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Medical Forum / Diseases and Disorders / Prostate BPH / May 2006

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Holap (Holium Laser Resection/Vaporization) death report

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intotechs@gmail.com - 19 May 2006 16:41 GMT
Question to the people that have researched Holap or practice it.  What
would cause death in a Holap procedure?  The report is unclear.

COHERENT MEDICAL GROUP VERSAPULSE DUAL 80/100 SURGICAL LASERS    back
to search results

Catalog Number 0623-704-01
Event Date 10/03/2005
Event Type  Death   Patient Outcome  Death; Required Intervention
Event Description
Customer requested service in 10/2005 to check proper operations of the
versapulse select unit. Customer biomedical engineering department
informed lumenis service in advance that a pt had expired due to a
surgical complication in association with a case performed with a
versapulse select. Lumenis field service evaluated the versapulse
select 5 days later and found the versapulse select, to be operating
within specification. Lumenis has requested from the hospital
additional information regarding the pt, procedure, cause of death and
laser fiber used.

Manufacturer Narrative
Lumenis service evaluated the customer's versapulse select laser and
found it to be within specification. Lumenis field service engineer
(fse) inquired about the laser fiber used in the suspect procedure;
lumenis fs was informed by hospital staff that the fiber used in the
case was probably thrown away. The fiber was stated by the hospital
staff to be a hblf-200, a 200 micron bare holmium laser. Fiber. The
hblf-200 fiber is not manufactured by lumenis, and lumenis does not
recomment the use of fibers manufactured by "third party" manufactures
for use with the lumenis versapulse select laser. Lumenis has requested
from the hospital a confirmation of which fiber (lumenis vs third
party) was used in the procedure in question. H6 no conclusion for
"results", as regards the fiber used at its interface with the laser,
can be drawn without the additional information requested from the
customer.

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Detail.CFM?MDRFOI__ID=
640439

Lee - 19 May 2006 19:22 GMT
> Question to the people that have researched Holap or practice it.  What
> would cause death in a Holap procedure?  The report is unclear.

What makes you think it was a Holap procedure?  Their VersPlus laser is used
in a wide variety of surgical applications.  See:

http://www.surgical.lumenis.com/wt/page/versapulse

I think we need to wait until the hospital supplies the requested additional
information and it is made public.

Regards,
Lee
intotechs@gmail.com - 19 May 2006 20:31 GMT
That specific model is being marketed principally for BPH and urologic
surgical procedures.  I suppose it could have been used for breaking up
a stone.  Still would be interested in understanding what happened in
either situation.  Marketing video below covers the utility of system,
Holap/Holep being most of it.

  http://www.surgical.lumenis.com/wt/content/versapulse_video_news
Lee - 19 May 2006 21:51 GMT
> That specific model is being marketed principally for BPH and urologic
> surgical procedures.  I suppose it could have been used for breaking up
[quoted text clipped - 3 lines]
>
>   http://www.surgical.lumenis.com/wt/content/versapulse_video_news

It looks like they change that video regularly.  When I just viewed it, it
covered the use of the laser to treat varicose veins.

Holap and Holep are totally different procedures.  Holep has a much steeper
learning curve, and the use of a morcellator to remove residual prostate
tissue from the bladder makes it dangerous.

We need to know more details from the hospital.

Regards,
Lee
 
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