MAUDE Adverse Event Report: STORZ MEDICAL AG MODULITH SLX-F2 180MM 29000; LITHOTRIPTER

Model Number	29000
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Hematoma (1884)
Date of Event	03/21/2023
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The device was found to be functional within the manufacture specifications.Hematoma are a known side effect of eswl.
Event or Problem Description
Oem storz medical ag was informed by medical personnel from treating hospital that a patient was diagnosed with hematoma post eswl treatment.The facility and physician has provided limited information concerning the patient pre and post eswl treatment.Patient was admitted for treatment on (b)(6) 2023 for left renal stone which was complicated by 7x5x9cm perinephric hematoma with haemorrhagic shock.

• Brand Name: MODULITH SLX-F2 180MM 29000
• Common Device Name: LITHOTRIPTER
• Manufacturer (Section D): STORZ MEDICAL AG; lohstampfesstrasse 8; taegerwilen, 8274 ; SZ 8274
• Manufacturer (Section G): STORZ MEDICAL AG; lohstampfesstrasse 8; taegerwilen, 8274 ; SZ 8274
• Manufacturer Contact: devonne pavlak ; 1000 cobb place blvd; building 400 suite 450; kennesaw, GA 30144 ; 6785817255
• MDR Report Key: 16855161
• Report Number: 9613347-2023-00005
• Device Sequence Number: 20745147
• Product Code: LNS
• UDI-Device Identifier: 07630039100919
• UDI-Public: (01)07630039100919(11)211106
• Combination Product (Y/N): N
• Initial Reporter Country: HK
• PMA/510(K) Number: K072788
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 04/11/2023

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?: No
• Device Model Number: 29000
• Device Catalogue Number: 29000
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/24/2023
• Initial Report FDA Received Date: 05/02/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 11/06/2021
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Reuse
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention; Hospitalization
• Patient Sex: Male