Purpose: To define a peak force of insertion (PFOI) threshold for ureteral damage during ureteral access sheath (UAS) placement on an experimental ureteral orifice model. Methods: A specially designed water tank using 2 laparoscopic 5 mm ports and 2 different size (10 Fr and 8 Fr) sealing cap adaptors (SCA) as ureteral orifices was used to perform the test. A 10–12 Fr UAS was fixed to a load cell and the force of insertion (FOI) was continuously recorded with a digital force gauge.13 experts in the field of endourology who participated performed 3 UAS insertions. The FOI was recorded initially with 10 Fr followed by 8 Fr SCA. On the final insertion, the orifice was obstructed, leaving a 5 cm length to insert the UAS. The experts were asked to “Stop at the point they anticipate ureteral damage, and they would not proceed in real life”. Results: Using 10 Fr SCA the PFOI was 2.12 ± 0.58 Newton (N) (range:1.48–3.48) while 8 Fr SCA showed a PFOI 5.76 ± 0.96 N (range:4.05–7.35). Six of the experts, said they would stop proceeding when they reached above 5.1 N. Three experts had PFOI < 5.1 N and the other 4 stated they would go with PFOIs of 5.88, 6.16, 6.69 and 7.35 N when using SCA of 8 Fr.The highest load they would stop proceeding had a PFOI of 6.09 ± 1.87 N (range: 2.53–10.74). Conclusion: The PFOI threshold for ureteral damage inserting UAS of the experts is variable. Although FOI is a subjective perception, experience suggests that ureteral injury may occur at an average of 6.05 N perceived by surgeons’ tactile feedback. In-vivo measurement of UAS PFOI may confirm a threshold.

Postoperative neurocognitive disorders (PNDs) are highly prevalent among the elderly population. Identifying an ideal biomarker for postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) remains a significant challenge. This study aimed to investigate the relationship between these syndromes and various biomarkers, including S-100β, neuron-specific enolase (NSE), interleukin-6 (IL-6), and high-mobility group box-1 (HMGB-1). The study included patients aged 60 years and older who underwent surgery for primary urologic malignancies. POD was evaluated in the recovery room using the Confusion Assessment Method (CAM). POCD was assessed preoperatively and at the first week (POCD1) and third month (POCD3) postoperatively using Addenbrooke's Cognitive Examination-III (ACE-III). Biomarker levels of S-100β, neuron-specific enolase (NSE), interleukin-6 (IL-6), and high-mobility group box-1 (HMGB-1) were measured using enzyme-linked immunosorbent assay (ELISA). A total of 54 patients completed the study. POD was diagnosed in 12 patients (22.2%), while POCD1 and POCD3 were identified in 17 (31.5%) patients and 12 (22.2%) patients respectively. The mean age of the participants was 73.8 ± 7.1 years. Preoperative levels of NSE were significantly higher in patients with POD compared to those without (p = 0.04). Additionally, preoperative and postoperative IL-6 levels, as well as preoperative and postoperative S-100β levels, were significantly elevated in patients with POCD1 compared to those without (p < 0.01, p = 0.01, p < 0.01, and p = 0.03, respectively). Furthermore, preoperative IL-6 and S-100β levels were higher in patients with POCD3 compared to those without (p = 0.01 and p = 0.03, respectively). In major urologic oncologic surgeries among geriatric patients, IL-6 and S-100β were found to be associated with both POD and POCD, while NSE was specifically associated with POD.