|
A male patient underwent aquablation therapy for symptomatic benign prostatic hyperplasia (bph).Procept biorobotics (procept) became aware that, during focal bladder neck cautery (fbnc), the patient's left ureteral orifice was roughened.The surgeon placed a stent as a safety precaution and plans to remove it in 6 weeks.No additional surgeries/interventions were required.No malfunction of the aquabeam robotic system was reported.
|
|
The aquabeam robotic system is a reusable device; therefore, it is still currently in possession of the user facility.The investigation of this event consisted of a review of the treatment log files, device history record (dhr), and instructions for use (ifu).The aquabeam robotic system's treatment log files were reviewed, which confirmed no malfunction occurred.The review of the treatment log files revealed that the aquabeam robotic system functioned as intended, as no malfunction was observed during aquablation therapy.A review of the device history record (dhr) for ab2000/serial number (b)(6) 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 aquabeam robotic system instructions for use (ifu), ifu0101-00, rev.E, was reviewed.Although the aquabeam robotic system labeling does not specifically mention damage to ureteral orifices, procept's risk management documentation includes damage to ureteral orifices as a clinical effect of aquablation therapy.The aquabeam robotic system is a reusable device; therefore, it is still currently in possession of the user facility.It was reported that the patient's left ureteral orifice was roughed up during focal bladder neck cautery (fbnc).The surgeon placed a stent as a safety precaution and plans to remove it in 6 weeks.No additional surgeries/interventions were required.Although the aquabeam robotic system's labeling does not specifically mention damage to ureteral orifices, procept's risk management documentation lists ureteral orifice damage as a clinical effect of aquablation therapy.Based on the information received, plus a review of the treatment log files, dhr, ifu, and procept's risk documentation, the event is considered not to be device related.Submission of this report does not constitute an admission that the manufacturer's product caused or contributed to the event.
|