Investigation of Medical Device Program Defects Affecting Pharmacotherapy / 医薬品情報学

Objective:Medical device malfunctions can significantly impact pharmacotherapy. With advances in digital technology, smartphone applications for the treatment of nicotine addiction have recently been released in Japan. However, it cannot be denied that the malfunction of medical devices related to such programs may affect drug treatment. Therefore, we investigated malfunctioning medical devices related to the program.Methods: We investigated reports on malfunctions from FY 2006 to 2021, using the Pharmaceuticals and Medical Devices Agency database.Results: A total of 94 cases of program-related medical device failures were reported in Japan. The malfunction of medical devices (such as infusion pumps and dialysis machines) associated with drug treatment were confirmed. The events included a rapid infusion of the drug and an inability to ascertain the total dose, both of which were caused by bugs in the program. Although the specifics are unknown, there was a malfunction in the contrast medium injection device as well.Conclusion: When issues arise with the dosage setting of medical devices, it is necessary to consider both human errors by medical staff as well as program bugs. Additionally, to provide safe drug therapy to patients, pharmacists must inspect the medical devices used in drug therapy when visiting hospital wards and patients' homes.

Infecciones del sistema nervioso central asociadas a dispositivos de derivación de LCR en niños, en un centro neuro-quirúrgico de referencia nacional / Central nervous system infections associated with CSF shunt devices in children, at a national reference hospital

INTRODUCCIÓN: Las infecciones asociadas a dispositivos de derivación de LCR son una complicación frecuente en su utilización. Lo más habitual es la presencia de cocáceas grampositivas, como Staphylococcus coagulasa negativa (50% en algunas series) y Staphylococcus aureus. Esta complicación agrega morbimortalidad al paciente neuroquirúrgico, aumentando la estadía hospitalaria y los costos de tratamiento. OBJETIVO: Conocer la incidencia de infecciones asociadas a dispositivos de derivación de LCR en un centro de referencia nacional. METODOLOGÍA: Estudio descriptivo, retrospectivo. Se recolectó la información de los pacientes pediátricos (bajo 18 años) entre 2018 y 2019. Se realizó un análisis estadístico descriptivo e inferencial utilizando el lenguaje estadístico R 3.4.0 y RStudio 1.3.9. Se calculó la incidencia acumulada para cada procedimiento, evaluando si existe diferencias significativas entre ellas. Estudio aprobado por el Comité de Ética Pediátrico del SSMO. RESULTADOS: En el período estudiado se realizaron 175 cirugías. Encontramos 19 casos de ventriculitis asociada a derivativa ventriculo-peritoneal y 7 casos en derivativa ventricular-externa. Los agentes más frecuentes fueron las cocáceas grampositivas. No se logró identificar factores de riesgo significativos.

BACKGROUND: Infections associated with CSF shunt devices are a frequent complication in their use. The most common is the presence of gram positive coccaceae, such as coagulase negative Staphylococcus (50% in some series) and Staphylococcus aureus. This complication adds morbidity and mortality to the neurosurgical patient, increasing hospital stay and treatment costs. AIM: To determine the incidence of infections associated with CSF shunt devices in a national referral center. METHODS: Retrospective, descriptive study. Information was collected on pediatric patients between 2018 and 2019. A descriptive and inferential statistical analysis was performed using the statistical language R 3.4.0 and RStudio 1.3.9. The cumulative incidence for each procedure was calculated, evaluating whether there were significant differences between them. This study was approved by the Pediatric Ethics Committee of the SSMO. RESULTS: In the period studied, 175 surgeries were performed. We found 19 cases of ventriculitis associated with ventriculoperitoneal derivative and 7 cases in ventricular-external derivative. The most frequent agents were grampositive coccaceae. It was not possible to identify significant risk factors.

Incidence of congenital anomalies in newborn in tertiary care hospital

Background: Just about three decades ago (1976) congenital malformations comprised 8% of perinatal deaths, from available data and ranked fifth as a cause of perinatal mortality. But the trend is rapidly changing over the years. perinatal death was due to congenital malformation, is the second commonest cause. This changing trend over years warns us that with the control of nutritional and infectious diseases, congenital malformations will come to the forefront as it is in India. To find out the incidence of congenital anomalies in stillbirth. And the probable etiology of congenital anomalies.Methods: The study was conducted at Government Mohan Kumaramangalam Medical College Hospital, Salem in the year 2017 August- September 2018. Totally 5000 babies born of consecutive deliveries were taken for the study, over the period of one year. All mothers were interrogated within 48 Hours of delivery as per the proforma prepared, which contains the following particulars like, maternal and paternal age, consanguinity, detailed antenatal history with reference to exposure to teratogens, especially during 1st Trimester.Results: Of the five thousand consecutive deliveries 48 deliveries were multiple delivers and a number of stillbirths were 108. The incidence of congenital anomalies was 30.4 per 1000 live birth (152 cases). Major malformations were present in 20.8 per 1000 (104 cases) while minor malformations were 9.6 per 1000 (48 cases).Conclusions: Incidence of malformation were higher in preterm babies 6.31%. Incidence of malformations were higher in male babies, especially genitourinary system anomalies. Antenatal events in the 1st trimester like fever, drug intake could be implicated in the etiology of malformations especially neural tube defects in our study.

High Intra-Abdominal Pressure Secondary to Obesity as a Determining Factor for Ventriculoperitoneal Shunt Malfunction

The ventriculoperitoneal shunt (VPS) is an established treatment for hydrocephalus. The functioning of the system requires a pressure difference between the cranial and abdominal cavities. The VPS can be particularly problematic in patients with increased intra-abdominal pressure (IAP). We report the case of a 16-year-old girl with VPS since she was 2 months old due to hydrocephalus secondary to myelomeningocele. The patient had been asymptomatic ever since, but she sought the emergency service with intermittent headache and vomiting. A non-enhanced brain tomography, a shunt trajectory X-ray and an abdominal ultrasound revealed no cause of system malfunction. In view of the persistent clinical picture, a revision of the shunt was performed, which revealed adequate intraoperative functioning. She returned with the same symptoms two weeks after surgery. The patient was obese (body mass index [BMI]: 48). We hypothesized intermittent valve malfunction due to increased intra-abdominal pressure. She underwent a ventriculoatrial shunt, without intercurrences. In the postoperative period, the patient presented transient tachycardia and was asymptomatic at the 6-month follow-up. Obesity should be considered an important variable for the inadequate functioning of the VPS due to increased IAP and catheter dystocia to the extraperitoneal cavity. Studies have already correlated the IAP with the BMI, which reaches between 8 mm Hg and 12 mm Hg in obese individuals. Therefore, the BMI can be considered during the selection of valve pressure in systems with non-adjustable valves to prevent insufficient drainage. The recognition of obesity as a cause of VPS malfunction is fundamental to avoid unnecessary surgeries and intermittent malfunction of the system.

A derivação ventriculoperitoneal (DVP) é um tratamento estabelecido para a hidrocefalia; contudo, algumas variáveis podem influenciar na eficácia desta modalidade. O funcionamento do sistema requer uma diferença de pressão entre as cavidades craniana e abdominal. A DVP pode ser particularmente problemática em pacientes com aumento da pressão intra-abdominal (PIA). Neste artigo, relatamos o caso de uma paciente do sexo feminino, de 16 anos, portadora de DVP desde os 2 meses de idade por hidrocefalia secundária a mielomeningocele. Desde então assintomática, procurou o pronto-socorro com queixa de cefaleia e vômitos intermitentes. Uma tomografia de crânio sem contraste, um raio X (RX) do trajeto do cateter distal, e uma ultrassonografia (USG) abdominal não evidenciaram a causa do mau funcionamento do sistema. Diante do quadro persistente, realizou-se uma revisão da derivação, que mostrou funcionamento adequado no período intraoperatório. A paciente retornou com os mesmos sintomas duas semanas após a cirurgia. A paciente era obesa (índice de massa corporal [IMC]: 48). Aventou-se possível funcionamento intermitente da válvula pelo aumento da PIA. A paciente foi submetida a uma derivação ventrículo-atrial, que foi realizada sem intercorrências. No pós-operatório, ela apresentou quadro transitório de taquicardia, e não apresentou sintomas no acompanhamento feito depois de 6 meses. A obesidade deve ser considerada uma variável importante para o funcionamento inadequado da DVP, pelo aumento da PIA e pela associação com distocia do cateter para a cavidade extraperitoneal. Estudos já correlacionaram a PIA com o IMC, que pode atingir entre8 mm Hg e 12 mm Hg em obesos. Logo, o IMC pode ser considerado na seleção da pressão da válvula em sistemas com válvulas não ajustáveis, para prevenir a drenagem insuficiente. O reconhecimento da obesidade de risco para o mau funcionamento da DVP é fundamental para evitar cirurgias desnecessárias e o mau funcionamento intermitente do sistema.

A Case Report of Re-mitral Prosthetic Valve Replacement due to Björk-Shiley Delrin Valve Malfunction after a 38-Year Duration / 日本心臓血管外科学会雑誌

The patient was a 57-year-old man who, in 1973, at 19 years of age, had undergone mitral valve replacement for mitral valve stenosis using a Björk-Shiley Delrin (BSD) valve. When the patient visited our hospital, he was living in an assisted-living facility due to paresis of the right side of the body, dysarthria, and other sequelae of cerebral infarction. The patient was referred to and visited our hospital with a chief complaint of chest pain in 2011, 38 years after the BSD valve was implanted. In 2012, mitral valve re-replacement, aortic valve replacement, and tricuspid annuloplasty were performed for congestive heart failure associated with prosthetic valve failure, combined aortic stenosis and insufficiency, and tricuspid insufficiency, which were identified by transesophageal echocardiography. The patient's postoperative course was generally favorable. The disc of the resected prosthetic valve showed a groove and bidirectional cracks caused by wear, and its condition suggested a risk of potential rupture. Transthoracic echocardiography on admission showed mild to moderate prosthetic transvalvular regurgitation, and the symptoms were therefore unlikely to have resulted from the prosthetic valve failure alone at this time. Consequently, it was considered that the heart failure was attributed to the prosthetic transvalvular regurgitation caused by the disc abnormalities in addition to the combined valvular disease by transesophageal echocardiography. In this case, detailed investigation of the heart failure by transesophageal echocardiography led to the discovery of prosthetic valve abnormalities, thus enabling the prevention of a serious cardiac accident due to disc rupture. Detailed examination by transesophageal echocardiography is essential, and early surgical intervention should also be considered if transthoracic echocardiography suggests even a minor prosthetic valve abnormality in a patient who has had this prosthetic valve implanted for such a long time.

The current progress in the mechanism of insulin malfunction in central nervous system leading to the spo-radic type of Alzheimer's disease and its applications / 医学研究生学报

Alzheimer's disease is the most common disease which causes dementia in senior citizens. It is a neurodegenerative disease which is characterized by the degradation of the neurons and synapses in the brain. Usually,the irreversible and progressive neuron loss particular in the regions of cortex and hippocampus,the plaques of the accumulation of amyloidosis outside the cells,as well as the neurofibrillary tangles which is made by the hyperphosphorylation of Tau microtubule proteins can be seen in the lesion loca-tion of the patients. The Insulin malfunction in the central nervous system is now regarded as an important pathogenesis of Alzheimer's disease. This review focuses on the development of the knowledge of the mechanism of the malfunction of insulin in the central nervous system leading to the sporadic type of Alzheimer's disease and its applications,aiming to provide a reference in the study of Alzheimer 's disease.

Cerebrospinal Fluid Lumbar Tapping Utilization for Suspected Ventriculoperitoneal Shunt Under-Drainage Malfunctions

OBJECTIVE: The diagnosis of shunt malfunction can be challenging since neuroimaging results are not always correlated with clinical outcomes. The purpose of this study was to evaluate the efficacy of a simple, minimally invasive cerebrospinal fluid (CSF) lumbar tapping test that predicts shunt under-drainage in hydrocephalus patients. METHODS: We retrospectively reviewed the clinical and radiological features of 48 patients who underwent routine CSF lumbar tapping after ventriculoperitoneal shunt (VPS) operation using a programmable shunting device. We compared shunt valve opening pressure and CSF lumbar tapping pressure to check under-drainage. RESULTS: The mean pressure difference between valve opening pressure and CSF lumbar tapping pressure of all patients were 2.21±24.57 mmH₂O. The frequency of CSF lumbar tapping was 2.06±1.26 times. Eighty five times lumbar tapping of 41 patients showed that their VPS function was normal which was consistent with clinical improvement and decreased ventricle size on computed tomography scan. The mean pressure difference in these patients was −3.69±19.20 mmH₂O. The mean frequency of CSF lumbar tapping was 2.07±1.25 times. Fourteen cases of 10 patients revealed suspected VPS malfunction which were consistent with radiological results and clinical symptoms, defined as changes in ventricle size and no clinical improvement. The mean pressure difference was 38.07±23.58 mmH₂O. The mean frequency of CSF lumbar tapping was 1.44±1.01 times. Pressure difference greater than 35 mmH₂O was shown in 2.35% of the normal VPS function group (2 of 85) whereas it was shown in 64.29% of the suspected VPS malfunction group (9 of 14). The difference was statistically significant (p=0.000001). Among 10 patients with under-drainage, 5 patients underwent shunt revision. The causes of the shunt malfunction included 3 cases of proximal occlusion and 2 cases of distal obstruction and valve malfunction. CONCLUSION: Under-drainage of CSF should be suspected if CSF lumbar tapping pressure is 35 mmH₂O higher than the valve opening pressure and shunt malfunction evaluation or adjustment of the valve opening pressure should be made.

Troubleshooting of GE discovery MR 7503.0 T magnetic resonance imaging / 国际生物医学工程杂志

The GE discovery MR 7503.0 T magnetic resonance imaging is an advanced magnetic resonance imaging system. The troubleshooting and maintenance of this system is a complex systems engineering. The common failures of MR 750 MRI were analyzed, and the cause of the malfunction, treatment methods, and routine maintenance methods were introduced.

Salt Sensitivity and Hypertension: A Paradigm Shift from Kidney Malfunction to Vascular Endothelial Dysfunction

Hypertension is a complex trait determined by both genetic and environmental factors and is a major public health problem due to its high prevalence and concomitant increase in the risk for cardiovascular disease. With the recent large increase of dietary salt intake in most developed countries, the prevalence of hypertension increases tremendously which is about 30% of the world population. There is substantial evidence that suggests some people can effectively excrete high dietary salt intake without an increase in arterial BP, and another people cannot excrete effectively without an increase in arterial BP. Salt sensitivity of BP refers to the BP responses for changes in dietary salt intake to produce meaningful BP increases or decreases. The underlying mechanisms that promote salt sensitivity are complex and range from genetic to environmental influences. The phenotype of salt sensitivity is therefore heterogeneous with multiple mechanisms that potentially link high salt intake to increases in blood pressure. Moreover, excess salt intake has functional and pathological effects on the vasculature that are independent of blood pressure. Epidemiologic data demonstrate the role of high dietary salt intake in mediating cardiovascular and renal morbidity and mortality. Almost five decades ago, Guyton and Coleman proposed that whenever arterial pressure is elevated, pressure natriuresis enhances the excretion of sodium and water until blood volume is reduced sufficiently to return arterial pressure to control values. According to this hypothesis, hypertension can develop only when something impairs the excretory ability of sodium in the kidney. However, recent studies suggest that nonosmotic salt accumulation in the skin interstitium and the endothelial dysfunction which might be caused by the deterioration of vascular endothelial glycocalyx layer (EGL) and the epithelial sodium channel on the endothelial luminal surface (EnNaC) also play an important role in nonosmotic storage of salt. These new concepts emphasize that sodium homeostasis and salt sensitivity seem to be related not only to the kidney malfunction but also to the endothelial dysfunction. Further investigations will be needed to assess the extent to which changes in the sodium buffering capacity of the skin interstitium and develop the treatment strategy for modulating the endothelial dysfunction.

Acute Shunt Malfunction Caused by Percutaneous Endoscopic Gastrostomy without Shunt Infection

Percutaneous endoscopic gastrostomy tube placement is often performed in patients with a ventriculoperitoneal shunt and it has been accepted as a safe procedure. The authors report a case of a 50-year-old male who developed acute exacerbation of the hydrocephalus immediately after the percutaneous endoscopic gastrostomy tube placement without any signs of shunt infection, which has not been reported until now. After revision of the intraperitoneal shunt catheter, the sizes of the intracranial ventricles were normalized.

Prophylactic and dealing methods of the common malfunctions of electronic gastroscopy / 中国医学装备

To introduce the prophylaxis methods and dealing experiences of the common malfunctions of electronic gastroscopy. To summarize the prophylaxis methods and dealing experiences of the common malfunctions of electronic gastroscopy in recent years. To do everything carefully in the prophylaxis of the common malfunctions could ensure the high definition and resolution of the electronic gastroscopy. To manipulate properly with effective methods of preventing and dealing common malfunctions in use of electronic gastroscopy can not only lower the cost of repair but also prolong the service life of the machine.

Analysis on the troubleshooting of continuous blood purification machine malfunction in the clinical use / 中国医学装备

Objective: To provide a basis for proper use of the continuous blood purification machine through analysis of its malfunction related factors. Methods: Through study of using continuous blood purification machine by Baxter Aquarius in four of the best hospitals in Shanghai for the past three years, lists frequent incidences of malfunction classification, causes, and treatment methods based on statistics on the process of using the alarm malfunction, and solved malfunction by manufacturer’s engineers. Results:To provide clinical guidance for operation of CRRT equipment, improve the safe and stable operating condition through comparison and analysis of the continuous blood purification machine malfunction. Conclusion: The regular maintenance and proper use of clinical operations will help the stability of operating condition of the continuous blood purification machine.

Asymptomatic Fracture of a Distal Shunt Catheter after Ventriculoperitoneal Shunt for Post-traumatic Hydrocephalus / 대한소아신경학회지

A fracture of a distal shunt catheter is a rare complication. In many cases of shunt failure, shunt revision should be performed to prevent the development of hydrocephalus. However, the question of whether to operate on asymptomatic patients remains to be answered. Our patient received a ventriculoperitoneal shunt due to post-traumatic hydrocephalus, and his symptoms improved. Abdominal x-ray revealed a fracture of the distal shunt catheter at the 5- year follow-up. However, the patient was asymptomatic. In this case, the patient improved without shunt revision during the year after the fracture of the distal shunt catheter.

Laryngeal mask airway (LMA-ProSeal™) malfunction causing acute airway obstruction

The Laryngeal Mask Airway ProSeal™ (LMA-ProSeal™; Laryngeal Mask Company Limited) is a reusable supraglottic airway device developed to enhance supraglottic airway protection and extend the benefits of the classic LMA (Laryngeal Mask Airway) to greater number of patients. Added features include an additional drain tube to channel fluid away from the airway and a tighter seal against the glottic opening with no increase in mucosal pressure. Clinicians have extended the use of the LMA-ProSeal™ inside and outside the operating theatre including use for difficult airway management and airway rescue. However, even these new devices have their limitations. We report an unforeseen acute airway obstruction caused by LMA-ProSeal™ malfunction during ophthalmic surgery. The cuff of the device was deformed with herniation to one side upon insufflation of the balloon.

The influence of sealing tube with urokinase on the malfunction of central venous catheter with Dacron ring / 中国基层医药

Objective To explore the effect of sealing tube with regular urokinase for the malfunction of central venous catheter(CVC) in patients with hemodialysis (HD).Methods This was a prospective randomized controlled study,132 HD patients with cuff CVC were studied.In the early stage,52 H D patients without 80 patients with regular catheter-locking solution of urokinase.To analyze effect of cuff CVC malfunction,blood flow(BF),dialysis adequacy,anemia and serum albumin (ALB) with regular catheter-locking solution of urokinase.The incidence of catheter malfunction was calculated based on the catheter dysfunction in the first 3 months.Clinical index was measured,recorded BF and calculated urea clearance rate (Kt/V).Results HD patients catheter-locking solution with regular urokinase could reduce the incidence of dialysis catheter malfunction ( 26.3％ vs 32.7％,x2 =32.727,P ＜0.01 ),increase the BF,Kt/V,levels of hemoglobin(HGB) and ALB(P＜0.05 or P ＜0.01).Conclusion Regular catheter-locking solution with urokinase is effective in reducing HD patients incidence of dialysis CVC malfunction,increasing patients BF,dialysis adequacy and the level of ALB,improving anemia.

Does CSF composition predict shunt malfunction in Tuberculous Meningitis.

Background: Hydrocephalus secondary to tuberculous meningitis (TBM) continues to be a challenging condition to treat for neurosurgeons in developing countries. Shunt complications are reportedly more frequent in patients undergoing ventriculo-peritoneal shunt in patients with TBM than in those undergoing shunt surgeries for other causes. Aim: The aim of this study was to evaluate the relationship of cerebrospinal fluid (CSF) composition on shunt malfunction. Methods: We compared the CSF composition of 53 patients who had shunt malfunction during a five year period with that of 137 matched controls. Results: Patients who had shunt malfunction had a significantly higher concentration of CSF protein. The CSF cellularity and glucose concentration did not have any significant bearing in predicting shunt malfunction. Patients with CSF protein concentration of more than 200 mg/dL had a four times higher risk of having shunt malfunction than those with a concentration of less than 100 mg/dL. Patients with CSF protein in the 100-200 mg/dL range represent an intermediate zone. Conclusion: To conclude, patients with CSF protein concentration of more than 200 mg/dL have a significantly higher risk of shunt malfunction and hence have to be followed up closely.

Principales caracteristicas clinicoepidemiológicas de pacientes con fibrosis quística en la provincia de Santiago de Cuba / Main clinical-epidemiological characteristics of patients with cystic fibrosis in Santiago de Cuba province

Se efectuó un estudio descriptivo y transversal durante el 2008 para determinar las principales características clinicoepidemiológicas de los 34 pacientes con fibrosis quística en la provincia de Santiago de Cuba, atendidos por el Grupo Provincial de esta especialidad. En la casuística primaron las siguientes variables: sexo masculino, piel amarilla, procedentes del municipio de Santiago de Cuba, bajo peso, con síntomas y diagnóstico de la enfermedad en la primera década de la vida e infección respiratoria; esta última como principal complicación. Entre los síntomas más frecuentes figuraron: tos, expectoración, dolor abdominal, apetito voraz, así como forma mixta según tipo de presentación, que fue además la causante del mayor número de ingresos; entre los resultados de otras pruebas predominaron, por citar algunos: disfunción ventilatoria obstructiva moderada, mutación genética DF 508 homocigótico, así como aislamiento de la Pseudomonas aeuruginosa en el esputo y estreptococo beta hemolítico en el exudado nasofaríngeo

A descriptive and cross-sectional study was carried out during 2008 in order to determine the main clinical-epidemiological characteristics of 34 patients with cystic fibrosis in Santiago de Cuba province assisted by the Provincial Group of this field. In the case material, the following variables: male sex, yellow skin, residents in Santiago de Cuba municipality, low weight, presenting symptoms and the diagnosis of a disease during the first decade of life and respiratory infection, the latter as main complication, were relevant. Among the symptoms, the most frequent were cough, expectoration, abdominal pain, voracious appetite, as well as the mixed form according to the occurrence type which also was the cause of the major number of admissions. Among the results of some other tests, just for quoting some examples, mild obstructive breathing malfunction, homozygotic DF 508 genetic mutation as well as isolation of the Pseudomonas aeuruginosa in the sputum and hemolytic ¦Â-streptococcus in the nasopharyngeal exudate were predominant

Iliac Vein Injury Due to a Damaged Hot Shearstrade mark Tip Cover During Robot Assisted Radical Prostatectomy

We report a rare case of vascular injury secondary to a damaged Hot Shearstrade mark tip cover. Two 1 mm holes in the tip cover resulted in perforations in the obturator and external iliac veins during pelvic node dissection. Bleeding was controlled with bipolar coagulation and a 5 mm metal clip in the obturator and iliac vein, respectively. The rest of the procedure was completed uneventfully. Frequent integrity assessment of this accessory is necessary. Its function is important in order to carry out safe dissection in proximity to delicate structures. When injuries arise from areas not directly involved in the dissection, immediate inspection of the instruments should be mandatory.

Spinal cord stimulator malfunction caused by radiofrequency neuroablation: A case report / 대한마취과학회지

The implantation of spinal cord stimulators (SCSs) to treat chronic intractable pain is steadily increasing. And there is an increased likelihood of instances where other therapies or procedures are found to interfere with SCS function, which in turn may result in pain. Since SCS utilize electric impulses as well as magnets, special considerations need for patients with a SCS in situ who require these procedures. The present report describes a case where radiofrequency (RF) ablation of the third occipital nerve resulted in spontaneous activation of a cervical SCS device.

A Unique Instrumental Malfunction during Robotic Prostatectomy

Over the past decade, the introduction of robotics in the field of medicine has provided a new approach to patients requiring surgery, and both its advantages and disadvantages are currently under study by many groups worldwide. The use of robotics has especially been considered by the urological community as a treatment option in radical prostatectomy. The current case report is one in which the da Vinci Surgical Systemtrade mark, with fourth arm use was employed in radical prostatectomy. This case presents a unique occurrence in which a bolt of the Prograsper forcep became loose during an operation, leading to diminished device functionality and later impedance of its removal. A circumstance such as this has not previously been reported, so we introduce for other robotic surgeons our unique instrumental malfunction case during a robotic prostatectomy.