MAUDE Adverse Event Report: COOK INC BANDER URETERAL DIVERSION STENT SET; FAD; STENT, URETERAL

Model Number	G14779
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/14/2026
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Blank fields on this form indicate the information is unknown or unavailable.D2a - common device name: additional names: lje catheter, nephrostomy.D2b - product code: additional product codes: lje.E1 - phone number: (b)(6).H3 - device evaluation anticipated but not yet begun.This report includes information known at this time.A follow up report will be submitted should additional relevant information become available.This report is required by the fda under 21 cfr part 803.This report is based on unconfirmed information submitted by others.Neither the submission of this report nor any statement made in it is intended to be an admission that any cook device is defective or malfunctioned; that a death or serious injury occurred; or that any cook device caused or contributed to; or is likely to cause or contribute to a death or serious injury if a malfunction occurred.
Event or Problem Description
It was reported that during use of the bander ureteral diversion stent set, the stent was observed to have broken.The device fractured with only slight traction.No portion of the stent remained inside the patient.The user replaced it with a new bander ureteral diversion stent set and successfully completed the procedure.The patient did not experience any adverse effects or require any additional procedures due to this occurrence.

• Brand Name: BANDER URETERAL DIVERSION STENT SET
• Common Device Name: FAD; STENT, URETERAL
• Manufacturer (Section D): COOK INC; 750 daniels way; bloomington IN
• Manufacturer Contact: jason crouch ; 750 daniels way; bloomington, IN 47404 ; 8123392235
• MDR Report Key: 25277837
• Report Number: 1820334-2026-00543
• Device Sequence Number: 9205660
• Product Code: FAD
• UDI-Device Identifier: 00827002147799
• UDI-Public: (01)00827002147799(17)290113(10)16943015
• Combination Product (Y/N): N
• Initial Reporter Country: CN
• PMA/510(K) Number: K181971
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,Distributor
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 07/08/2026

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: G14779
• Device Catalogue Number: 025707
• Device Lot Number: 16943015
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/13/2026
• Supplement Date Received by Manufacturer: 07/06/2026
• Initial Report FDA Received Date: 05/26/2026
• Supplement Report FDA Received Date: 07/08/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 01/13/2026
• 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
• Patient Age: 62 YR
• Patient Sex: Male
• Patient Weight: 65 KG
• Patient Ethnicity: Non Hispanic
• Patient Race: Asian