Revolutionizing Surgical Training With Dr. Ahmed Ghazi: Advanced Simulation Models

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 1 of this series, Dr. Ghazi describes his journey from learning laparoscopic surgery in Europe to advancing in robotic surgery at the University of Rochester, emphasizing the challenges and innovations in surgical training he encountered.

He also discusses the evolution of surgical training from open to laparoscopic and robotic techniques, highlighting the increasing need for structured simulation and training outside the operating room to keep up with rapidly advancing surgical technologies and techniques.

View their continued comments on Innovative Techniques in Surgical Simulation: Dr. Ghazi’s Approach to Perfecting Practice.

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Dr. Ambinder: Could you tell us about your training and how you transitioned from laparoscopy to robotics, and how that journey led you to where you are today?

Dr. Ghazi: The inspiration to pursue this field actually began early on. I completed my urology training as a foreign medical graduate at Cairo University, where I underwent six years of urology residency. At that time, laparoscopy was just starting to gain prominence. I spent about four years in Europe, between France and Austria, where I earned the European Board of Urology certification and learned from leading experts in laparoscopic surgery.

Back then, mastering laparoscopic surgery was quite challenging due to the required skill set and specialized instruments. Despite completing four years and two certified fellowships, it took time to grasp the intricacies involved. I realized that advancing my skills required a proactive approach. There was no standardized curriculum or method for learning, which was typical of fellowships about a decade or two ago. We relied heavily on volume: performing numerous cases—seven per day, three days a week—was considered sufficient. However, this approach meant that there were parts of procedures that we never fully mastered.

I discovered a simulation lab set up in a small room with a lap trainer. I began creating training tools using foam, soft tissues, and paper, trying to replicate aspects of a radical prostatectomy. I mastered a few challenging stitches through this practice and saw the value of training outside the operating room. However, I felt a significant disconnect between simulation and actual OR procedures.

As I became proficient in laparoscopic surgery, robotic surgery emerged as the next big technological advancement in urology. I pursued a two-year fellowship at the University of Rochester, where I began studying various training paradigms and curricula from other surgical fields. I designed my own curriculum and discussed it with my fellowship director, outlining how I wanted to progress through my cases.

The first iteration of Intuitive’s virtual reality simulator had just been released, and we acquired one. I practiced on it during weekends and after cases. This led to the concept of warming up before surgeries. I found substantial value in structured training outside the operating room, which included not only psychomotor skills but also understanding procedural steps and orientation. I recorded all my cases, as well as those of my fellowship director, to analyze each step and its purpose.

When I started as a faculty member, my passion shifted towards transforming the hurdles in training and simulation into a comprehensive curriculum and realistic platform. This led me to begin my research journey with a small project funded by the Dean’s Teaching Fellowship from the University of Rochester. That marked the beginning of my work in this area about 15 years ago.

Dr. Ambinder: Incredible. Now you are at Hopkins, continuing this work. For our listeners, it is worth referencing our previous interview with Dr. Stiefelman, who outlined the significant shifts from open surgery to laparoscopy and then to robotic surgery, which have shaped our current practices. Given this context, how has education evolved? How were people preparing in the past, and how has it changed?

Dr. Ghazi: Open surgery did not present the same challenges for training outside the operating room. In those settings, a surgeon would directly guide the trainee, correcting issues in real time. Open surgery was safe, reproducible, and allowed for an apprenticeship model due to its high volume.

With the advent of laparoscopic surgery, new skill sets were required: hand-eye coordination, lack of haptic feedback, and the complexity of suturing in a confined space. This shift highlighted the need for simulation, as our experts became trainees, leaving many to struggle with teaching these new skills. This is when simulation began to flourish in the surgical field.

With robotic surgery, the complexity has only increased. We now have various multi-port and single-port robots, and new technologies emerge regularly. For instance, there are now around 40 to 50 modalities for treating the same size prostate gland. In the past, we had only open prostatectomy. Today, residents need to master technologies ranging from aquablation to Rezūm, steam, UroLifts, and HoLEPs, among others. Urology residencies still last five to six years, yet trainees are expected to learn three times as much in a more challenging environment. Additionally, patients are more aware of academic institutions, often asking, “Are you performing the surgery?” This raises the need for training paradigms outside the operating room to complement in-situ learning and ensure the competence of future surgeons.

Dr. Ambinder: Indeed, the reduced autonomy and the ongoing need for training beyond residency pose significant challenges. It leaves the next generation of surgeons, including myself, facing a difficult situation.