MAUDE Adverse Event Report: Axonics Modulation Technologies, Inc. Axonics; Stimulator, Electrical, Implantable, For Incontinence

Model Number	1101
Medical Device Problem Code	Migration (4003)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/13/2023
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Block d2b: product code: additional product code qon.Block g4: premarket / 510(k) #: additional premarket / 510(k) # p190006.Udi for concomitant product, tined lead: block d10: model number/catalog number: 1201.Serial number: unknown.Batch/lot number: unknown.Model/catalog description: tined lead.Unique identifier (udi) #: (b)(4).
Event or Problem Description
It was reported that the patient with this neurostimulator (ins) had surgery to revise their ins and tined lead.Additionally, the patient had this revision done was due to the ins falling out of their pocket.The patient stated their ins felt too superficial.The patient received a new ins and tined lead.There was no patient complications reported.
Event or Problem Description
It was reported that the patient with this neurostimulator (ins) had surgery to revise their ins and tined lead.Additionally, the patient had this revision done was due to the ins falling out of their pocket.The patient stated their ins felt too superficial.The patient received a new ins and tined lead.There was no patient complications reported.
Event or Problem Description
It was reported that the patient with this neurostimulator (ins) had surgery to revise their ins and tined lead.Additionally, the patient had this revision done was due to the ins falling out of their pocket.The patient stated their ins felt too superficial.The patient received a new ins and tined lead.There was no patient complications reported.
Additional Manufacturer Narrative
Block d2b: product code: additional product code qon.Block g4: premarket / 510(k) #: additional premarket / 510(k) # p190006.Udi for concomitant product, tined lead: block d10: model number/catalog number: 1201, serial number: (b)(6), batch/lot number: al1f321271, model/catalog description: tined lead, unique identifier (udi) #: (b)(4).Correction: block d4: device model number and serial number.
Additional Manufacturer Narrative
Block d2b: product code: additional product code qon block g4: premarket / 510(k) #: additional premarket / 510(k) # p190006 udi for concomitant product, tined lead: block d10: model number/catalog number: 1201 serial number: al1f321271 batch/lot number: (b)(6).Model/catalog description: tined lead.Unique identifier (udi) #: (b)(4).Block h11: investigation details: the device was not returned for analysis; therefore, a technical analysis could not be performed.Good faith effort attempts were made to try and retrieve the device; however, the product was not returned.It was confirmed the device met manufacturing specification prior to distribution and there were no manufacturing deviations which could have contributed to the reported event.Review of the instructions for use (ifu) confirmed there was relevant content and sufficient guidance with respect to the circumstances described within this complaint.No updates are required to the ifu as a result of this event.A risk review was completed and confirmed that the event of migration and revision surgery (loss of therapy or long-term ineffective therapy, etc.) (repeat exposure to surgical risks) was defined in the product risk documentation.This event type has been accounted for during analysis to support acceptable risk benefit for the product.Based on a thorough review of the reported complaint, boston scientific has assigned an investigation conclusion code of cause not established.

• Brand Name: Axonics
• Common Device Name: Stimulator, Electrical, Implantable, For Incontinence
• Manufacturer (Section D): Axonics Modulation Technologies, Inc.; 15515 sand canyon ave; irvine CA 92618
• Manufacturer (Section G): Axonics Inc; 15515 sand canyon ave; irvine CA 92618
• Manufacturer Contact: farshad fahimi ; 4100 hamline avenue north; building c; saint paul, MN 55112
• MDR Report Key: 25815450
• Report Number: 2124215-2026-37642
• Device Sequence Number: 6038676
• Product Code: EZW
• UDI-Device Identifier: 10810005340066
• Combination Product (Y/N): N
• Initial Reporter State: KY
• Initial Reporter Country: US
• PMA/510(K) Number: P180046
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2022
• Device Explanted Year: 2023
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 09/08/2026

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
• Operator of Device: Lay User/Patient
• Device Expiration Date: 07/16/2024
• Device Model Number: 1101
• Device Catalogue Number: 1101
• Device Lot Number: AX1H166955
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/17/2026
• Supplement Date Received by Manufacturer: 07/20/2026; 08/17/2026
• Initial Report FDA Received Date: 07/14/2026
• Supplement Report FDA Received Date: 08/12/2026; 09/08/2026
• Date Device Manufactured: 07/16/2021
• 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: Hospitalization; Required Intervention
• Patient Age: 62 YR
• Patient Sex: Female