MAUDE Adverse Event Report: COLOPLAST A/S (2BO)TITAN OTR INFRA 16CM; INFLATABLE PENILE PROSTHESIS

Model Number QSR8161400

Device Problems Break (1069); Fluid/Blood Leak (1250)

Patient Problem No Code Available (3191)

Event Date 09/08/2017

Event Type  Injury  

Manufacturer Narrative

Without the benefit of examination and testing, coloplast is precluded from commenting on the condition of the device or the cause of the occurrence.Should additional facts prompt us to alter or supplement any information of conclusions contained in the original mdr or in any prior supplemental reports, a follow-up report will be submitted.

Event Description

According to the available information, loss of fluid, broken tubing at pump.

Manufacturer Narrative

This follow-up mdr is created to document the evaluation of the returned device.A titan otr pump, two cylinders, and a reservoir were received for evaluation.Examination and testing of the returned components revealed a separation within abrasion at the exhaust tube/strain relief junction of the serialized exhaust tube of the pump.Testing revealed this to be a site of leakage.The separation appears to be rough and irregular, indicating sufficient stress was exerted.No functional abnormalities are noted with cylinder #1 or cylinder #2.Quality concluded that while in-vivo both the exhaust tubes and inlet tube positioned themselves in such a way that caused them to overlap and abrade against one another.This positioning, in combination with device usage over time, could contribute to sufficient stress(s) to separate the serialized exhaust tube of the pump at this site.A separation of this type would then allow the loss of fluid, making the device inoperable.

• Brand Name: (2BO)TITAN OTR INFRA 16CM
• Type of Device: INFLATABLE PENILE PROSTHESIS
• Manufacturer (Section D): COLOPLAST A/S; holtedam 1; humlebaek, 3050 ; DA 3050
• Manufacturer (Section G): COLOPLAST MANUFACTURING US, LLC; 1601 west river road north; minneapolis MN 55411
• Manufacturer Contact: christine buckvold ; 1601 west river road north; minneapolis, MN 55411 ; 6123024982
• MDR Report Key: 6893516
• MDR Text Key: 87352013
• Report Number: 2125050-2017-00463
• Device Sequence Number: 1
• Product Code: FHW
• Combination Product (y/n): N
• PMA/PMN Number: P000006
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,other
• Type of Report: Initial,Followup
• Report Date: 12/12/2017

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 09/26/2017
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Lay User/Patient
• Device Model Number: QSR8161400
• Device Catalogue Number: QSR8161400
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/20/2017
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 09/08/2017
• Was Device Evaluated by Manufacturer?: Yes
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: N
• Patient Sequence Number: 1
• Patient Outcome(s): Other
• Patient Age: 47 YR