Metro Urology

Misconfigurations in enterprise IT systems remain a leading cause of service disruptions and vulnerabilities. In this paper, we present a self-adaptive AI agent that interactively collects diagnostic symptoms through natural language conversations and collaborates with an automated diagnosis system to identify root causes. The AI agent holds a dialog with the user to clarify the user complaint and then translates it into structured diagnostic tickets by mapping symptoms to relevant configuration variables (CVs) and assigning initial confidence scores. These tickets guide ConfExp, a confidence-driven diagnostic framework, which refines hypotheses through system-level test execution. The combined system significantly improves the diagnosis process. In evaluations across 75 fault scenarios in emulated enterprise environments, the system correctly identified misconfigured components in over 93% of cases while reducing the number of tests required by up to 47% compared to using ConfExp alone. This demonstrates the e ectiveness of combining a large language model (LLM)-driven symptom elicitation with confidence-guided test execution for scalable, automated troubleshooting.

This study explores the feasibility and advantages of implementing a Communications-Based Train Control (CBTC) signalling system on the Copenhagen Metro. As urban rail transit faces increasing passenger demand and the impending obsolescence of its current signalling system, CBTC emerges as a promising solution to enhance operational efficiency. Through microsimulation, the study compares the existing system with CBTC, focusing on key performance indicators such as headway adherence, running time reliability, and delay management. Results demonstrate that CBTC significantly improves service reliability, capacity, energy efficiency, and operational robustness. Additionally, the study identifies Vanløse station as a critical bottleneck in capacity utilization, which can be alleviated through CBTC deployment. This research underscores the potential of CBTC to transform urban rail systems, providing insights into its application in brownfield projects.

To confirm the performance and safety of the rechargeable sacral neuromodulation system (InterStim™ Micro) through 2-year follow-up, we report results from the fecal incontinence (FI) cohort through 6-month follow-up. Eligible patients were enrolled following successful therapy evaluation and implant. Participants completed bowel diaries and questionnaires at baseline, 3, and 6 months post-implant. The primary objective was improvement in Cleveland Clinic Incontinence Score (CCIS) at 3 months post-implant compared to baseline. Safety was evaluated by collection of reportable adverse events (AE). Of 53 patients implanted, 90.6% were female and the mean (± SD) age was 58 ± 11years. There was a statistically significant improvement in CCIS at 3months vs baseline, with a mean change of -4 ± 3.7 (p < 0.001, n = 52). This improvement was maintained at 6months, with a mean change of -4.0 ± 3.58 (n = 52). The mean change in Fecal Incontinence Quality of Life (FIQoL) at 3months was 3.2 ± 2.8 (n = 52) and 3.6 ± 2.9 (n = 53) at 6months. On the Patient Global Impression of Improvement (PGI-I), 94% (n = 52) and 90.6% (n = 53) of participants reported their condition was better at 3- and 6-month follow-up compared to baseline, respectively. The incidence of device-, procedure-, or therapy-related AEs in enrolled participants was 18.9% (10/53); among these was one serious related AE. There were no unanticipated adverse device effects. The primary objective of the FI cohort was met, with statistically significant improvement in CCIS and patient-reported outcomes. These data confirm clinical performance and safety through 6 months post-implant. NCT04506866.

Diabetic autonomic neuropathy (DAN) and its associated cardiovascular autonomic neuropathy (CAN) can lead to potentially fatal complications. We analyzed two distinct cases of DAN/CAN based on comprehensive cardiovascular autonomic reflex tests (CARTs). Case 1 involves a 27-year-old patient with T1DM suffering from recurrent severe hypoglycemic unawareness due to DAN. After implementing an automated insulin delivery system, the glucose management improved significantly. Case 2 describes a 60-year-old patient with type 2 diabetes experiencing debilitating orthostatic hypotension. The initiation of Midodrine and Fludrocortisone markedly improved symptoms and capacity of daily activities. This observational study highlights the critical yet frequently overlooked severe manifestations of DAN/CAN, specifically hypoglycemic unawareness and orthostatic hypotension. CARTs play a pivotal role in confirming the diagnosis and guiding therapeutic decisions. Tailored interventions, including advanced technologies like automated insulin delivery systems for T1DM and pharmacotherapy targeting neurogenic orthostasis, can significantly improve patient outcomes and quality of life.

Abstract Disclosure: A. Tiwari: None. R. Berry: None. A. Mokbel: None. A. Abotouk: None. A.R. Alrifai: None. J. Waleed: None. O. Alzohaili: None. Introduction: Oral regimens of exogenous cortisol fail to mimic physiologic levels. The discrepancy leads to complications, notably nausea, hyperglycemia, and susceptibility to infection. Finer control over cortisol delivery may be achievable with infusion pumps. While international groups have published their experiences with cortisol pumps, these studies often include less than ten patients. We share the largest, single-center cohort ever documented and the first from an American clinic. Methods: We conducted a retrospective cohort study. Through chart review, we identified all patients who received a cortisol pump at a private clinic; these pumps were originally designed to deliver insulin, but we repurposed them for patients with adrenal insufficiency. Clinic notes allowed collection of cortisol dosing pre- and post-exposure to the cortisol pump. We supplemented this information with telephone and digital surveys on the frequency of hospitalization, symptoms, and quality of life; patients provided verbal consent before participation. A Wilcoxon signed rank test and Fisher exact test evaluated significant differences between groups. Results: We identified thirty patients who received a cortisol infusion pump. Our study revealed a statistically significant decrease in hospitalization rate after exposure to a cortisol pump (n=26, mean difference = -5.94 hospitalizations per year, p=0.003), a decrease in the frequency of fatigue (n=25, p=0.0001) and a decrease in the frequency of hypotension (n=25, p=0.005). A validated, quality of life survey corroborated these findings with improvement in twenty-seven out of twenty-eight questions (n=22, p&amp;lt;0.05). However, we did not detect a statistically significant difference in the frequency of eighteen other symptoms nor cortisol dosing between pre- and post-exposure groups. Conclusion: Infusion pumps can better mimic physiological variations in cortisol than oral dosing regimens. We show the extent to which cortisol dosing may reduce hospitalization rate - and therefore cost - as well as improve quality of life. We hope our findings encourage the availability of infusion pumps for adrenal insufficiency, a smaller market that may not otherwise attract commercial investment for a dedicated, randomized trial. Presentation: 6/3/2024

Abstract Introduction The Optilume Urethral Drug Coated Balloon (DCB) is a novel endoscopic treatment for recurrent male anterior urethral strictures. An important topic of discussion with patients during counseling on treatment options includes the potential affect of treatment on sexual function and fertility. The ROBUST III study was a prospective, randomized study comparing standard of care endoscopic therapy against treatment with the Optilume DCB. Assessments included evaluation of sexual function and andrology parameters. Objective The objective was to study the potential affect of treatment with the Optilume DCB on sexual function and, for younger patients, fertility. Methods A total of 79 men were randomized to receive treatment with the Optilume DCB. Sexual function was assessed via the 15 item International Index of Erectile Function (IIEF) questionnaire. Erectile function, orgasmic function, and overall satisfaction sub-domains were assessed at 3, 6, and 12 months after treatment in patients that were sexually active at baseline. Fifteen additional subjects were enrolled in a non-randomized pharmacokinetic sub-study that included assessments of paclitaxel concentration in semen and sperm quality parameters through 6 months post-treatment. Results Average erectile function and overall satisfaction scores improved from baseline to 12 months post-treatment, while orgasmic function was not changed (Figure). The improvement in satisfaction was statistically significant at 12 months (p=0.003). No adverse events of de novo erectile or ejaculatory dysfunction were reported. Average ejaculate sperm concentration did not change from baseline to 6 months (49 million/mL vs 46.6 million/mL, p=0.88), nor did total spermatozoa per ejaculate (107.2 million vs 104.0 million, p=0.94). Paclitaxel concentration in semen after treatment was maximal at 30 days (2.99 ng/mL) and was reduced near the limit of quantitation of the analytical method by 6 months (0.12 ng/mL). Conclusions Treatment of male anterior urethral strictures with the Optilume DCB did not appear to have an impact on sexual function as measured by the IIEF and adverse event assessments. Average sperm quality parameters did not differ from baseline to 6 months post-treatment. Low levels of paclitaxel were detected in semen after treatment but were nearly undetectable by 6 months. Disclosure Yes, this is sponsored by industry/sponsor: Urotronic Inc. Clarification Industry funding only - investigator initiated and executed study. Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Sci, Coloplast, Medtronic USA Inc., PROCEPT BioRobotic Corporation, NeoTract Inc., Janssen Biotech Inc., Endo Pharmaceuticals Inc., Tolmar Pharmaceuticals, Inc., 180 Medical Inc., AbbVie Inc., Pfizer Inc., Bluewind Medical, Astellas Pharma US Inc., Antares Pharma Inc., Axonic Modulation Technologies Inc., Allergan Inc., Terumo Medical Corporation, Dendreon Pharmaceuticals llc, Blue Earth Diagnostics Limited, Ferring Pharmaceuticals Inc., Olympus America Inc., Karl Storz Endoscopy-America, Clovis Oncology Inc., Dornier MedTech America Inc., Travere Therapeutics Inc., Valeant Pharmaceuticals North America LLC

Purpose: We report results of a prospective, multicenter single-arm study of transurethral vapor ablation (TUVA) of prostate tissue in patients with unilateral, intermediate-risk, localized prostate cancer (PCa). Materials and Methods: Men ≥45 years of age with biopsy-confirmed unilateral Gleason grade group 2 (GGG2) adenocarcinoma of the prostate, prostate volume of 20-80 cc, and prostate-specific antigen (PSA) ≤15 ng/mL were enrolled. Cystoscopy and transrectal ultrasound (TRUS) guidance were used to deliver ∼103°C water vapor to prostate zones for unilateral hemigland ablation, including destruction of cancers detected by multiparametric MRI (mpMRI) and confirmed by biopsy. The primary outcomes were device-related serious adverse events (SAEs). At 7 days and 6 months postprocedure, the ablation extent was assessed by mpMRI; MRI/TRUS fusion biopsies were completed at 6 months. Quality of life (QOL) was assessed with validated questionnaires. Results: All subjects underwent a single hemigland TUVA procedure. No SAEs occurred. Grade 2 procedure-related AEs included transient urinary retention (n = 4) and erectile (n = 1) or ejaculatory dysfunction (n = 1). At 7 days, mpMRI revealed complete ablation of 14/17 (82%) visible lesions. At 6 months, biopsies showed no Gleason pattern ≥4 or ≥GGG2 cancer on the treated side of prostates in 13/15 (87%) subjects. Ten of 15 (67%) subjects were biopsy negative. Of the 5 biopsy-negative subjects, 2 had one core each of 3 + 4 disease and 3 had one core each of 3 + 3 disease with ≤5% involvement. Median prostate volume was reduced by 40.7% and PSA by 58%. Extensive QOL assessments showed, on average, no appreciable negative effects of treatment. Conclusions: Initial evidence suggests that TUVA is safe in men with intermediate-risk PCa. Preliminary results demonstrate the absence of ≥GGG2 disease on the treated side in 87% of men and a favorable QOL profile.

To determine if Aquablation therapy can maintain long term effectiveness in treating men with moderate to severe lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with a baseline prostate volume between 30 and 80 mL at 5 years compared to TURP. In a double-blinded, multicenter prospective randomized controlled trial, 181 patients with moderate to severe LUTS secondary to BPH underwent TURP or Aquablation. The primary efficacy endpoint was reduction in International Prostate Symptom Score (IPSS) at 6 months. The primary safety endpoint was the occurrence of Clavien-Dindo persistent Grade 1 or Grade 2 or higher operative complications at 3 months. The assessments included IPSS, Male Sexual Health Questionnaire (MSHQ), International Index of Erectile Function (IIEF) and uroflow (Qmax). The patients were followed for 5 years. The primary safety endpoint was successfully achieved at 3 months where the Aquablation group had a lower event rate than TURP (26% vs. 42%, p = .0149 for superiority). Procedure-related ejaculatory dysfunction was lower for Aquablation (7% vs. 25%, p = .0004). The primary efficacy endpoint was successfully achieved at 6 months, where the mean IPSS decreased from baseline by 16.9 points for Aquablation and 15.1 points for TURP; the mean difference in change score at 6 months was 1.8 points larger for Aquablation (p < .0001 for non-inferiority, p = .1346 for superiority). At 5 years, IPSS scores improved by 15.1 points in the Aquablation group and 13.2 points in TURP (p = .2764). However, for men with larger prostates (≥ 50 mL), IPSS reduction was 3.5 points greater across all follow up visits in the Aquablation group compared to the TURP group (p = .0123). Improvement in peak urinary flow rate was 125% and 89% compared to baseline for Aquablation and TURP, respectively. The risk of patients needing a secondary BPH therapy, defined as needing BPH medication or surgical intervention, up to 5 years due to recurrent LUTS was 51% less in the Aquablation arm compared to the TURP arm. The improvement in net health outcomes from Aquablation therapy outweigh those offered by a TURP when considering the efficacy benefit along with the lower risk of needing a secondary BPH therapy and avoiding retrograde ejaculation. Following Aquablation therapy, symptom reduction and uroflow improvement at 5 years have shown to be durable and consistent across all years of follow up compared to TURP. Larger prostates (≥ 50 mL) demonstrated a larger safety and efficacy benefit for Aquablation over TURP.