A male patient underwent an aquablation procedure for symptomatic benign prostatic hyperplasia (bph).Procept biorobotics corporation (procept) became aware that during procedural setup, the aquabeam robotic system generated an "e22 - motorpack error".Multiple troubleshooting steps were performed; however, the issue persisted.A second aquabeam handpiece was used; however, the issue continued to persist.A third aquabeam handpiece was used which resolved the issue.The reported event caused a surgical delay of over 20 minutes.There were no adverse health consequences to the patient due to this event.
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The aquabeam handpieces were returned for investigation.Investigation into this issue has confirmed the occurrence of "e22 - motorpack" errors.The issue is being addressed through procept's quality system.A review of the device history record (dhr) ab2000-b / serial number (b)(6) and aquabeam handpiece / lot number 23c11055 was conducted, which confirmed that there were two (2) non-conformance issued to this lot during the manufacturing process that could potentially be related to the reported event.The affected units within the lot were segregated and reworked to address the non-conformance.The handpiece passed final inspection prior to release for distribution.The current user manual um0101-00 rev.F, aquabeam robotic system user manual, us, english was reviewed and states: table 5 system detected errors and faults.E22 - motorpack error.Release foot pedal and click x.1) if error persists, reconnect handpiece to motorpack.2) if error continues, replace handpiece.Submission of this report does not constitute an admission that the manufacturer's product caused or contributed to the event.
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