Robot-assisted upper urinary tract repair surgery using the MP1000 system: a prospective, single-center, single-arm clinical study

Introduction

Upper urinary tract repair is mainly to reconstruct the structure and function of congenital urinary tract malformation and acquired urinary tract injury. The surgery aims to achieve the goal of restoring the continuity and integrity of urinary tract, reducing hydronephrosis and protecting renal function. Commonly used methods of upper urinary tract reconstruction include ureteroureterostomy, ureteroneocystostomy, bladder flap ureteroplasty, pyeloplasty, oral mucosal ureteral repair, appendix patch ureteral repair, ileal ureter replacement, autologous kidney transplantation, etc. (1,2).

Upper urinary tract repair surgery is mainly performed through open, laparoscopic or robotic procedures. Open surgery has large incision, large amount of intraoperative blood loss, severe postoperative pain and more complications (3). Laparoscopic surgery is more effective than open surgery in terms of blood loss and complications, but its learning curve is longer (4,5). Robot-assisted laparoscopic surgery has a short learning curve, and many studies have reported that robotic upper urinary tract repair surgery is a safe and effective ureteral repair method with high success rate and low complication rate (4,6-8).

The da Vinci Surgical Robot system dominates the surgical robot market with its visibility, operability, flexibility, ergonomics for the surgeon and ease of performing internal sutures. With the progress of research, a variety of systems such as REVO-I, Senhance, Versiusand TELELAP ALF-X surgical robot system have been developed, and more robots have been applied in the clinic (9-14). In this study, a new robotic surgical system named MP1000 (Shenzhen Edge Medical Company, Shenzhen, China) developed by Jingfeng Robotics Co., Ltd. (Shenzhen, China) was introduced, and the safety and effectiveness of the system in various upper urinary tract repair operations were reported. This is the first report of MP1000 for upper urinary tract repair surgeries. We present this article in accordance with the TREND reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-228/rc).

Methods

This prospective, single-center, single-arm clinical study protocol has been approved by the Institutional Review Committee of Peking University First Hospital - Miyun Hospital (No. 2023-013-001). All patients have provided informed consent. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. From June 2023 to December 2023, a total of 20 patients underwent MP1000 system robot-assisted upper urinary tract repair in Peking University First Hospital - Miyun Hospital. These included pyeloplasty (n=7), ureteroureterostomy (n=3), ureteroplasty with a buccal mucosa graft (n=1), ileal ureter replacement (n=3), and ureteroneocystostomy (n=6). All surgeries were performed by the same surgeon, who has 20 years of surgical experience and has conducted over a thousand urinary tract repair surgeries.

Inclusion criteria: (I) age 18–75 years old; (II) agree to sign informed consent forms and be able to follow medical advice and regular follow-up visits; (III) upper urinary tract repair surgery is required (there is lumbago or decreased kidney function or both).

Exclusion criteria: (I) serious uncontrolled disease or acute infection, such as sepsis, uncontrolled severe pneumonia, etc.; (II) patients with cardiovascular and cerebrovascular diseases, blood system diseases and diabetes that cannot be controlled and cannot meet surgical standards; (III) patients with immune system diseases that cannot be controlled and cannot meet surgical standards, such as severe systemic lupus erythematosus, etc.

Demographic characteristics, preoperative data, intraoperative parameters, and follow-up results were prospectively collected. Preoperative data included age, sex, body mass index (BMI), ureteral stenosis length, ureteral stenosis location, stenosis side, degree of hydronephrosis, preoperative creatinine, and estimated glomerular filtration rate (eGFR) on the affected side. Intraoperative parameters included robot docking time, operation console time, operative time, estimated blood loss (EBL), intraoperative adverse events, and NASA-TLX score. Follow-up results included patients with Clavien-Dindo complications, creatinine on day 1, creatinine on day 3, creatinine on month 3, degree of postoperative fluid accumulation, and eGFR on the affected side. Docking time refers to the process of moving the surgical arm system towards the operating table until the last sheath tube is docked to the corresponding robotic arm of the surgical arm system. Console time is defined as the time from the robot pair to the robot undocking. The national aeronautics and space administration task load index (NASA-TLX) was used for subjective evaluation, and the original NASA-TLX continuous score (0E100) was revised to 10 points (15,16). Evaluation of surgical safety criteria: there were no intraoperative complications, adverse events and equipment defects. Criteria for evaluating the effectiveness of the operation: Judging whether the operation is effective by whether the operation is successful. If all the following criteria is met, the operation can be considered successful: (I) the lumbago is relieved or disappeared 3 months after the operation; (II) within 3 months after surgery, the degree of hydronephrosis of the patient decreased or did not progress, and the renal function increased or did not progress.

The MP1000 system is a master-slave robot system. It consists of a surgical open console, a robotic arm, and an imaging system (Figure 1). A comparison between the MP1000 system and the da Vinci Surgical System is shown in Table 1.

Figure 1 Components of the MP1000 system. (A) The console. (B) The patient side cart. (C) The vision cart.

Surgical procedure

Pyeloplasty/ureteroureterostomy

Position the patient in a 60° lateral decubitus position on the healthy side. Insert a camera trocar (C) at the point where the midline of the clavicle intersects with the horizontal line of ureteral stricture. Subsequently, place a trocar (R1) on the left side at a distance of 10 cm from this horizontal line, and another trocar (R2) on the right side at a distance of 8 cm. Trocar (R3) is positioned at the midpoint of the line connecting C and R1, intersecting with the anterior axillary line. Trocar (A) is positioned 3 cm below the midpoint of the line connecting C and R2 (Figure 2A). Open the paracolic gutter on the affected side, exposing the upper segment of the ureter at the level of the lower pole of the kidney (Figure 2B). Trim the proximal and distal ends of the ureter to normal caliber and longitudinally incise the narrowed segment of the ureter towards the distal end (Figure 2C). Subsequently, make a transverse incision on the ureter (Figure 2D) and perform a tension-reducing stitch using absorbable suture material at the lower edge of the renal pelvis incision and the lowest point of the ureter incision (Figure 2E). Excise the narrow segment of the ureter (Figure 2F), and suture the posterior and anterior walls of the cut ends of the ureter separately using absorbable sutures (Figure 2G). Restore the continuity of the peritoneum (Figure 2H).

Figure 2 Key steps of pyeloplasty. (A) Trocar layout. (B) Mobilization of the bladder-ureter junction. (C) Longitudinal incision of the ureter. (D) Transverse incision of the ureter. (E) First stitch for reducing tension suturing. (F) Excision of the narrowed segment of the ureter. (G) Ureter-bladder anastomosis. (H) Restoration of peritoneal continuity.

The procedure of ureteroureterostomy is like pyeloplasty, involving anastomosis between the ureters.

Ureteroneocystostomy

Position the patient in the supine position. Make an incision at the midpoint between the umbilicus and xiphoid process and insert a camera trocar (C) at this point. Place two trocars (R1 and R2) 2 cm to the right of C, at the intersection of the outer edges of the bilateral rectus abdominis muscles. Insert another trocar (R3) 11 cm below R2. Place a trocar (A) 2 cm to the left of the midpoint between R1 and C (Figure 3A). Incise the retroperitoneum at the junction of the iliac vessels and the ureter on the affected side and extend the incision downwards along the retroperitoneum to the bifurcation of the iliac vessels, flipping the descending colon inward and downward. Expose the retroperitoneal tissues near the midline and mobilize the lower segment of the affected-side ureter (Figure 3B), followed by transaction (Figure 3C). Suture the bladder-ureter stump (Figure 3D), eversion of the distal end of the ureter to form a nipple-like structure (Figure 3E), and suspend the affected-side bladder wall at the lateral border of the affected-side psoas muscle tendon. After bladder instillation, sequentially incise the bladder muscle layers and mucosa, suturing the ureteral mucosa to the bladder mucosa with absorbable suture material, and then suturing the muscle layers together (Figure 3F).

Figure 3 Key steps of ureteroneocystostomy. (A) Trocar layout. (B) Mobilization of the bladder-ureter junction. (C) Transection of the ureter. (D) Suturing of the bladder-ureter stump. (E) Eversion of the ureteral mucosa. (F) Anastomosis of the ureter to the bladder.

Ureteroplasty with a buccal mucosa graft

Position the patient in a 60° lateral decubitus position on the healthy side. Insert a trocar (C) at the point where the lateral border of the rectus abdominis muscle intersects with the horizontal line of the ureteral stricture. Place trocars (R2 and R1) 8 cm to the left and 10 cm to the right in the horizontal direction from C. Trocar (R3) is positioned 4 cm above the midpoint of the horizontal line between C and R1. Trocar (A1) is placed 2 cm below R1, and trocar (A2) is positioned 6 cm to the left of the umbilicus (Figure 4A). Open the paracolic gutter on the affected side and expose the ureter (Figure 4B). Longitudinally incise the narrowed segment of the ureter from top to bottom (Figure 4C), measure the length of the narrowed segment (Figure 4D), and trim oral mucosa to the appropriate size based on the length of the narrowed segment. Suture the posterior wall of the ureter (Figure 4E) and repair the defect in the anterior wall of the ureter (Figure 4F) using absorbable sutures.

Figure 4 Key steps of ureteroplasty with a buccal mucosa graft. (A) Trocar layout. (B) Mobilization of the narrowed segment of the ureter. (C) Excision of the narrowed segment of the ureter. (D) Measurement of the length of ureteral defect. (E) Suturing of the posterior wall of the ureter. (F) Suturing of the buccal mucosa and the anterior wall of the ureter.

Ileal ureteral replacement

Assuming a supine position, insert a camera trocar (C) at the midpoint between the umbilicus and xiphoid process. Insert a trocar (R1) 2 cm to the right at the intersection of the midline of the clavicle and the affected side. Place a trocar (A1) 2 cm to the left at the intersection of the lateral border of the rectus abdominis muscle and the affected side. Insert a trocar (A2) 8 cm to the right at the intersection of the anterior axillary line and the affected side. Insert a trocar (R2) 2 cm to the right at the intersection of the midline of the clavicle and the healthy side. Place a trocar (R3) 6 cm to the right at the intersection of the anterior axillary line and the healthy side (Figure 5A). Open the retroperitoneum at the level of the lower pole of the affected side kidney, mobilize the ureter (Figure 5B), excise the narrowed segment of the ureter (Figure 5C), and measure the distance from the ureter to the top of the bladder (Figure 5D). Measure and obtain corresponding lengths of ileal tissue (Figure 5E,5F), preserve its blood supply, and transect it. Place the resected ileal segment on the outer side of the ileum and anastomose the cut end of the ileum using a stapler (Figure 5G) to restore intestinal continuity. Anastomose the intestine with the ureter (Figure 5H), create an artificial nipple by eversion at the end of the ileum (Figure 5I), and insert the lower ileal nipple into the bladder and anastomose it with the bladder (Figure 5J).

Figure 5 Key steps of ileal ureteral replacement. (A) Trocar layout. (B) Disconnection of the bladder-ureter junction. (C) Transection of the ureter. (D) Suturing of the bladder-ureter stump. (E) Eversion of the ureteral mucosa. (F) Anastomosis of the ureter to the bladder. (G) Restore intestinal continuity. (H) Anastomosis of the intestine and ureter. (I) Artificial nipple by eversion at the end of the ileum. (J) Anastomosis between the ileum and the bladder.

Postoperative management and follow-up

The patients with ileal replacement ureter underwent cystography 2 weeks after operation, and Foley catheter was removed after no urinary extravasation. The other patients with other repair methods had urinary catheter removed 1 week after operation. In patients who underwent nephrostomy before surgery, the nephrostomy tube was clamped 2 weeks after surgery. The double-J (DJ) stent was removed 2 to 3 months after surgery. The degree of hydronephrosis and glomerular flow filtration were collected 3 months after the operation.

Statistical analysis

Statistical analyses were performed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Categorical variables were described using frequencies (n) and percentages (%), whereas continuous variables were presented as the mean value with the range indicated.

Results

As shown in Table 2, 20 patients underwent upper urinary tract repair surgery using the MP1000 system between June 2023 and December 2023. The mean age of the patients was 41.5 [interquartile range (IQR), 30.0–54.0] years and the mean BMI was 24.79 (IQR, 21.2–29.4) kg/m². Two patients had undergone pyeloplasty and ureteroureterostomy in other hospitals before joining the study and were treated with secondary repair. The average stricture length for unilateral ureteral stricture is 2.97 (IQR, 2–3) cm. There are two cases of bilateral ureteral stricture, with the left side having stricture lengths of 12 and 15 cm, and the right side also having stricture lengths of 12 and 15 cm. Before nephrostomy, ultrasound diagnosis showed that 9 cases (45%) had no hydronephrosis, 1 case (5%) had mild hydronephrosis, 1 case (5%) had moderate hydronephrosis, and 9 cases (45%) had severe hydronephrosis. After nephrostomy, ultrasound diagnosis showed that 8 cases (40%) had no hydronephrosis, 11 cases (55%) had mild hydronephrosis, and 1 case (5%) had severe hydronephrosis. 12 patients (60%) had symptoms of lumbago before surgery, and 8 patients (40%) had no obvious symptoms.

Table 3 shows perioperative and follow-up variables. No cases were referred to laparoscopic or open surgery. Five surgical procedures were performed in this study, including ureteroureterostomy (n=3, 15%), pyeloplasty (n=7, 35%), ureteroneocystostomy (n=6, 30%), ileal ureter replacement (n=3, 15%) and Ureteroplasty with a buccal mucosa graft (n=1, 5%). The average docking time was 4.1 (IQR, 3–5) min, the average console time was 145.1 (IQR, 102–195) min, and the average operation time was 189.1 (IQR, 145–248) min. The average EBL was 58.5 (IQR, 20–100) mL. The mean length of stay was 6.95 (IQR, 4–8) days.

There were no adverse events or equipment defects during the operation. All patients had no postoperative lumbago symptoms and no Clavien-Dindo grade III or above complications. The postoperative degree of hydronephrosis in patients was as follows: no hydronephrosis (n=6, 30%), mild hydronephrosis (n=11, 55%), moderate hydronephrosis (n=2, 10%), and severe hydronephrosis (n=1, 5%). The eGFR was 99.29 (IQR, 95.39–126.14) mL/min/1.73 m² on the first day after surgery, 101.13 (IQR, 89.73–124.7) mL/min/1.73 m² on the third day after surgery, and 78.38 (IQR, 57.12–91.84) mL/min/1.73 m² on the third months after surgery. The short-term success rate was 100%.

The mean NASA-TLX scores for overall needs, mental needs, physical needs, temporal needs, performance, effort and frustration were 6.70±4.81, 1.38±0.89, 1.25±0.94, 1.35±1.06, 0.73±0.60, 1.05±0.95 and 0.95±0.84, respectively (Table 4).

Discussion

Many studies have provided evidence for the safety and effectiveness of robotic systems in the application of self-robotic systems in clinical surgery, but the research on robotic surgical systems mainly focuses on the da Vinci surgical robot system (17-19). Since the da Vinci surgical robot system has been approved for clinical practice, it has further improved fine surgery due to its flexible robotic arm and three-dimensional enlarged field of view. However, due to its high cost, the popularization of this system has been limited (20). Because of the complexity of upper urinary tract repair surgery, the robotic system can better assist in fine suturing and other operations. To evaluate the safety and efficacy of the MP1000 system for upper urinary tract repair, we conducted a prospective single-arm study. To our knowledge, this is the first report of the MP1000 system for upper urinary tract repair surgeries.

Since the da Vinci Surgical Robotic System (Intuitive Surgery, Sunnyvale, CA, USA) has been approved for use in clinical practice, many studies have reported that it can refine surgical steps through flexible robotic arms, while enlarging the surgical field of view in three dimensional, improving surgical accuracy while reducing surgical difficulty. The application of da Vinci robot in surgery has undoubtedly played a promoting role in the development of medicine, but it still has certain limitations. The MP1000 system and other brands of robots make up for the disadvantages of robots in terms of cost, and its surgical effect has been shown to be comparable to that of da Vinci robots in previous studies. Gao et al. (21) conducted a prospective, single-blind, randomized controlled trial to test the safety and efficacy of the MP1000 surgical system (n=31) and the da Vinci^® Si robotic system (n=31) in robot-assisted partial nephrectomy, and found that the MP1000 system was a suitable platform for robotic assisted partial nephrectomy. Its safety and efficacy are comparable to those of da Vinci^® Si systems.

The MP1000 components and console are similar to those of the da Vinci (Table 1). Both have similar immersive viewing Windows and also have a four-arm structure with 1 mirror and 3 operating arms. Both have 5 degrees of freedom of adjusting arm and 7 degrees of freedom of carrying arm. However, the MP1000 presents a larger rotation Angle of 322° in terms of the maximum rotation Angle supported by the boom, which is conducive to better layout of the robot arm and avoid mutual interference of the robot arms. At the same time, the MP1000 presents a greater advantage in remote control surgery. Wang et al. used the MP1000 remote surgery system to achieve a round-trip communication distance of more than 6000 km. Six patients diagnosed with retrocaval ureter, renal cancer, prostate cancer, and adrenal tumor were operated on respectively, and all patients successfully completed the operation (22). The MP1000 also has certain disadvantages, as the MP1000 includes a safety feature that detects when the surgeon leaves the console and stops the robotic arm. However, in some cases, this function can be inadvertently activated even though the surgeon is still operating the robot. This also requires the Jingfeng robot team to further optimize and upgrade the system.

The purpose of this study is to introduce the application of MP1000 surgical robot system in upper urinary tract repair. All operations were successfully completed. The MP1000 system is like previous studies on da Vinci robotic repair surgery in terms of installation time, operation time and EBL (23,24). In this study, the short-term success rate of upper urinary tract repair surgery was 100%, and no third-grade or above complications occurred, indicating that MP1000 system is feasible, safe and effective for various upper urinary tract repair procedures. The NASA-TLX score was 1.35±1.15. The psychological demands, physiological demands, time demands, and effort were all within the acceptable range, while the performance and frustration were all good, indicating that the MP1000 system has a good ergonomic effect. In terms of surgical difficulty, the upper urinary tract repair surgery includes excision, ligation, suture and anastomosis and other delicate operations, so it is considered that the MP1000 system may also achieve good results in other surgical areas.

However, there are some limitations in this study, such as a small sample size of just 20 patients and a lack of comparisons with the da Vinci robot. In addition, our data showed a 100% success rate for lower and upper urinary tract repair surgery with the MP1000 system, and no serious complications were observed, but the 3-month follow-up period may not be sufficient to fully assess long-term outcomes. The strengths of this study are prospective data collection and rigorous follow-up.

Conclusions

The MP1000 system is safe and effective for a variety of upper urinary tract repair procedures.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the TREND reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-228/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-228/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-228/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-228/coif). Xuesong Li serves as an Editor-in-Chief of the Translational Andrology and Urology from March 2025 to February 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Peking University First Hospital - Miyun Hospital (No. 2023-013-001). All patients have provided informed consent.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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