Robotic prostate surgery in Morocco: when high precision preserves men's quality of life

Among technological achievements, the preservation of sexual and urinary functions, and national ambitions, Dr. Adil Ouzzane, Urological-Andrologist Surgeon, and Director of the Robotic Surgery program of the AKDITAL group provide an unprecedented insight into this medical revolution in Morocco. Far from the preconceived ideas where machines operate alone, the reality of robotic surgery remains above all a matter of humans. It is the experience of the surgeon, combined with the reactivity of an entire operating room team, that gives value to this cutting-edge technology. The robot does not replace the doctor nor conventional techniques, but offers an extension of remarkable surgical precision where every millimeter counts. Although robotic surgery was introduced in Morocco only recently, mainly in the field of urology, it has already been the subject of a study on 132 robot-assisted prostatectomies (prostate ablation surgeries for cancer), conducted by Dr. Adil Ouzzane, published in the Journal of Robotic Surgery. As an expert in robotic and minimally invasive surgery of the prostate and urinary tract, Dr. Adil Ouzzane explains how robotic surgery takes place in the operating room, how it has improved the lives of several patients. With over 1,500 procedures performed since 2008, the surgeon presents a particularly encouraging assessment of the first 132 robot-assisted prostatectomies carried out within the AKDITAL group, showing up to 98% recovery of urinary control at six months. Concretely, what does it look like when you are in the console or manipulating the robot? "When I am installed at the robot's console, I have a three-dimensional, enlarged, extremely precise image of the area I am operating on. It is a bit like being immersed inside the patient's body, with a much more detailed view than what we have with the naked eye. I can clearly distinguish the small blood vessels, nerves, and different tissues. My hands control miniaturized instruments that reproduce my movements with great precision. One must especially understand one thing: it is not the robot operating, it is the surgeon. The robot does not make any decisions and does not perform any action autonomously. It is a tool that allows the surgeon to see better and to perform particularly precise movements, especially in anatomically difficult-to-reach areas." Does the sensation of touch change compared to conventional surgery? How do you compensate for the absence of direct contact with the tissues? "It is indeed a significant difference. With the robotic systems we use, we do not directly feel the resistance of the tissues as in open surgery. However, we have an exceptional vision quality. The enlarged, three-dimensional image allows us to observe very fine details, particularly how the tissues react when manipulated. With experience, the surgeon develops what is called a visual perception of forces. He learns to evaluate the tension exerted on the tissues simply by observing their behavior. This is a specific learning that is an integral part of training in robotic surgery. The robot brings remarkable precision, but this only has value if it is accompanied by a perfect knowledge of anatomy and true surgical experience." What specific training must the surgical team and operating room nurses undergo before being able to use this system? "Robotic surgery is not simply about installing a robot in an operating room. It requires the training of an entire team. The surgeon must follow a specific path combining theoretical training, simulation, practical training, and supervised procedures before being able to operate autonomously. But the training does not only concern the surgeon. Operating room nurses, anesthetists, and the entire team must learn to work with this technology, to correctly position the patient, prepare the instruments, and react to the different situations that may arise during the procedure. It is truly a collective effort. The quality of a robotic surgery program depends as much on the surgeon's competence as on the coordination and experience of the entire team. Our ambition within the AKDITAL group is precisely to develop this collective expertise, with particular attention to the training and safety of patients." What happens in case of a technical problem or power outage during the operation? "Patient safety is obviously our absolute priority. Robotic surgery systems are subject to specific maintenance contracts, with regular technical checks and preventive maintenance aimed at considerably reducing the risk of failure. We also apply a safety philosophy comparable to that of aviation: before each procedure, and especially before the patient's anesthesia, we carry out systematic checks of the equipment and its proper functioning. Operating rooms also have backup electrical supply systems, including generators, and the robots are equipped with devices to manage certain power interruptions. Finally, the entire surgical team is trained to react in case of a technical incident. If necessary, we can stop the use of the robot and continue the procedure with another surgical technique. The principle is simple: safety never rests on a single machine, but on an entire organization, regularly checked equipment, and a perfectly prepared team." If this technology offers great precision, why does conventional surgery remain indispensable in some cases? And in what cases do you propose robot-assisted surgery? "We must not present robotic surgery as a universal solution. It is an important technological advance, but it does not replace all other surgical techniques. The choice depends above all on the disease, its stage, the patient's anatomy, and their medical and surgical history. In urology, robotic surgery has particular interest for certain complex procedures, particularly the surgical treatment of prostate cancer, certain kidney operations, or urinary tract reconstruction procedures. It allows for very precise movements in sometimes narrow anatomical spaces while limiting the invasive nature of the intervention. But in some situations, open surgery or conventional laparoscopy remain perfectly adapted, or even preferable. The real progress is not to operate all patients with a robot. It is to be able to offer each patient the technique best suited to their situation." You have conducted a study on 132 robot-assisted prostatectomies (prostate ablation surgeries for cancer). Prostate surgery often worries men about two things: urinary leakage and sexuality. How does the robot's precision help protect these essential functions? "This is indeed one of the major concerns of men who are operated on for prostate cancer. They naturally wish to be cured of their cancer, but also to preserve their urinary continence and their sexual life. The prostate is located in a particularly complex anatomical region, in immediate contact with the structures that control urinary control and erection. Robotic surgery offers us an enlarged three-dimensional view and remarkable instrumental precision, which allow working with great finesse. But I want to emphasize an essential point: the robot is a tool, no matter how capable it is. What truly makes the difference is the surgeon's expertise, his deep knowledge of anatomy, and the operative technique he implements. I have been practicing robotic surgery since 2008 and have performed more than 1,500 robot-assisted procedures during my career. This experience, combined with our research work, our scientific publications, and our collaborations with international teams, has allowed us to gradually evolve our techniques. We particularly favor the maximum preservation of the anatomical structures around the prostate that play an essential role in urinary continence and erectile function, when cancer treatment allows it. Regarding erectile function, this preservation obviously depends on the characteristics of the cancer. When the disease is diagnosed early, when nerve preservation is possible from a oncological point of view, and the patient presents favorable conditions, particularly in terms of age and sexual function before the operation, we can obtain excellent functional results. Our philosophy is therefore to seek the best possible oncological outcome while maximally preserving the patient's quality of life. This is this requirement that guides our practice and research work." Your study shows that more than 9 out of 10 patients regain normal urinary control in just 3 months. Is this a return to normal life faster than before? "Yes, and this is precisely one of the most encouraging aspects of our results. In our first series, more than 90% of patients regained satisfactory urinary continence as early as the third month after the intervention. This is a particularly important result when we know how much urinary problems can affect the quality of life after a prostate surgery. But one must understand that these results are from a preliminary analysis. We are currently continuing the evaluation of our patients and updating our data. With a greater perspective, our data under review suggest a continence rate of 97 to 98% at six months. Persistent incontinence situations have thus become rare and can be associated with individual factors, such as certain medical histories or pre-existing functional disorders. These results are not simply related to the use of the robot. They are above all the fruit of significant surgical experience and perfected operative technique over the years, constantly seeking to better preserve the anatomical structures responsible for continence. We are also working to update our results regarding erectile function recovery, with very encouraging results in patients for whom nerve preservation is possible. Our goal is not only to treat cancer effectively but also to allow patients to regain a normal daily life as quickly as possible." What does the success of these first 132 operations represent for the future of medicine and surgery in Morocco and Africa? "These first interventions and the results we have published represent an important step, but I think they must be placed in a much broader perspective. Robotic surgery is not simply a technological innovation introduced in an institution. It is a true discipline that requires years of experience, demanding training, rigorous organization, and permanent evaluation of results. Having started practicing robotic surgery in 2008, I have been able to measure how much this discipline has evolved, both in terms of technology and operative techniques. Today, our ambition is to put this experience to the service of developing robotic surgery in Morocco. The results we obtain show that we can develop a very high level of surgery locally while actively participating in scientific research and exchanges with international teams. Within the AKDITAL group, we wish to go beyond the acquisition of surgical robots: it is about structuring sustainable programs, training teams, developing national expertise, and gradually making these techniques accessible to more patients. I am convinced that Morocco has the human and medical skills necessary to become an important actor in the development of robotic surgery in Africa. True success is not measured only by the number of procedures performed, but by our ability to sustainably improve patient outcomes, to transmit our know-how, and to advance surgery in our country."