MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION AMS 800 URINARY CONTROL SYSTEM; DEVICE INCONTINENCE MECHANICAL/HYDRAULIC

Model Number	72400168
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	03/25/2019
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that due to a presence of a leak on the tube before setting up, the patient had his artificial urinary sphincter (aus) not used.There were no clinical consequences related to this event.Should additional information be received a supplemental report will be submitted.
Event or Problem Description
It was reported that due to a presence of a leak on the tube before setting up, the patient had his artificial urinary sphincter (aus) not used.There were no clinical consequences related to this event.Should additional information be received a supplemental report will be submitted.
Additional Manufacturer Narrative
The complaint component was returned and analyzed, and the reported allegation was not confirmed via product analysis.The event cannot be reproduced or substantiated; therefore, no escalation to ncep, capa or scar is required.

• Brand Name: AMS 800 URINARY CONTROL SYSTEM
• Common Device Name: DEVICE INCONTINENCE MECHANICAL/HYDRAULIC
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 10700 bren road w; minnetonka MN 55343
• MDR Report Key: 8532604
• Report Number: 2183959-2019-62387
• Device Sequence Number: 11222414
• Product Code: EZY
• UDI-Device Identifier: 00878953000794
• UDI-Public: 00878953000794
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• PMA/510(K) Number: P000053
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: foreign,health professional
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 06/20/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Lay User/Patient
• Device Expiration Date: 04/27/2021
• Device Model Number: 72400168
• Device Catalogue Number: 72400168
• Device Lot Number: 0131704001
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/24/2019
• Initial Date Received by Manufacturer: 03/29/2019
• Supplement Date Received by Manufacturer: 06/14/2019
• Initial Report FDA Received Date: 04/19/2019
• Supplement Report FDA Received Date: 06/20/2019
• Patient Sequence Number: 1