Ahmed E. Ghazi – Revolutionizing and Scaling Surgical Training Through Simulation Models

Ahmed E. Ghazi, MD, serves as the Director of Surgical Simulation Training and the Division of Minimally Invasive and Robotic Surgery at the Johns Hopkins Brady Urological Institute. In addition, he is an associate professor of urology at the Johns Hopkins University School of Medicine.

A specialist in urologic surgical oncology, Dr. Ghazi is recognized as a pioneer in patient-specific surgical simulation, employing state-of-the-art techniques in minimally invasive surgery. His work also focuses on expanding surgical education for aspiring urologic surgeons.

In a recent interview for GU Oncology Now, Advisory Board Editor David Ambinder, MD, of New York Medical College/Westchester Medical Center, spoke with Dr. Ghazi about his journey  from mastering laparoscopic surgery in Europe to advancing robotic surgery at the University of Rochester. Their conversation delved into the evolution of surgical training from open to laparoscopic and robotic techniques; Dr. Ghazi’s innovative use of 3D printing and hydrogel to develop advanced simulation models; and the impact, reception, challenges, and successes in creating and disseminating these groundbreaking tools.

Could you tell us about your training – how you learned laparoscopic surgery, transitioned to robotics, and how that journey led to where you are today?

Dr. Ghazi: That is an excellent question and a great place to start because the inspiration for what I do today really stems from my early experiences. I completed my urology training as a foreign medical graduate at Cairo University, where I underwent a 6-year residency in urology. At that time, laparoscopy was emerging as a significant advancement in the field. To build on my skills, I spent four years in Europe, working in France and Austria. During this period, I earned the European Board of Urology certification and trained with experts to learn laparoscopic surgery.

Laparoscopy was incredibly challenging to master back then. The skill set required, combined with the complexity of the instruments, made it difficult to achieve proficiency. Despite completing four years of training and two certified fellowships, it took a significant amount of personal initiative to refine my skills. At the time, there were no standardized curricula or training programs. Fellowships largely relied on sheer volume; you would perform seven cases a day, three days a week. While this provided exposure, it often meant starting a case but not always completing it, leaving certain aspects of the procedure unmastered.

I came across a small simulation lab that had basic equipment – a lap trainer and a tower. I began developing my own training materials using foam, soft tissue, crumpled paper, and gloves to replicate various aspects of a radical prostatectomy. Over time, I mastered a few complex stitches that had been challenging in the operating room. This hands-on practice demonstrated the value of training outside the OR, though I noticed a disconnect between simulation exercises and real-life surgery.

By the time I became proficient in laparoscopy, robotic surgery was emerging as the next big advancement in urology. I pursued a 2-year fellowship at the University of Rochester, where I began exploring training paradigms and curricula. Most of the literature on these topics came from general surgery, not urology. Drawing from this research, I devised my own curriculum and discussed it with my fellowship director, outlining how I wanted to progress through cases and improve my skills.

During this time, the first iteration of the intuitive virtual reality simulator became available. I practiced on it extensively, both after cases and on weekends. I adopted strategies like warming up before surgeries and recorded my own cases, as well as those of my fellowship director, to narrate and analyze each step. This allowed me to understand the procedures deeply, including step-by-step techniques and necessary modifications.

When I transitioned to a faculty role, I became passionate about addressing the challenges I had faced during my training. I wanted to create a structured curriculum and a realistic simulation platform. This led to my first research project, supported by a small Dean’s Teaching Fellowship grant at the University of Rochester. That initial effort, about 15 years ago, marked the beginning of my journey to transform surgical training and simulation.

You have described your journey, but what was happening around you during that time? How were others preparing, and how minimal were those efforts compared to where things stand now?

Dr. Ghazi: Open surgery never posed a significant need for training outside the operating room. The traditional apprenticeship model worked well – trainees learned directly from the attending surgeon, who could guide their hands, correct mistakes in real-time, and walk them through every step of the procedure. The high volume of open surgeries made this method effective, safe, and reproducible.

However, when laparoscopic surgery emerged, the landscape changed drastically. Mastering laparoscopy required entirely new skill sets, such as advanced hand-eye coordination, working without haptic feedback, and performing intricate suturing in a constrained and challenging environment. During this shift, many experts in the field were still learning these skills themselves. As a result, it became difficult for them to effectively teach trainees. This gap spurred the rise of surgical simulation, which began to gain prominence as a critical tool for developing these new capabilities.

Now, fast-forward to robotic surgery. Not only do we have multiple multi-port robotic systems, but we also have single-port robots and other innovations that continue to evolve. Surgeons must continuously train, retrain, and refine their skills to keep pace with these advancements. This has created an environment where highly realistic surgical training platforms are essential.

Consider something like benign prostatic hyperplasia (BPH). There are now around 40 to 50 different modalities to treat the same condition. As a resident, mastering every one of these techniques is an overwhelming challenge. In the past, we only had open prostatectomy. Today, there are 12 to 16 distinct technologies, such as aquablation, Rezūm, UroLift, and HoLEP, all requiring specialized training. Despite this explosion of complexity, the length of urology residency programs remains the same – five to six years.

This has placed immense pressure on trainees, who must learn three times as much in the same amount of time. Compounding this, patients are now more conscious about academic institutions, frequently asking, “Are you performing the surgery?” This is a common concern, regardless of where you are.

These factors make it clear that if we do not develop robust training paradigms outside the operating room to supplement in-OR learning, we risk falling short in our ability to produce competent surgeons. The current environment demands innovative approaches to ensure trainees are prepared for the complexities of modern surgical practice.

Can you tell us about the work others have done in surgical simulation and how it compares to what you have accomplished?

Dr. Ghazi: The core issue with surgical simulation is that the primary users are those already engaged in patient care, whether they are surgeons adapting to a new technique or trainees like yourself who have been exposed to patient care early on. For example, robotic surgery started as a faculty-only domain, then became a fellowship focus, and now many residents graduate confident in their ability to perform this complex technique. The same evolution applies across various urologic technologies and procedures.

However, if a simulation platform does not replicate the experience of operating on a real patient, it falls short. Many consider cadavers the gold standard for simulation, but cadavers present significant limitations. While they offer excellent anatomical accuracy, their tissue consistency is very different from live tissue. For example, I have encountered cadavers with missing organs or scenarios where we simulate tumors that are not actually there, making them far from ideal for realistic training.

My goal has been to create a simulation platform that mimics the look, feel, and behavior of true surgery. To achieve this, we needed a two-pronged approach: first, develop a technique and platform capable of replicating real-life surgical experiences; and second, rigorously test, prototype, and refine until we achieved accurate tissue consistency.

From the outset, I collaborated with a biomedical engineer and conducted engineering research to explore existing technologies and identify ways to replicate surgical environments. Early on, 3D printing became an integral part of our approach. But instead of directly printing organs, as many others do, we developed a method of printing molds and filling them with hydrogel. This technique allows us to recreate complex internal structures.

I vividly remember one of our first breakthroughs, a small Petri dish with a simulated blood vessel inside. We made the vessel bleed and tested whether suturing could stop the bleeding. It took me 20 minutes to fully control the simulated bleeding, and in that moment, I realized we were onto something groundbreaking.

Another key innovation was using software to segment patient CT scans and develop CAD models, which we then used to create highly detailed molds. What sets our work apart is not just the technology but our relentless commitment to perfection. For every model, we go through 12 to 15 prototypes, continuously refining the design to achieve the highest standards. While we might achieve 80% accuracy by the fifth prototype, the fine refinements in subsequent iterations make the difference between a simulation that feels truly authentic and one that requires imagination to bridge the gap.

This commitment to precision is why we remain a research lab. Unlike commercial ventures that aim to fast-track the prototyping phase, we are dedicated to iterative development. Our focus is on creating simulations that truly mirror the experience of real surgery, and that requires ongoing innovation and refinement.

For what are the models being used?

Dr. Ghazi: Our goal with these models is to create an educational experience, not just to build models for their own sake. Early on, I realized my passion lies in education, so I pursued a full master’s degree in education to deepen my understanding of how people learn. This program, while focused on health professions, also covered teaching methods for learners at different stages, including high school and college. My challenge was to condense the theoretical foundations of education into something applicable in the fast-paced surgical world.

The models we create serve as a medium that we integrate into curricula. We focus on three key areas of training:

1. Long-term Learning

Here at the Brady Urological Institute, we have developed year-long curricula tailored to different levels of residents. Each resident works on mastering specific aspects or procedures – whether it is endourology, reconstruction, robotics, open surgery, or pediatrics. Alongside operating room experience, their training is supplemented by simulation models under the guidance of an expert proctor. This hands-on supervision ensures the training is meaningful. Additionally, residents watch video-based lectures and are regularly evaluated. This approach is resource-intensive and time-consuming, but it produces highly skilled surgeons.

2. Masterclasses

These are short, intensive courses aimed at practicing surgeons or fellows looking to adopt new technologies or refine specific skills. For example, in October, we are hosting a course on prostate enucleation using laser technology. Over 2.5 days, participants undergo a mastery process that includes initial skill evaluations, faculty-guided practice, lectures, live surgeries, and final assessments. By the end, we certify their competency to perform these procedures at their institutions. The brevity of these courses is intentional, catering to the busy schedules of practicing surgeons, while ensuring rapid skill acquisition and competency.

3. Medium-Length Expert Courses

These courses, lasting one to two weeks, focus on more complex transitions, such as shifting from multi-port to single-port surgery. Using the Delphi methodology, we collaborated with 20 experts to identify the essential skills for this transition. We developed a “dome,” a deconstructed model comprising various smaller training modules. Participants receive this dome at their institutions to practice on specific skills. They then visit us to observe surgeries, practice on simulation models, and refine their techniques. The training concludes with proctoring at their institutions for their initial cases.

This structured “packaged learning” approach combines online modules, skill-building exercises, simulation training, and expert-guided practice. By following these steps, participants progress from zero experience to surpassing the typical learning curve within two weeks.

Each phase of these programs integrates our models, ensuring that learners work through challenges before performing their first live cases. This systematic preparation creates a safer and more effective learning environment.

You have essentially formalized robotic and surgical education. Many have tried to move away from the traditional “see one, do one” approach, but some efforts, like virtual simulations, have not fully succeeded. This, however, seems to be taking off. What do the people involved say about it, and what does the data show?

Dr. Ghazi: As a research-driven entity, we prioritize collecting data to assess the effectiveness of our approaches. Our ultimate goal is to replicate the rigor of pilot training in surgery. Pilots undergo the majority, if not all, of their initial training in sophisticated VR simulations. These simulations are highly realistic because the environment—a cockpit with buttons, movements, and visuals—does not disconnect them from reality. Their first real flight, with an experienced copilot and hundreds of passengers, is the culmination of this thorough preparation, referred to as zero flight time training.

In surgery, however, no patient comes with an “operating manual.” While the stakes are different—a single patient rather than a plane full of passengers—the risks in surgery are incredibly high. A surgeon is not just delivering someone to a destination; they are performing a treatment critical to their well-being. This reality underscores the need for our trainees to reach competency before entering the operating room. My vision is for residents to enter the OR operating at a fellow’s level, having already undergone extensive and structured training. This would allow residents to focus on refining skills rather than learning them from scratch.

Other specialties like orthopedics, anesthesia, and plastics are already advancing in this direction, particularly in other countries. However, urology has yet to adopt these standards widely, partly due to resource and funding constraints. While there are barriers, I believe we can overcome them by setting standards and creating accessible frameworks that everyone can use.

Our aim is not to monopolize this field. On the contrary, we want to partner with institutions to share these models and methodologies. For instance, in our single-port curriculums, endorsed by the Endourology Society, we provide fellows with models and online platforms for free. They also receive hands-on proctoring at our events. We have sought societal and industry funding to support this effort and keep it accessible.

We are also developing a tool—still in the early stages—that would allow institutions to manufacture these models in-house. This would eliminate the need for extensive infrastructure and reduce costs significantly. Currently, our annual lab expenses run between $300,000 and $400,000, which is not feasible for most institutions. By enabling prominent institutions to replicate these models and distribute them, we can democratize access to high-quality surgical training.

Ultimately, we hope to collaborate with organizations like the American Board of Urology and other societies to supply these models to programs nationwide. This vision is not just about improving individual institutions; it is about raising the bar for surgical education across the board.

It is unbelievable what you are doing, and it is becoming so much more common over time, which shows your success in implementing this. Can you share a time when you wanted to give up, and how you managed to push through?

Dr. Ghazi: Honestly, there have been too many moments like that. But one of the key lessons I learned during my Dean’s Teaching Fellowship—and from a book called Our Iceberg Is Melting by John Kotter, a Harvard business professor—has been pivotal. The book is a fictional story about a penguin colony facing the challenge of a melting iceberg, and it delves into navigating change and inspiring leadership. One of its main takeaways is the importance of creating a new status quo and celebrating small victories along the way.

For me, the first significant win was when I submitted a video of my simulation to the American Urological Association. It won Best Video, chosen out of all the submissions that year. That was a big milestone. And over time, I have learned to cherish these small wins – like hearing positive feedback from residents or colleagues who use our models and genuinely appreciate them. Just today, I had a simulation session with residents, and they were thrilled, saying, “This is awesome!” Moments like that fuel my passion and keep the fire alive.

I dream of a day when we can say we have played a major role in training a substantial number of urologists across the US and when our models are the gold standard for training – not because we monopolize the field, but because they are widely available, realistic, and truly effective.

The biggest challenges I have faced revolve around spreading this technology. Different institutions often prioritize protecting their proprietary approaches, which can limit collaboration. Despite this, we have had the privilege of distributing many models free of charge, allowing more people to use them and benefit from the training.

To overcome these challenges, our next step is to create a dedicated training center here at Hopkins. It will be a place where people can come to train with these models, learning from experts not just at Hopkins but from other institutions as well. The idea is to establish a consistent training program that sets an example for others.

This program is intended to inspire other institutions to follow suit. If they approach us, I will gladly share our roadmap, saying, “Here is the entire blueprint. Just follow this, and let us collaborate to collect data and build a substantial evidence base that proves what we are doing truly benefits patient care.” It is that vision—and the progress we are making toward it—that keeps me going, even in the toughest moments.

David Ambinder, MD is a urology resident at New York Medical College/Westchester Medical Center. His interests include surgical education, GU oncology and advancements in technology in urology. A significant portion of his research has been focused on litigation in urology.