Two Arms-one Assisted Port Extraperitoneal Robot-assisted Radical Prostatectomy: A Simplified, Safe, Alternative Technique

<h3>Background/Aim:</h3> Robot-assisted radical prostatectomy (RARP) has become the standard procedure for treating prostate cancer. Conventionally, RARP is performed using a three-arm, two-assistant-port transperitoneal approach, which may increase costs, pose a risk of intraperitoneal complications, and be less suitable for patients with prior abdominal surgery. To address these limitations, we developed a simplified and cost-effective two-arm, one-assistant-port extraperitoneal RARP technique. <h3>Patients and Methods:</h3> This technique evolved from a conventional transperitoneal three-arm, two-assistant-port system to an extraperitoneal three-arm, one-assistant-port system, and ultimately to an extraperitoneal two-arm, one-assistant-port configuration. Following Institutional Review Board approval, consecutive patients who underwent RARP performed by a single surgeon were enrolled. Baseline characteristics, number of dissected lymph nodes, estimated blood loss, operative time, and surgery-related adverse events were compared among groups. <h3>Results:</h3> Between September 2014 and May 2025, a total of 361 robotic prostatectomies were consecutively performed, including 28 transperitoneal and 333 extraperitoneal procedures. The extraperitoneal cases were further categorized into 175 three-arm and 158 two-arm procedures. Compared with the three-arm approach, the two-arm approach demonstrated comparable blood loss (<i>p</i>=0.646) and number of dissected lymph nodes (<i>p</i>=0.160), but significantly shorter operative time (<i>p</i>&lt;0.0001). A total of 10 surgery-related adverse events required radiologic or surgical intervention, including two cases of bowel ileus, one hemorrhagic shock, one ureteral obstruction, and six infected lymphoceles. Notably, both cases of bowel ileus occurred following the transperitoneal approach. <h3>Conclusion:</h3> The two-arm, one-assistant-port extraperitoneal RARP technique provides a simplified, safe, and cost-effective approach to robotic prostate surgery. Furthermore, this technique may serve as a practical transitional platform for surgeons adopting single-port robotic systems.