MAUDE Adverse Event Report: HERNIAMESH SRL T-SLING; DEVICE FOR STRESS URINARY INCONTINENCE

Model Number	5194001400
Health Effect - Clinical Codes	Incontinence (1928); Pain (1994); Urinary Tract Infection (2120); Prolapse (2475)
Date of Event	10/01/2015
Type of Reportable Event	Serious Injury
Event or Problem Description
Patient's legal representative stated severe pain with daily activities and intercourse, chronic urinary tract infections, incontinence and pelvic organ prolapse.

• Brand Name: T-SLING
• Common Device Name: DEVICE FOR STRESS URINARY INCONTINENCE
• Manufacturer (Section D): HERNIAMESH SRL; via fratelli meliga 1/c; chivasso 10034 torino it, ; IT
• MDR Report Key: 7506217
• Report Number: 9614846-2018-00001
• Device Sequence Number: 2018178
• Product Code: PAH
• UDI-Device Identifier: 28032919892120
• UDI-Public: 28032919892120
• Combination Product (Y/N): N
• PMA/510(K) Number: K020652
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2013
• Device Explanted Year: 2015
• Reporter Type: Manufacturer
• Report Source: distributor
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 05/11/2018

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: No Information
• Device Model Number: 5194001400
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 05/10/2018
• Initial Report FDA Received Date: 05/11/2018
• 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: Hospitalization