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A male patient underwent aquablation therapy to treat symptomatic benign prostatic hyperplasia (bph).Procept biorobotics corporation became aware that during aquablation therapy, two handpieces of the aquabeam robotic system experienced incomplete water jet calibration, in conjunction with repeated errors: 'e22 - motorpack error' and 'e50 - console error.' despite efforts, these errors could not be cleared.A third handpiece was opened and successfully used to complete the procedure without further issues.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 handpiece was returned for investigation.During functional testing, an e22 error triggered upon docking and could not be cleared, confirming the reported failure.The aquabeam handpiece was observed to have signs of fluid ingress on the sensor board and encoder wheel.The root cause is determined to be fluid ingress and the root cause source of the fluid remains underminable.A review of the device history record (dhr) for ab2000/serial number (b)(6) and aquabeam handpiece/lot number 24c04279 was conducted, which confirmed that there were no non-conformances, failures, discrepancies, or missed steps during the manufacturing process that could be related to the reported event.The review indicated that the device met all design and manufacturing specifications when released for distribution.The user manual um0101-00 rev.F, aquabeam robotic system user manual, us, english was reviewed.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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