OLYMPUS XCYF-1T3 OES CYSTOFIBERSCOPE/NEPHROFIBERSCOPE ACCESSORIES AND ANCILLARY EQUIPMENT

K993041 · The Olympus Optical Co. · FAJ · Mar 30, 2000 · Gastroenterology, Urology

Device Facts

• Record ID: K993041
• Device Name: OLYMPUS XCYF-1T3 OES CYSTOFIBERSCOPE/NEPHROFIBERSCOPE ACCESSORIES AND ANCILLARY EQUIPMENT
• Applicant: The Olympus Optical Co.
• Product Code: FAJ · Gastroenterology, Urology
• Decision Date: Mar 30, 2000
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 876.1500
• Device Class: Class 2
• Attributes: Therapeutic

Indications for Use

The Olympus XCYF-1T3 OES CYSTOFIBERSCOPE/NEPHROFIBERSCOPE, accessories and ancillary equipment have been specifically designed to be used in endoscopic diagnosis and treatment within the bladder, urethra and kidney. Do not use these instruments for any purpose other than their intended use.

Device Story

The Olympus XCYF-1T3 is a fiber-optic cystofiberscope/nephrofiberscope used for visualization and therapeutic intervention in the bladder, urethra, and kidneys. It functions as a conduit for endoscopic tools, allowing physicians to perform diagnostic and electrosurgical procedures. The device transmits light and images via fiber optics to an external display monitor. It is operated by a physician in a clinical or surgical setting. The device features a large instrument channel to facilitate the passage of endo-therapy accessories. By providing direct visualization and access to the urinary tract, it enables minimally invasive diagnosis and treatment, potentially reducing patient trauma compared to open surgery.

Clinical Evidence

Bench testing only. The device was manufactured and tested according to voluntary safety standards IEC60601-1 and IEC60601-2-18.

Technological Characteristics

Fiber-optic endoscope; large instrument channel; compatible with electrosurgical units, light sources, and documentation equipment. Designed for use in the bladder, urethra, and kidneys. Complies with IEC60601-1 and IEC60601-2-18 safety standards.

Indications for Use

Indicated for endoscopic diagnosis and treatment within the bladder, urethra, and kidneys. Used with light sources, documentation equipment, display monitors, suction pumps, endo-therapy accessories, and electrosurgical units.

Regulatory Classification

Identification

An endoscope and accessories is a device used to provide access, illumination, and allow observation or manipulation of body cavities, hollow organs, and canals. The device consists of various rigid or flexible instruments that are inserted into body spaces and may include an optical system for conveying an image to the user's eye and their accessories may assist in gaining access or increase the versatility and augment the capabilities of the devices. Examples of devices that are within this generic type of device include cleaning accessories for endoscopes, photographic accessories for endoscopes, nonpowered anoscopes, binolcular attachments for endoscopes, pocket battery boxes, flexible or rigid choledochoscopes, colonoscopes, diagnostic cystoscopes, cystourethroscopes, enteroscopes, esophagogastroduodenoscopes, rigid esophagoscopes, fiberoptic illuminators for endoscopes, incandescent endoscope lamps, biliary pancreatoscopes, proctoscopes, resectoscopes, nephroscopes, sigmoidoscopes, ureteroscopes, urethroscopes, endomagnetic retrievers, cytology brushes for endoscopes, and lubricating jelly for transurethral surgical instruments. This section does not apply to endoscopes that have specialized uses in other medical specialty areas and that are covered by classification regulations in other parts of the device classification regulations.

Special Controls

*Classification* —(1)*Class II (special controls).* The device, when it is an endoscope disinfectant basin, which consists solely of a container that holds disinfectant and endoscopes and accessories; an endoscopic magnetic retriever intended for single use; sterile scissors for cystoscope intended for single use; a disposable, non-powered endoscopic grasping/cutting instrument intended for single use; a diagnostic incandescent light source; a fiberoptic photographic light source; a routine fiberoptic light source; an endoscopic sponge carrier; a xenon arc endoscope light source; an endoscope transformer; an LED light source; or a gastroenterology-urology endoscopic guidewire, is exempt from the premarket notification procedures in subpart E of part 807 of this chapter subject to the limitations in § 876.9.(2) Class I for the photographic accessories for endoscope, miscellaneous bulb adapter for endoscope, binocular attachment for endoscope, eyepiece attachment for prescription lens, teaching attachment, inflation bulb, measuring device for panendoscope, photographic equipment for physiologic function monitor, special lens instrument for endoscope, smoke removal tube, rechargeable battery box, pocket battery box, bite block for endoscope, and cleaning brush for endoscope. The devices subject to this paragraph (b)(2) are exempt from the premarket notification procedures in subpart E of part 807of this chapter, subject to the limitations in § 876.9.

In combination with the general controls of the FD&C Act, the integrated operating table-electromechanical surgical system is subject to the following special controls: 1. (1) Premarket clinical performance testing, or a combination of premarket clinical performance testing and postmarket surveillance (in accordance with special control (2)), must include the following: 1. (i) Objective performance measures (e.g., rate and number of conversions to other surgical modalities, rate of device related adverse events (including tissue injury, hematoma, and increased blood loss), and their severity, cause, and outcomes) must be reported with relevant descriptive comparator performance measures. 2. (ii) The data must demonstrate the performance of the device for providing accurate and precise control of attached surgical instruments in range of clinical conditions relevant to the device's intended use. 3. (iii) The test dataset must include data collected from a patient population representative of the intended patient population under anticipated conditions of use. 2. (2) Data obtained from postmarket surveillance must demonstrate, in consideration of the premarket data obtained in accordance with special control (1), that the device performs in accordance with special control (1), unless FDA determines, based on the totality of the premarket data, that data from postmarket surveillance is not required to demonstrate that the device performs as intended. Such postmarket surveillance must be conducted per a protocol determined appropriate by FDA to demonstrate that the device performs as intended (in consideration of the premarket data obtained in accordance with special control (1)), and must include initiation, enrollment, and reporting requirements to ensure timely periodic updates to FDA on post-market surveillance progress and outcomes. 3. (3) Animal performance testing must evaluate the extent of port site trauma due to repositioning of table during surgical procedures when utilizing robotic minimally invasive and laparoscopic approaches 4. (4) The device manufacturer must develop, and update as necessary, a device-specific use training program that ensures proper device setup/use/shutdown, accurate control of instruments to perform the intended surgical procedures, troubleshooting and handling during unexpected events or emergencies, and safe practices to mitigate use error. 5. (5) The device manufacturer may only distribute the device to facilities that implement and maintain the device-specific use training program and ensure that users of the device have completed the device-specific use training program. (6) Human factors assessment must demonstrate that the user can correctly use the device system across all intended use environments with the provided instructions and training materials, including patient access during normal operating conditions and emergency situations, and effects arising from the integrated nature of the operating table and robotic surgical arms. (7) Labeling must include: (i) A detailed summary of clinical performance testing conducted with the device, including study population, results, adverse events, and comparisons to any comparator groups identified; (ii) A statement in the labeling that the safety and effectiveness for the representative specific procedures was based on evaluation of the device as a surgical tool and did not include evaluation of outcomes related to the treatment of the patient's underlying disease or condition, unless FDA determines that it can be removed or modified based on clinical performance data submitted to FDA; (iii) Identification of compatible devices; (iv) The list of surgical procedures for which the device has been determined to be safe with clinical justification; (v) Reprocessing instructions for reusable components; (vi) A shelf life for any sterile components; (vii) A description of the device-specific use training program; (viii) A statement that the device is only for distribution to facilities that implement and maintain the device-specific use training program and ensure that users of the device have completed the device-specific use training program; and (ix) A summary of any completed postmarket surveillance data collected as required by special control (2), including updated labeling to accurately reflect outcomes observed in postmarket surveillance. (8) Non-clinical performance testing must demonstrate that the device performs as intended under anticipated conditions of use and must include: (i) Device motion accuracy and repeatability; (ii) System testing; (iii) Instrument reliability; (iv) Crosstalk; (v) Table motion control; (vi) Thermal effects on tissue; (vii) User-device interface performance; (viii) Workspace access testing; and (ix) Performance testing with compatible devices. (9) Software verification, validation, and hazard analysis must be performed. (10) Electromagnetic compatibility and electrical, thermal, and mechanical safety testing must be performed. (11) Performance data must demonstrate the sterility of all patient-contacting device components. (12) Performance data must support the shelf life of the device components provided sterile by demonstrating continued sterility and package integrity over the labeled shelf life. (13) Performance data must validate the reprocessing instructions for the reusable components of the device. (14) Performance data must demonstrate that all patient-contacting components of the device are biocompatible. (15) Performance data must demonstrate that all patient-contacting components of the device are non-pyrogenic. (16) The device manufacturer must submit a report to the FDA annually on the anniversary of initial marketing authorization for the device, until such time as FDA may terminate such reporting, which comprises the following information: (i) Cumulative summary, by year, of complaints and adverse events since date of initial marketing authorization; and (ii) Identification and rationale for changes made to the device, labeling, or device specific use training program, which did not require submission of a premarket notification during the reporting period.

Predicate Devices

• Olympus Nephroscope/Cystoscope (K843084)
• Infant Resectoscope & Accessories (K904940)

Reference Devices

• Olympus Nephroscope/Cystoscope Model CHF-P10

Submission Summary (Full Text)

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Image /page/0/Picture/0 description: The image is a black and white logo for the U.S. Department of Health & Human Services. The logo is circular in shape, with the words "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" arranged around the top half of the circle. In the center of the circle is a stylized image of an eagle, with its wings spread and its head turned to the left.

Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002

The Olympus Optical Company % Robert Schiff, Ph.D., RAC, CQA (ASQC) President Schiff & Company 1129 Bloomfield Avenue West Caldwell, NJ 07006

JUL 2 7 2015

Re: K993041

> Trade/Device Name: Olympus XCYF - 1T3 OES Cystofiberscope/Nephrofiberscope Regulation Number: 21 CFR 876.1500 Regulation Name: Endoscope and accessories Regulatory Class: II Product Code: FAJ, FGA, FDI, KGE, KNS, FCL Dated (Date on orig SE ltr): March 14, 2000 Received (Date on orig SE ltr): March 15, 2000

Dear Dr. Schiff,

This letter corrects our substantially equivalent letter of March 30, 2000.

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be

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found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting (reporting of medical device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Division of Small Manufacturers. International and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Also, please note the regulation entitled. "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to

http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm.

Sincerely yours,

# Benjamin R. Fisher -S

Benjamin R. Fisher, Ph.D. Director Division of Reproductive, Gastro-Renal, and Urological Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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K993041

:

# OLYMPUS!

# INDICATIONS FOR USE STATEMENT

510(k) Number (if known): Not assigned yet Oiympus XCYF-1 T3 OES CYSTOFIBESCOPE/ Device Name: NEPHROFIBERSCOPE, accessories and ancillary equipment.

Indications for Use:

These instruments have been designed to be used with an Olympus Light Source, Documentation Equipment, Display Monitor, Suction Pump, Endo-Therapy Accessories, elecrosurgical Unit, and other ancillary equipment for endoscopic diagnosis and treatment within the bladder, urethra, and kidneys.

Do not use this instrument for any purpose other than its intended use.

(Please Do Not WRITE BELLOW THIS LINE-CONTINUE ON ANOTHER PAGE IF NEEDED) ASE BO NOT WARE BEES AND A BELLE - SE - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Concurrence of CDRH, Office of Device Evaluation(ODE)

Prescription Use
(Per 21 CFER 801.109) OR Over-The-Counter Use
(Optional Format 1-2-96)

(Division Sign-Off)
Division of Reproductive, Abdominal, ENT,
and Radiological Devices
510(k) Number K993041

# OLYMPUS OPTICAL CO., LTD.

2951, Ishikawacho, Hachioji, Tokyo, Japan TEL. [phone] FAX [phone]

011

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MAR 3 0 2000

510(k) Premarket Notification Olympus Optical Co., Ltd. OES Cystofiberscope/Nephrofiberscope

K993041
pg 1 of 3

## 510(k) SUMMARY

### OLYMPUS XCYF-1T3

# OES CYSTOFIBERSCOPE/NEPHROFIBERSCOPE

#### Submitter's Name, Address, Phone and Fax Numbers A.

Name & Address of manufacturer:

Olympus Optical Co., Ltd.

22-2 Nishi-Shinjuku, 1-Chome,

Shinjuku-ku, Tokyo 163-8610

Japan

Registration No:

8010047

Address, Phone and Fax Numbers:

2951 Ishikawa-Cho,

Hachioji-shi, Tokyo 192-8507, Japan

R&D Department, Endoscope Division

Tel: [phone]

Fax: [phone]

#### B. Name of Contact Person

Tadahiko Ogasawara

Prepared by Schiff & Company

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### C. Trade Name, Common Name, Classification Number, Classification

Trade Name :

Olympus XCYF - 1T3

OES Cystofiberscope/Nephrofiberscope

Accessories and Ancillary Equipment

Common Name:

Classification Number:

Cystofiberscope/Nephrofiberscope

21 CFR 876.1500 Endoscopes and

Accessories

Predicate Device

Classification :

K843084 Olympus Nephroscope/Cystoscope K904940 Infant Resectoscope & Accessories

#### Description of the Device D.

The Olympus XCYF-1T3 OES CYSTOFIBERSCOPE/NEPHROFIBERSCOPE has been specifically designed to be used with an Olympus Light Source, documentation, equipment, and display monitor. The XCYF-1T3 is equipped with a large Instrument Channel of bright optical quality compared to the

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K993041

### 510(k) Premarket Notificatio Olympus Optical Co., L OES Cystofiberscope/Nephrofiberscope

pg 3 of 3

predicate device, XCYF-1T3. These characteristics facilitate operation under endoscopic-surgery including high-frequency treatment within the bladder, urethra and kidnev.

# E. Intended Use of the Device(s)

The Olympus XCYF-1T3 OES CYSTOFIBERSCOPE/NEPHROFIBERSCOPE, accessories and ancillary equipment have been specifically designed to be used in endoscopic diagnosis and treatment within the bladder, urethra and kidney. Do not use these instruments for any purpose other than their intended use.

#### F. General Safety

The Olympus XCYF-1T3 OES Cystofiberscope/Nephrofiberscope is manufactured and tested according to voluntary safety standards IEC60601-1 and IEC60601-2-18. XCYF-1T3 is designed for electrosurgical treatment within the bladder, urethra and kidney. When compared to the predicate device, the Olympus Nephroscope/Cystoscope Model CHF-P10, except for the electrosurgical treatment, does not incorporate any significant change in operation, material or design that could affect safety or effectiveness.