Innovative Techniques in Surgical Simulation: Dr. Ghazi’s Approach to Perfecting Practice

GU Oncology Now Advisory Board Editor David Ambinder, MD, of New York Medical College/Westchester Medical Center, sat down with Ahmed E. Ghazi, MD, of Johns Hopkins Medicine, to discuss in length his groundbreaking work on advanced simulation models as a urology training resource.

In Part 2 of this series, Dr. Ghazi discusses the challenges and innovations in surgical simulation, emphasizing the need for simulation platforms that replicate real surgery experiences more accurately than cadavers.

He describes his development of advanced simulation models using 3D printing and hydrogel, and details the structured educational programs he has implemented, including long-term curricula, masterclasses for advanced techniques, and medium-sized expert courses, all designed to enhance surgical training and proficiency.

View their continued comments on Scaling Surgical Education: Dr. Ghazi’s Vision for Global Training Standards.

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Dr. Ambinder: Tell us about what has been done in the field of surgical simulation, beyond your own contributions, and then describe your own work in detail.

Dr. Ghazi: The core issue with surgical simulation is that those who use it the most are often either experienced surgeons needing to adapt to new techniques or trainees who have had substantial exposure to patient care from an early stage. Initially, robotic surgery was largely faculty-driven, then it became fellowship-focused, and now many residents graduate with confidence in this complex field. This pattern applies across various urology technologies and procedures. Those engaging with simulation are generally those who have already experienced patient care, which is often considered the gold standard.

However, if a simulation platform does not replicate the real-life experience of operating on a patient, it falls short. Many people believe cadavers are the gold standard for simulation. Yet, in my experience, cadavers present significant challenges. The tissue consistency is different from live tissue, and cadavers are often not ideal for certain procedures. For example, finding a prostate in a cadaver and performing a semi-prostatectomy or pretending to remove a tumor when there is not one can be difficult.

My goal was to create a simulation that mimics real surgery as closely as possible. To achieve this, we developed a platform that involved extensive testing, prototyping, and retesting to ensure that the tissue consistency closely mirrors what is encountered in real-life surgeries. I began by collaborating with a biomedical engineer and conducting my own engineering research to understand existing technologies and develop a suitable training platform.

We initially explored 3D printing, but early on, it became clear that directly printing organs was not the solution. Instead, we printed molds and then poured a hydrogel into these molds to create structures with realistic characteristics. I recall an early experiment where we used a Petri dish to simulate bleeding from a small vessel. I spent nearly 20 minutes controlling the bleeding and ensuring the vessel was sealed. This experience affirmed that we were on the right path and had a foundation to build upon.

We also acquired software capable of segmenting CT scans to create CAD models for mold development. What sets our work apart is our dedication to perfection. We develop 12 to 15 prototypes for each model to continually improve and reach a high standard of realism. It is this attention to detail that distinguishes our simulations from others that might not fully replicate the surgical experience.

Dr. Ambinder: That is incredibly impressive. I have observed the development of your prototypes and the challenges you have overcome. It is fascinating to see how your models have evolved.

With that in mind, how is this technology being used?

Dr. Ghazi: We designed these models to enhance educational experiences. My passion extends beyond model-building to education itself. To deepen my understanding of educational theories, I pursued a master’s in education, focusing on health professions but also exploring broader educational concepts. The goal was to integrate these theories into practical applications for the fast-paced surgical world.

We use our models as part of comprehensive curricula. At the Brady Urological Institute, for instance, we have developed curricula for different resident levels. Residents go through a year-long program mastering specific procedures—such as endourology, reconstruction, robotics, or pediatric open surgery—complementing their OR experience with simulation models. These sessions are guided by expert proctors, who provide essential feedback. This approach ensures a structured and thorough learning process, though it is time and resource-intensive.

We also conduct masterclasses focused on new technologies. For example, we have an upcoming course on prostate inoculation with lasers. This course targets practicing surgeons and fellows seeking to refine their skills. Over two and a half days, participants undergo mastery training, including evaluations, hands-on practice, discussions, and semi-live surgeries. We assess their skills before and after the course, certifying them to perform these procedures independently at their institutions.

Additionally, we offer medium-sized expert courses, such as those for single-port surgery. We provide a model that breaks down the skills required to transition from multi-port to single-port surgery. Surgeons receive this model, train on it, then come to our center for hands-on practice and observation. Afterward, we proctor them for their initial cases back at their institutions. This “packaged learning” includes online modules, practice on skill-specific models, hands-on simulation, and initial proctoring. This comprehensive approach helps trainees quickly progress from novice to competent practitioners.

Dr. Ambinder: That is extraordinary. You’ have essentially systematized surgical education.

Dr. Ghazi: That is exactly what we have aimed to do.