MAUDE Adverse Event Report: BOSTON SCIENTIFIC - MARLBOROUGH XENFORM SOFT TISSUE REPAIR MATRIX; MESH, SURGICAL, NON-SYNTHETIC, UROGYNECOLOGIC FOR APICAL VAGINAL AND UTERINE PRO

Model Number	M0068302470
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Erosion (1750); Pain (1994)
Date of Event	04/08/2015
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(6).The complainant indicated that the device is implanted and will not be returned for evaluation; therefore a failure analysis of the complaint device could not be completed.If any further relevant information is identified, a supplemental mdr will be filed.
Event or Problem Description
It was reported to boston scientific corporation that a xenform soft tissue repair matrix device was implanted during a pelvic floor repair procedure with xenform including apical vault suspension and cystocele repair procedure performed on (b)(6) 2014.According to the complainant, on (b)(6) 2015, the patient experienced a suture exposure in the anterior vagina with associated spontaneous pain.The suture exposure and the pain resolved on (b)(6) 2015 by cauterizing the granulation tissue with silver nitrate and trimming the suture.
Additional Manufacturer Narrative
Additional/alternative patient identifier: (b)(6).The event reported in this report ¿suture exposure in the anterior vagina associated with spontaneous pain¿ with onset (b)(6) 2015 for this patient was also reported previously under mfr report #3005099803-2015-01182.Any further information regarding the event will be sent under mfr report 3005099803-2015-01182.
Event or Problem Description
It was reported to boston scientific corporation that a xenform soft tissue repair matrix device was implanted during a pelvic floor repair procedure with xenform including apical vault suspension and cystocele repair procedure performed on (b)(6) 2014.According to the complainant, on (b)(6) 2015, the patient experienced a suture exposure in the anterior vagina with associated spontaneous pain.The suture exposure and the pain resolved on (b)(6) 2015 by cauterizing the granulation tissue with silver nitrate and trimming the suture.

• Brand Name: XENFORM SOFT TISSUE REPAIR MATRIX
• Common Device Name: MESH, SURGICAL, NON-SYNTHETIC, UROGYNECOLOGIC FOR APICAL VAGINAL AND UTERINE PRO
• Manufacturer (Section D): BOSTON SCIENTIFIC - MARLBOROUGH; 100 boston scientific way; marlborough MA 01752
• MDR Report Key: 6892844
• Report Number: 3005099803-2017-02845
• Device Sequence Number: 10950430
• Product Code: PAJ
• UDI-Device Identifier: 08714729774198
• UDI-Public: 08714729774198
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K060984
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 09/05/2017

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: Physician
• Device Expiration Date: 01/31/2017
• Device Model Number: M0068302470
• Device Lot Number: 0001403009
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 09/05/2017
• Supplement Date Received by Manufacturer: 07/16/2018
• Initial Report FDA Received Date: 09/25/2017
• Supplement Report FDA Received Date: 08/10/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 65 YR
• Patient Weight: 78