MAUDE Adverse Event Report: BOSTON SCIENTIFIC - MARLBOROUGH XENFORM SOFT TISSUE REPAIR MATRIX; MESH, SURGICAL, NON-SYNTHETIC, UROGYNECOLOGIC FOR APICAL VAGINAL AND UTERINE PRO

Model Number M0068302470

Device Problem Adverse Event Without Identified Device or Use Problem (2993)

Patient Problem Vaginal Mucosa Damage (2124)

Event Date 04/20/2015

Event Type  Injury  

Event Description

It was reported to boston scientific corporation that a xenform tissue repair matrix was used during a pelvic floor repair procedure performed on (b)(6) 2014.The procedure was completed without complications.According to the complainant, on (b)(6) 2015, the patient presented with a suture exposure in the vagina of less than one centimeter away from the area of the suture line.The suture was excised and the event was reported to be resolving.

Manufacturer Narrative

The complainant indicated that the device will not be returned for evaluation; therefore a failure analysis of the complaint device could not be completed.If any further relevant information is identified, a supplemental medwatch will be filed.

Manufacturer Narrative

(b)(4).

Event Description

It was reported to boston scientific corporation that a xenform tissue repair matrix was used during a pelvic floor repair procedure performed on (b)(6) 2014.The procedure was completed without complications.According to the complainant, on (b)(6) 2015, the patient presented with a suture exposure in the vagina of less than one centimeter away from the area of the suture line.The suture was excised and the event was reported to be resolving.Additional information received on october 1, 2015 - on (b)(6) 2015, the patient experienced difficulty emptying her bladder.No treatment was given and the event has not yet resolved.

• Brand Name: XENFORM SOFT TISSUE REPAIR MATRIX
• Type of Device: MESH, SURGICAL, NON-SYNTHETIC, UROGYNECOLOGIC FOR APICAL VAGINAL AND UTERINE PRO
• Manufacturer (Section D): BOSTON SCIENTIFIC - MARLBOROUGH; 100 boston scientific way; marlborough MA 01752
• Manufacturer (Section G): TEI BIOSCIENCES INCORPORATED; 7 elkins street; boston MA 02127
• Manufacturer Contact: nancy cutino ; 100 boston scientific way; marlborough, MA 01752 ; 5086834000
• MDR Report Key: 4787635
• MDR Text Key: 5815784
• Report Number: 3005099803-2015-01475
• Device Sequence Number: 1
• Product Code: PAJ
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K060984
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other,Study,Health Professional,Company Representative,company represent
• Reporter Occupation: Other
• Type of Report: Initial
• Report Date: 04/22/2015

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Physician
• Device Expiration Date: 01/31/2017
• Device Model Number: M0068302470
• Device Lot Number: 0001403009
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Initial Date Manufacturer Received: 04/22/2015
• Initial Date FDA Received: 05/21/2015
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 05/02/2014
• 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
• Patient Age: 59 YR
• Patient Weight: 79