deformity/ Disfigurement (2360); Dysuria (2684)

Event Date 10/06/2010

Event Type  Death  

Event Description

It was reported by the plaintiff's attorney that the plaintiff allegedly experienced excruciating pain and suffering, laceration of internal body tissue and organs, dyspareunia, dysuria, permanent scarring, recurrence, inability to walk without extreme pain, permanent bodily disfigurement, impairment and damage, related sequelae, mental anguish, and loss of enjoyment of life, and a product problem and other injuries requiring additional surgeries and corrective treatment.It was also reported that he plaintiff experienced stress urinary incontinence, urethral hypermobility and exposure of vaginal mesh.Furthermore, it was reported that the plaintiff died.No cause of death was reported.Related to manufacturer report #: 2183959-2015-56581.

Manufacturer Narrative

(b)(4).

• Brand Name: AMS ELEVATE ANTERIOR PROLAPSE REPAIR SYSTEM
• Type of Device: MESH, SURGICAL, POLYMERIC
• Manufacturer (Section D): AMERICAN MEDICAL SYSTEMS, INC.; 10700 bren road west; minnetonka MN 55343
• Manufacturer Contact: sharon zurn, director ; 10700 bren road west; minnetonka, MN 55343 ; 9529306347
• MDR Report Key: 4944909
• MDR Text Key: 6039832
• Report Number: 2183959-2014-51947
• Device Sequence Number: 1
• Product Code: OTP
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K082677
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other,Consumer
• Reporter Occupation: Not Applicable
• Type of Report: Initial
• Report Date: 07/15/2014

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 07/24/2015
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Lay User/Patient
• Device Expiration Date: 05/24/2013
• Device Catalogue Number: 720093-01
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Date Manufacturer Received: 07/15/2014
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 05/01/2010
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Treatment: MINIARC ((B)(4) 2010); OBTRYX ((B)(4) 2008)
• Patient Outcome(s): Death
• Patient Age: 64 YR