MAUDE Adverse Event Report: COLOPLAST A/S SUPRIS® RETROPUBIC SLING SYSTEM; SURGICAL MESH

Model Number	5195622400
Medical Device Problem Code	Migration (4003)
Health Effect - Clinical Codes	Erosion (1750); Micturition Urgency (1871); Hemorrhage/Blood Loss/Bleeding (1888); Inflammation (1932); Pain (1994); Urinary Tract Infection (2120); Urinary Frequency / Polyuria (2275); Dyspareunia (4505)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Coloplast has not been provided any corroborating evidence to verify the information contained in this report.The lot number was reviewed for complaint trend, nonconforming report and capa.¿ devices met specification prior to release and no trends were noted.Without the benefit of examination and testing, coloplast is precluded from commenting on the condition of the device or the cause of the occurrence.Should additional facts prompt us to alter or supplement any information or conclusions contained in the original mdr or in any prior supplemental reports, a follow-up report will be submitted.
Event or Problem Description
As reported to coloplast, though not verified, legal representative stated the patient with this device experienced lower left quadrant pain, pain worse with movement and cycle, frequent urinary tract infections, dyspareunia, urinary urgency, urinary frequency, pelvic pressure, a cystoscopy noted a 5 mm erosion encrusted with stone at 7 o¿clock at the distal third end of the urethra.Patient had partial explantation of the device.Intraoperative findings noted a suburethral portion of the midurethral device was removed with urethral erosion identified and included in the removal.Multilayer closure of urethrotomy, with multiple tests of the urethroplasty revealing a watertight closure.Pathology noted a section of mesh material measuring 3x2 x 1.1 x 0.4 cm with attached soft tissue showing squamous mucosa with erosion or ulcer, underlying marked acute and chronic inflammation, foreign material, hemorrhage and vascular proliferation.Gross examination only for mesh material.

• Brand Name: SUPRIS® RETROPUBIC SLING SYSTEM
• Common Device Name: SURGICAL MESH
• Manufacturer (Section D): COLOPLAST A/S; holtedam 1; humlebæk 3050 ; DA 3050
• Manufacturer (Section G): COLOPLAST MANUFACTURING US, LLC; 1601 west river road north; minneapolis MN 55411
• Manufacturer Contact: usbes brian e schmidt ; 1601 west river road north; minneapolis, MN 55411 ; 8007880293
• MDR Report Key: 16221505
• Report Number: 2125050-2022-01500
• Device Sequence Number: 18015494
• Product Code: OTN
• UDI-Device Identifier: 05708932490016
• UDI-Public: 05708932490016
• Combination Product (Y/N): N
• PMA/510(K) Number: K111233
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2021
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Consumer
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 01/21/2023

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?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 10/31/2023
• Device Model Number: 5195622400
• Device Catalogue Number: 519562
• Device Lot Number: 6830243
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 12/24/2022
• Initial Report FDA Received Date: 01/21/2023
• Date Device Manufactured: 04/22/2019
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 34 YR
• Patient Sex: Unknown