It was reported during a cystoscopy procedure, while the physician utilized a cystoscope to insert through the urethra, he discovered the universa soft ureteral stent tip was split.He proceeded with another stent and completed the procedure successfully.No adverse effects or consequences were reported to the patient due to this occurrence.
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A review of documentation, manufacturing instructions, specification and quality control data was conducted during the investigation.One open package rpn ush-824 was received.Stent and positioner were returned.Stent was returned without the tether.Proximal coil was torn starting at the first sideport and continued through the end of the stent.A braided tether for repositioning and removal of the device is located on the proximal pigtail of the stent.Tether has been pulled out of the stent causing material to tear.No patient harm was reported.There is no indication that a design or process related failure mode contributed to this event.Review of production and quality documentation did not observe any specific issues with current manufacturing or quality controls that may have contributed to this incident.Based on the investigation evaluation, there is no indication that a design or process related failure mode contributed to this event.Current controls for manufacturing are in place to assure functionality and device integrity prior to shipping.Based on the provided information, the root cause will be attributed to the product receiving excessive pressure.We will notify the appropriate personnel and continue to monitor for similar complaints.Per the quality engineering risk assessment no further action is required.
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