K Number
K221557
Device Name
Visera Hysterovideoscope Olympus HYF Type V
Date Cleared
2022-09-02

(94 days)

Product Code
Regulation Number
884.1690
AI/MLSaMDIVD (In Vitro Diagnostic)TherapeuticDiagnosticis PCCP AuthorizedThirdparty
Intended Use
VISERA HYSTEROVIDEOSCOPE OLYMPUS HYF TYPE V has been designed to be used with an Olympus video system center, light source, document, display monitor, and other ancillary equipment for endoscopic diagnosis within the uterus. Do not use the instrument for any purpose other than its intended use.
Device Description
This instrument has been designed to be used with an Olympus video system center, light source, documentation equipment, display monitor, and other ancillary equipment for endoscopic diagnosis within the uterus.
More Information

No
The summary explicitly states that the device does not include software and software verification and validation testing was not performed. There is no mention of AI, ML, or image processing capabilities.

No.
The device is specifically designed for "endoscopic diagnosis within the uterus," indicating a diagnostic rather than a therapeutic purpose.

Yes
The "Intended Use / Indications for Use" and "Device Description" sections explicitly state that the device is "for endoscopic diagnosis within the uterus."

No

The device description and performance studies clearly indicate this is a hardware device (hysteroscope) used with other hardware components, and it explicitly states that software verification and validation testing was "Not applicable and not performed as the device does not include software."

Based on the provided information, this device is not an IVD (In Vitro Diagnostic).

Here's why:

  • Intended Use: The intended use is for "endoscopic diagnosis within the uterus." This involves directly visualizing the internal anatomy of the uterus using a video endoscope.
  • Device Description: The device is described as an instrument used with a video system, light source, etc., for "endoscopic diagnosis within the uterus."
  • Lack of IVD Characteristics: IVD devices are designed to examine specimens (like blood, urine, tissue) in vitro (outside the body) to provide information about a patient's health. This device operates in vivo (inside the body) for direct visualization.

The device is a medical device used for direct visualization and diagnosis within the body, not for testing samples outside the body.

N/A

Intended Use / Indications for Use

VISERA HYSTEROVIDEOSCOPE OLYMPUS HYF TYPE V has been designed to be used with an Olympus video system center, light source, document, display monitor, and other ancillary equipment for endoscopic diagnosis within the uterus. Do not use the instrument for any purpose other than its intended use.

Product codes

HIH

Device Description

This instrument has been designed to be used with an Olympus video system center, light source, documentation equipment, display monitor, and other ancillary equipment for endoscopic diagnosis within the uterus.

Mentions image processing

Not Found

Mentions AI, DNN, or ML

Not Found

Input Imaging Modality

Not Found

Anatomical Site

within the uterus

Indicated Patient Age Range

Not Found

Intended User / Care Setting

Not Found

Description of the training set, sample size, data source, and annotation protocol

Not Found

Description of the test set, sample size, data source, and annotation protocol

Not Found

Summary of Performance Studies

  1. Non-Clinical Bench Testing:

    • Thermal Safety: HYF-V. Thermal safety performance test verified compliance to Protection against excessive temperature and other safety hazards of IEC 60601-2-18:2009-08.
    • Photobiological Safety: HYF-V. The photobiological safety test verified compliance to IEC 32471:2006-07 and confirms the light emitted from subject devices connected to each light source is low enough not to cause injury to the skin and eye.
    • Noise and Dynamic Range: HYF-V. The substantial equivalence of Noise and Dynamic range between the subject device and predicate device connected with Video System Center / Light Source was confirmed and verified compliant to ISO 15739:2017.
    • Composite Durability: HYF-V. The durability test against composite stress of mechanical (angulation and wiping during reprocessing) and chemical stress demonstrates the subject device retains its safety and effectiveness against the stresses expected in its use-life.
    • Color Performance: HYF-V. The color performance of the subject devices is confirmed as substantially equivalent to the predicate devices in the WLI.
    • Image Intensity Uniformity: HYF-V. The image intensity uniformity of the subject devices is confirmed as substantially equivalent to the predicate devices.
    • Resolution: HYF-V. The resolution of the subject device is confirmed as substantially equivalent to the predicate device.
    • Direction of View: HYF-V. The direction of view test verified compliance to ISO 8600-1 and confirms that the subject device is consistent with the design specifications and does not introduce new questions related to safety and effectiveness.
    • Field of View: HYF-V. The field of view test verified compliance to ISO 8600-1 and confirms that the subject device is consistent with the design specifications and does not introduce new questions related to safety and effectiveness.
  2. Animal Test: Not applicable and not performed.

  3. Biocompatibility Evaluation: Biocompatibility of the subject device was evaluated according to ISO 10993-1 Biological Evaluation of Medical Devices-Part 1: Evaluation and Testing. The subject device passed testing for all applicable biocompatibility endpoints.

  4. Sterilization, Shelf Life, Reprocessing: HYF-V and their reusable accessories are not sterilized before shipment. Before using these instruments for the first time and between patient use the endoscopes must be cleaned and high-level disinfected and sterilized as shown in the Instruction for Use. All cleaning, disinfection, and sterilization methods were validated pursuant to FDA Guidance Reprocessing Medical Devices in Health Care Settings: Validation Methods and Labeling Guidance for Industry and Food and Drug Administration Staff, issued March 17, 2015. The reprocessing validation was conducted pursuant to the same FDA guidance document. HYF-V is validated as safe and effective for reprocessing with the following:

    • Manual Cleaning
    • Manual Disinfection with 2 - 3.5% glutaraldehyde
    • OER-Pro (K103264)
    • Sterilization with EO Gas
  5. Electrical Safety and Electromagnetic Compatibility (EMC): The HYF-V was tested for electrical safety and electromagnetic compatibility inclusive of Essential Performance Requirements in accordance with FDA recognized standards for endoscopic equipment as listed below.

    • IEC 60601-1:2005+A1:2012 Medical electrical equipment - Part 1: General requirements for basic safety and essential performance
    • IEC 60601-2-18:2009 Medical electrical equipment - Part 2-18: Particular requirements for the basic safety and essential performance of endoscopic equipment
    • IEC 60601-1-2:2014 Medical electrical equipment - Part 1-2: General requirements for basic safety and essential performance - Collateral standard: Electromagnetic compatibility - Requirements and tests (Edition 4)
  6. Software Verification and Validation Testing: HYF-V does not include any software; thus, software testing was not applicable and not performed.

  7. Risk Analysis: Risk analysis for the subject device was conducted in accordance with established in-house acceptance criteria based on ISO 14971. Design verification tests based on required risk mitigations, and their acceptance criteria were identified and performed as a result of this risk analysis assessment. These assessments confirmed that there was no unacceptable user-related residual risk for Visera Hysterovideoscope, HYF-V.

  8. Clinical Testing: Not applicable and not performed.

Key Metrics

Not Found

Predicate Device(s)

VISERA HYSTEROVIDEOSCOPE OLYMPUS HYF TYPE V K022445

Reference Device(s)

K111425, K051645, K954451, K102379, K103264

Predetermined Change Control Plan (PCCP) - All Relevant Information

Not Found

§ 884.1690 Hysteroscope and accessories.

(a)
Identification. A hysteroscope is a device used to permit direct viewing of the cervical canal and the uterine cavity by a telescopic system introduced into the uterus through the cervix. It is used to perform diagnostic and surgical procedures other than sterilization. This generic type of device may include obturators and sheaths, instruments used through an operating channel, scope preheaters, light sources and cables, and component parts.(b)
Classification. (1) Class II (performance standards).(2) Class I for hysteroscope accessories that are not part of a specialized instrument or device delivery system; do not have adapters, connectors, channels, or do not have portals for electrosurgical, laser, or other power sources. Such hysteroscope accessory instruments include: lens cleaning brush, cannula (without trocar or valves), clamp/hemostat/grasper, curette, instrument guide, forceps, dissector, mechanical (noninflatable), and scissors. The devices subject to this paragraph (b)(2) are exempt from the premarket notification procedures in subpart E of part 807 of this chapter, subject to the limitations in § 884.9.

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September 2, 2022

Olympus Medical Systems Corporation % Gary Brennan Regulatory Program Manager Olympus Corporation of the Americas 800 West Park Drive Westborough, MA 01581

Re: K221557

Trade/Device Name: VISERA HYSTEROVIDEOSCOPE OLYMPUS HYF TYPE V (HYF-V) Regulation Number: 21 CFR§ 884.1690 Regulation Name: Hysteroscope and Accessories Regulatory Class: II Product Code: HIH Dated: August 9, 2022 Received: August 11, 2022

Dear Gary Brennan:

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. Although this letter refers to your product as a device, please be aware that some cleared products may instead be combination products. The 510(k) Premarket Notification Database located at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm identifies combination product submissions. 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 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.

1

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 of medical device-related adverse events) (21 CFR 803) for devices or postmarketing safety reporting (21 CFR 4, Subpart B) for combination products (see https://www.fda.gov/combination-products/guidance-regulatoryinformation/postmarketing-safety-reporting-combination-products); good manufacturing practice requirements as set forth in the quality systems (OS) regulation (21 CFR Part 820) for devices or current good manufacturing practices (21 CFR 4, Subpart A) for combination products; and, if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to https://www.fda.gov/medical-device-safety/medical-device-reportingmdr-how-report-medical-device-problems.

For comprehensive regulatory information about mediation-emitting products, including information about labeling regulations, please see Device Advice (https://www.fda.gov/medicaldevices/device-advice-comprehensive-regulatory-assistance) and CDRH Learn (https://www.fda.gov/training-and-continuing-education/cdrh-learn). Additionally, you may contact the Division of Industry and Consumer Education (DICE) to ask a question about a specific regulatory topic. See the DICE website (https://www.fda.gov/medical-device-advice-comprehensive-regulatoryassistance/contact-us-division-industry-and-consumer-education-dice) for more information or contact DICE by email (DICE@fda.hhs.gov) or phone (1-800-638-2041 or 301-796-7100).

Sincerely,

Jason R. Roberts, Ph.D. Assistant Director DHT3B: Division of Reproductive. Gynecology and Urology Devices OHT3: Office of GastroRenal, ObGyn, General Hospital and Urology Devices Office of Product Evaluation and Quality Center for Devices and Radiological Health

Enclosure

2

Indications for Use

510(k) Number (if known) K221557

Device Name VISERA HYSTEROVIDEOSCOPE OLYMPUS HYF TYPE V (HYF-V)

Indications for Use (Describe)

VISERA HYSTEROVIDEOSCOPE OLYMPUS HYF TYPE V has been designed to be used with an Olympus video system center, light source, document, display monitor, and other ancillary equipment for endoscopic diagnosis within the uterus. Do not use the instrument for any purpose other than its intended use.

Type of Use (Select one or both, as applicable)

Prescription Use (Part 21 CFR 801 Subpart D)Over-The-Counter Use (21 CFR 801 Subpart C)

X Prescription Use (Part 21 CFR 801 Subpart D)

_ Over-The-Counter Use (21 CFR 801 Subpart C)

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K221557 Page 1 of 7

510(k) Summary

For

VISERA HYSTEROVIDEOSCOPE OLYMPUS HYF TYPE V (HYF-V)

General Information
Applicant:OLYMPUS MEDICAL SYSTEMS CORP.
2951 Ishikawa-cho, Hachioji-shi, Tokyo, Japan
192-8507
Phone: (+81) 42-642-2694
Fax: (+81) 42-642-2307
Establishment Registration Number: 8010047
Manufacturer:Shirakawa Olympus Co., Ltd.
3-1 Okamiyama, Odakura, Nishigo-mura,
Nishishirakawa-gun, Fukushima 961-8061,
Japan
Phone: (+81) 248-27-2239
Fax: (+81) 248-27-2429
Establishment Registration Number: 3002808148

Aizu Olympus Co., Ltd.
500 Muranishi, Niidera, Monden-machi,
Aizuwakamatsushi, Fukushima 965-8520, Japan
Phone: (+81) 172-52-8511
Fax: (+81) 172-52-8515
Establishment Registration Number: 9614641 |
| 510(k) Submitter: | Olympus Corporation of the Americas
3500 Corporate Parkway
Center Valley, PA 18034-0610 |
| Establishment Registration Number: | 2429304 |
| Contact Person: | Gary Brennan
Regulatory Affairs Program Manager
Mobile : (315) 877-7298
Email : Gary.Brennan@olympus.com |
| Date Prepared: | September 1, 2022 |

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K221557 Page 2 of 7

Device Description

Classification Name:Hysteroscope and accessories
Generic/Common Name:Hysteroscope
Trade Name:VISERA HYSTEROVIDEOSCOPE OLYMPUS HYF TYPE V
(HYF-V)
Model Number:HYF-V
Regulation Number:884.1690
Regulatory Class:Class II
Product Codes:HIH
Review Panel:Obstetrics/Gynecology

Table 15-1. Predicate Device

Predicate Device510(k) No.
VISERA HYSTEROVIDEOSCOPE OLYMPUS HYF TYPE VK022445

The predicate device has not been subject to a design-related recall.

Product Description

This instrument has been designed to be used with an Olympus video system center, light source, documentation equipment, display monitor, and other ancillary equipment for endoscopic diagnosis within the uterus.

Comparison of Technological Characteristics

Table 5-1 compares HYF-V to the predicate device with respect to intended use, technological characteristics, and principle of operation, providing detailed information regarding the basis for the determination of substantial equivalence.

ComparatorSubject DevicePredicate Device
Regulatory
Device Name (Model)Same as predicateVisera Hysterovideoscope (HYF-V)
Regulatory DecisionSame as predicateK022445
Product CodeSame as predicateHIH
Regulation NumberSame as predicate884.1690
Regulation NameSame as predicateHysteroscope and accessories
Indications for useVISERA
HYSTEROVIDEOSCOPE
OLYMPUS HYF TYPE V
has been designed to be used
with an Olympus videoThis instrument has been
designed to be used with an
Olympus video system center,
light source, documentation
equipment, display monitor, and
ComparatorSubject DevicePredicate Device
system center, light source,
documentation equipment,
display monitor, and other
ancillary equipment for
endoscopic diagnosis within
the uterus. Do not use the
instrument for any
purpose other than its
intended use.other ancillary equipment for
endoscopic diagnosis within the
uterus, including:
• Abnormal uterine bleeding
• Amenorrhea
• Evaluation of abnormal
hysterosalpingogram
• Infertility and pregnancy
wastage
• Pelvic pain
Optical system parameters
Field of ViewSame as predicate120°
Direction of ViewSame as predicate0° (Forward viewing)
Depth of FieldSame as predicate2-50mm
(for all compatible light sources)
Imaging System
NoiseOTV-S190/
CLV-S190OTV-S7V/
CLV-S40
Insertion Section
Insertion Flexible TubeSame as predicate3. 6mm
Outer DiameterSame as predicate3.8 mm
Distal EndSame as predicate240 mm
Working LengthSame as predicate
Instrument Channel
Channel Inner DiameterSame as predicate1.2 mm
Bending Section
Angulation RangeSame as predicateUp 100° / Down 100°
Connection to Light Source
ConfigurationLight Guide (LG) cable is not
detachableLight Guide (LG) cable is not
detachable
Venting Connector
PositionSame as predicateOn LG connector
Sterilization
EOSame as predicateAvailable
Others
Total lengthSame as predicate520mm
Suction FunctionSame as predicateNot provided
Compatible Video System Center/Light Source/Monitor/Reprocessor
Compatible Video System
CenterVISERA ELITE video
system center, OTV-S190
(K111425)VISERA video system center,
OTV-S7V (K051645)
Compatible Light SourceVISERA ELITE Xenon light
source, CLV-S190
(K111425)VISERA light source, CLV-S40
(K954451)
EVIS universal light source,
CLV-U40 (K954451)
Compatible MonitorOEV-262H (K102379)OEV-141/201/142/ 202/143/203
(K954451)
ComparatorSubject DevicePredicate Device
Compatible ReprocessorOER-Pro (K093106)Not available

Table 5-1: Comparison of the technological characteristics of HYF-V to predicate device

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K221557

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Image /page/6/Picture/0 description: The image shows the word "OLYMPUS" in large, bold, blue letters. The letters are all capitalized and evenly spaced. A registered trademark symbol is located to the right of the letter "S".

Indications for Use

VISERA HYSTEROVIDEOSCOPE OLYMPUS HYF TYPE V has been designed to be used with an Olympus video system center, light source, documentation equipment, display monitor, and other ancillary equipment for endoscopic diagnosis within the uterus. Do not use the instrument for any purpose other than its intended use.

Compliance to Voluntary Standards

The following voluntary standards have been applied to the subject device respectively:

  • . ANSI AAMI ES 60601-1:2005+A1:2012 Medical electrical equipment - Part 1: General requirements for basic safety and essential performance
  • . IEC 60601-2-18:2009 Medical electrical equipment - Part 2-18: Particular requirements for the basic safety and essential performance of endoscopic equipment
  • . ANSI AAMI IEC 60601-1-2:2014 Medical electrical equipment - Part 1-2: General requirements for basic safety and essential performance - Collateral standard: Electromagnetic compatibility - Requirements and tests (Edition 3)
  • ISO 15739:2017 Photography Electronic still-picture imaging Noise measurements
  • IEC 62471:2006 Photobiological safety of lamps and lamp systems
  • . ISO 10993-1:2009 Biological evaluation of medical devices – Part 1: Evaluation and testing within a risk management process
  • . ISO 10993-5:2009 Biological evaluation of medical devices - Part 5: Tests for in vitro cvtotoxicitv
  • . ISO 10993-10:2010 Biological evaluation of medical devices - Part 10: Tests for irritation and skin sensitization
  • ISO 10993-12:2012 Biological evaluation of medical devices Part 12: Sample preparation and reference materials
  • . ISO 11135:2014 Sterilization of health care products - Ethylene Oxide - requirements for development, validation and routine control of a sterilization process for medical devices
  • . ISO 10993-7: 2008 Biological evaluation of medical devices - Part 7: Ethylene oxide sterilization residuals [Including: Technical Corrigendum 1 (2009), AMENDMENT 1: Applicability of allowable limits for neonates and infants (2019)]
  • ISO 14971:2007 Medical Devices Application of risk management to medical devices

Device-Specific Guidance

  • Reprocessing Medical Devices in Health Care Settings: Validation Methods and Labeling Guidance for Industry and Food and Drug Administration Staff
  • FDA Guidance Use of International Standard ISO 10993-1, 'Biological evaluation of medical devices - Part 1: Evaluation and testing within a risk management process
  • . FDA Guidance Hysteroscopes and Gynecologic Laparoscopes

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Summary of Performance Testing

The following performance testing was conducted in support of the substantial equivalence determination.

1. Non-Clinical Bench Testing

ItemApplicable DeviceContents
Thermal SafetyHYF-VThermal safety performance test verified compliance to Protection against excessive temperature and other safety hazards of IEC 60601-2-18:2009-08.
Photobiological SafetyHYF-VThe photobiological safety test verified compliance to IEC 32471:2006-07 and confirms the light emitted from subject devices connected to each light source is low enough not to cause injury to the skin and eye.
Noise and Dynamic RangeHYF-VThe substantial equivalence of Noise and Dynamic range between the subject device and predicate device connected with Video System Center / Light Source was confirmed and verified compliant to ISO 15739:2017.
Composite DurabilityHYF-VThe durability test against composite stress of mechanical (angulation and wiping during reprocessing) and chemical stress demonstrates the subject device retains its safety and effectiveness against the stresses expected in its use-life.
Color PerformanceHYF-VThe color performance of the subject devices is confirmed as substantially equivalent to the predicate devices in the WLI.
Image Intensity UniformityHYF-VThe image intensity uniformity of the subject devices is confirmed as substantially equivalent to the predicate devices.
ResolutionHYF-VThe resolution of the subject device is confirmed as substantially equivalent to the predicate device.
Direction of ViewHYF-VThe direction of view test verified compliance to ISO 8600-1 and confirms that the subject device is consistent with the design specifications and does not introduce new questions related to safety and effectiveness.
Field of ViewHYF-VThe field of view test verified compliance to ISO 8600-1 and confirms that the subject device is consistent with the design specifications and does not introduce new questions related to safety and effectiveness.

2. Animal Test

Animal testing was not applicable and not performed.

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K221557 Page 6 of 7

3. Biocompatibility Evaluation

Biocompatibility of the subject device was evaluated according to ISO 10993-1 Biological Evaluation of Medical Devices-Part 1: Evaluation and Testing. The subject device passed testing for all applicable biocompatibility endpoints.

4. Sterilization, Shelf Life, Reprocessing

HYF-V and their reusable accessories are not sterilized before shipment. Before using these instruments for the first time and between patient use the endoscopes must be cleaned and high-level disinfected and sterilized as shown in the Instruction for Use. All cleaning, disinfection, and sterilization methods were validated pursuant to FDA Guidance Reprocessing Medical Devices in Health Care Settings: Validation Methods and Labeling Guidance for Industry and Food and Drug Administration Staff, issued March 17, 2015. The reprocessing validation was conducted pursuant to the same FDA guidance document. HYF-V is validated as safe and effective for reprocessing with the following:

  • . Manual Cleaning
  • . Manual Disinfection with 2 - 3.5% glutaraldehyde
  • . OER-Pro (K103264)
  • Sterilization with EO Gas

5. Electrical Safety and Electromagnetic Compatibility (EMC)

The HYF-V was tested for electrical safety and electromagnetic compatibility inclusive of Essential Performance Requirements in accordance with FDA recognized standards for endoscopic equipment as listed below.

  • . IEC 60601-1:2005+A1:2012 Medical electrical equipment - Part 1: General requirements for basic safety and essential performance
  • . IEC 60601-2-18:2009 Medical electrical equipment - Part 2-18: Particular requirements for the basic safety and essential performance of endoscopic equipment
  • . IEC 60601-1-2:2014 Medical electrical equipment - Part 1-2: General requirements for basic safety and essential performance - Collateral standard: Electromagnetic compatibility - Requirements and tests (Edition 4)

6. Software Verification and Validation Testing

HYF-V does not include any software; thus, software testing was not applicable and not performed.

7. Risk Analysis

Risk analysis for the subject device was conducted in accordance with established in-house acceptance criteria based on ISO 14971. Design verification tests based on required risk mitigations, and their acceptance criteria were identified and performed as a result of this risk analvsis assessment.

9

K221557

These assessments confirmed that there was no unacceptable user-related residual risk for Visera Hysterovideoscope, HYF-V.

8. Clinical Testing

Clinical testing was not applicable and not performed.

Substantial Equivalence Conclusion

HYF-V has the same intended use and has similar technological characteristics as the predicate device. Except for the differences summarized in Table 5-1, the technological characteristics, including principle of operation, materials, and directions for use are identical between the subject device and predicate device. The differences in technological characteristics between the subject and predicate do not raise different questions of safety and effectiveness.

The results of of non-clinical performance testing demonstrate that the Visera Hysterovideoscope, HYF-V is as safe and effective as the predicate device, and therefore is substantially equivalent to the predicate.