Zachary Klaassen: Hi, my name is Dr. Zach Klaassen. I'm a Urological Oncologist at the Georgia Cancer Center in Augusta, Georgia. We are live here in San Antonio, Texas at the American Urological Association 2024 Annual Meeting. I'm delighted to be joined today by Dr. Ahmed Ghazi, who is an Associate Professor of Urology and Director of Robotic Surgery at Johns Hopkins Hospital. Ahmed, thanks for joining us today.

Ahmed Ghazi: Thank you, Zach. Thanks for having me.

Zachary Klaassen: So we're going to have a very good discussion today about robotic simulation. You've really been a pioneer in this field over the last several years. So maybe for our listeners, just by way of background, talk through some of the early steps of your program and where we're leading to now.

Ahmed Ghazi: Yeah, that's an excellent question. From the very beginning, I wanted, or I wanted, to create a way in which we can teach surgeons using very realistic tools. So a little bit of background and story, of my story, is I started off doing more than one fellowship. I started off in Europe doing laparoscopic surgery. Then I moved to the US and started doing robotic surgery. And during that whole time, I felt that there was no ideal way to train a surgeon.

Zachary Klaassen: Yeah.

Ahmed Ghazi: There's no perfect way of training. We were training on the go.

Zachary Klaassen: Yes.

Ahmed Ghazi: Right? And adapting or building the plane as we fly, you might say. And so I wanted to really focus on a way in which we could kind of perfect training, and I thought the idea of having a virtual reality simulator was the end-all-be-all.

Zachary Klaassen: Yeah.

Ahmed Ghazi: At that time, Intuitive came out with its virtual simulator. And I was like, "Okay, I'm going to do a lot of studies on this. I'm going to read about educational literature." And unfortunately, it was far from perfect.

Zachary Klaassen: Right.

Ahmed Ghazi: I felt that surgeons needed to feel and recreate the operative experience, and I wanted to do that. And so 3D printing started to show up. I was like, "What if I use 3D printing in a way that nobody's used it before to build simulation?"

Zachary Klaassen: Sure. Yeah.

Ahmed Ghazi: Unfortunately, 3D printing wasn't the solution. We had to use 3D printing to make molds, and then develop hydrogel organs in those molds. But one of the things I knew from the very beginning, they needed to bleed.

Zachary Klaassen: Yes. It's real life.

Ahmed Ghazi: Because surgery bleeds.

Zachary Klaassen: Yes.

Ahmed Ghazi: And it needed to bleed. And I remember the first time we had our prototype petri dish, a small block of hydrogel and a vessel running right in the middle. And it was actually black ink because we couldn't find anything else like blood. And it was bleeding. And I was like, "This looks very realistic." I was throwing a suture, bleeding didn't stop. And I kept going, and I was like, "Okay, fine. We got the idea." I was like, "No, this needs to stop."

Zachary Klaassen: Yeah.

Ahmed Ghazi: And then I, that's when it was an aha moment. This really engages surgeons. And that's what we need. And that was the beginning of the whole journey of developing very realistic organs.

Zachary Klaassen: Absolutely. And I've seen some of your talks. The technology is very, very impressive. Let's fast-forward now to your move to Hopkins. You have a new program called SLICE. Tell us about that.

Ahmed Ghazi: Yeah, the Surgical Learning and Innovation Center of Excellence is really a way in which we can take these modeling organs and put them into a learning platform. So, we developed, with a biomedical engineer, a really novel way and patented the technique of how to develop realistic organs with all the textures that are required. But the missing piece was, how do we train on those?

Zachary Klaassen: Right.

Ahmed Ghazi: And so, I started my endeavor with taking educational professional development courses, something we call fellowships, until I ended up actually doing a full master's in education.

Zachary Klaassen: Wow.

Ahmed Ghazi: And that's where I started to really focus on curriculum development. So SLICE is about incorporating these very ultra-realistic models into an educational pathway.

Zachary Klaassen: I see.

Ahmed Ghazi: Whether it be a long, lifelong learning pathway for residents, where they go through curricula over years, or whether it's something in which we want to optimize a surgical technique, or learn a new technique for practicing surgeons. So those are like weekend, two- or three-day courses, a very short period of time. And so we have a multitude of courses that range from very long ones to very short ones, and it depends on what the learning objective is.

Zachary Klaassen: That's great. I want to get into some of the implications, but I want to take a step back and just talk about some logistics. How long does it take to make one of these molds? How much lead time do you need? Can you do the same operation on the same mold? Do you have to do a new one? Just take us through some of the behind-the-scenes.

Ahmed Ghazi: That's a great question. So, in the first couple of years of starting off the lab, which was basically in a small corner part of an existing lab, we focused on one thing, me and the biomedical engineers, perfecting the texture.

Zachary Klaassen: Yes.

Ahmed Ghazi: So, we had this great opportunity where orthopedic surgeons were using cadavers. Of course, they only used the limbs and the spine.

Zachary Klaassen: That's right.

Ahmed Ghazi: Leaving all the intra-abdominal organs intact.

Zachary Klaassen: Yeah.

Ahmed Ghazi: So we were like, "Do you mind if we take a kidney or a part of a liver or maybe a colon?" And they were like, "As long as you open and sew it back up, we're fine." And we went in, and we took a significant number of fresh organs. We also had at that point a donor that donated what we call a mechanical testing device, an Instron device, and we applied for an NIH grant and got an R03 with an engineering PI. Bringing that all together, we spent the first three years asking, what is the texture of a blood vessel? What's the texture of adipose tissue? What about muscle? What about fascia? What about kidney? What about liver? And we collected all that data. Then we perfected the hydrogel formulation that exactly replicates that.

Zachary Klaassen: Wow.

Ahmed Ghazi: Of course, it's not perfect, but it's very close.

Zachary Klaassen: Yeah.

Ahmed Ghazi: And then, we have this library of data that tells us what a kidney, what a liver, what a colon, what fat feels like. The idea is then putting it all together.

Zachary Klaassen: Right.

Ahmed Ghazi: Now, coming back to your questions about how long this takes, it depends on the outcome. If we want to make a patient-specific model, which is how we started, we need the patient's CT scan. We need to segment that on software, then smooth it out. Then we need to print 3D molds. It's not one; it's a series of molds, so the prostate is about 10 molds. Then we mold every single one separately and then register them together. It's like those Russian dolls.

Zachary Klaassen: Yeah.

Ahmed Ghazi: Where the small one comes up to the large one.

Zachary Klaassen: Just keeps spinning, yeah. That's a good example.

Ahmed Ghazi: That takes about two weeks on its own. That's in a perfect situation. What we've learned is we need to have two tracks: patient-specific simulation, where a surgeon practices on the model beforehand. And we've done this; that was part of the grant. And we showed a significant difference in outcomes in kidney surgery.

Zachary Klaassen: Right.

Ahmed Ghazi: I actually presented that at a debate in the plenary yesterday.

Zachary Klaassen: Excellent.

Ahmed Ghazi: The other thing was a generalized model, a model for training. That came through an educational pathway. We actually published on this, which is the Simulation Innovations Lab's approach to model development. So we get a group of experts through a different way of consensus. We tell them to break down the procedure, and then we look at the educational cues, then there are focused interviews, and we get a consensus. We come up with what you want in a surgical model that's ideal for training, and we make that. Then they prototype it, test it, give us feedback, and then on the 10th version, we get the perfect model.

Zachary Klaassen: I see.

Ahmed Ghazi: That has its molds already printed out. Has its formulations already set, that when you say go, we make four at a time.

Zachary Klaassen: Wow.

Ahmed Ghazi: Or three at a time. And so every week we can pop out three or four of those. Then we create it, we put it in the body cast, and then it becomes... We don't just make a model, we make the entire abdominal wall. So prostate, pelvis, and below. Kidney is umbilicus and above. So you have the entire kind of abdominal wall. Because part of this is, it has to be realistic. It's from access to exit. That's how our models are. It's a full procedural simulation.

Zachary Klaassen: Very fascinating. Coming back to your point you made about resident training versus the established surgeon who's got a complex case, it sounds like this is going to go both directions, right? And I think that's what's fascinating, you could have somebody in, I guess, Georgia, like myself, that says, "I got this case coming up. We need to practice on it. It's a complex partial solitary kidney." Versus the PGY-3 resident, who's getting into the simulator and doing cases on a two-centimeter lower pole, partial. Is that fair that we're going to be going both directions?

Ahmed Ghazi: We will be going in both directions, and there's actually a third direction. A surgeon who is very comfortable with doing robotic surgery, and now there's a new technology called single port surgery.

Zachary Klaassen: Sure.

Ahmed Ghazi: Or a surgeon that's comfortable with doing a TURP, and now there's HoLEP, etcetera, etcetera. The amount of technology that is being immersed into urology on a daily basis is incredible. And surgeons have to adapt to that. And we know now that we have to be facile enough to do this. At the same time, this is a very busy surgeon that doesn't have a lot of time.

Zachary Klaassen: Yeah.

Ahmed Ghazi: They want to come, work with experts, get the information, and then get proctored by it. So we just showed an abstract today that was about a master class. It was done using a very educational approach, educational pedagogy, and evaluated using the same approach. And what it is, it's a three-day master class.

Zachary Klaassen: Okay.

Ahmed Ghazi: And we've done it in a way in which the trainee comes, all the didactics are online. You do that—

Zachary Klaassen: Before you even come.

Ahmed Ghazi: ... before you even come.

Zachary Klaassen: Yep.

Ahmed Ghazi: You come in hungry to learn. You do a simulation, we evaluate you. Then you do a second simulation, get feedback from the experts, and the expert now has your evaluation, saying, "Oh, now I know what I need to work on. Because you're already a good surgeon. You're already a competent surgeon, but there are certain things we need to work on." Finally, they do a simulation to evaluate themselves—

Zachary Klaassen: I see.

Ahmed Ghazi: —before they leave. Then they go back to their home institution, and we then work to proctor them. It's full cycle training.

Zachary Klaassen: Yeah.

Ahmed Ghazi: And that way you're not only effective but you're efficient. Right? So in a matter of a week, you've turned them not from a competent to a proficient surgeon; they've become a competent robotic surgeon to a competent single-port surgeon. Or a competent endoscopic surgeon to a competent HoLEP surgeon. That's the switch that happened. We're not saying we got them to an expert level, but we put them to the level of safety.

Zachary Klaassen: Yes.

Ahmed Ghazi: Then they start to go through their own learning curve. Alternatively, they would just do a couple of cases, maybe get some bad results and stop doing it, maybe get some good results, get overconfident, do a case, and then have a complication, then stop doing it.

Zachary Klaassen: Yeah.

Ahmed Ghazi: That's the issue. The majority of these courses are run by industry, which is not a bad thing, but the industry focus is not education. We want to get supported by industry through equipment, but also supported through educational grants and philanthropy, to build an ideal educational framework, that can then be exported to other areas. We're not focused on just isolating it in SLICE.

Zachary Klaassen: Yes.

Ahmed Ghazi: We want SLICE to propagate this learning to other areas, but we feel where we are, we are best equipped to be able to introduce that, validate it, and formulate it.

Zachary Klaassen: Yeah. That's well said. And you kind of took the next question out of my mouth, in terms of, let's fast-forward 10 years. SLICE is up and running, we're proctoring people. Is this technology and this curriculum you're developing, is it generalizable to the other 140 programs, 5 years, 10 years, 15 years? How do you see it over the next little bit?

Ahmed Ghazi: That is definitely the goal.

Zachary Klaassen: Yep.

Ahmed Ghazi: When you start talking about education, you can't be exclusive. Our goal is, we feel we have the right kind of support, the equipment, the mindset, to start to develop this and formulate the structure of it. We then aim to have SLICE 2, 3, 4, 5, 6, where other institutions that are interested in providing the same level of care, and the same level of training, would partner with us.

Zachary Klaassen: Yeah.

Ahmed Ghazi: And yes, we would co-brand it, of course, but the idea would be that—

Zachary Klaassen: Spoke and wheel, kind of get things out there.

Ahmed Ghazi: Yes, exactly.

Zachary Klaassen: Yeah.

Ahmed Ghazi: And so, any model that's developed at the main center goes to all the other centers. Anything that they develop and start to innovate further comes back to us. It's a collaboration. We would train their engineers, we would train their personnel, and then the idea is, SLICE on its own cannot train the entire US, nor the entire world. But having franchises or other centers that are collaborative with us, would definitely be able to train the entire US. My goal is that this is the standard of training. We don't sacrifice one animal or one cadaver to train somebody. Nor do we expose a patient to a suboptimal surgeon who has not reached their peak in simulation. Our goal is that this is the standard training throughout urology, and maybe even throughout the entire surgical world.

Zachary Klaassen: Sure. It's fantastic. It's been a great discussion. I feel like we could talk for another hour about this. But maybe give our listeners a couple of take-home messages, just to wrap things up.

Ahmed Ghazi: I'm very thankful for this opportunity to really be able to expose SLICE to the world. Our goal is purely to be able to perfect surgical practice. And what we need for that start is really the know-how or the interest in what we do. We're going to start developing courses already. We are starting in a space that is equipped, until our permanent space is ready. If you want to really train something, we have to have our own building that is custom-built for this. But we're going to start running courses, we're going to have industry support. It is going to be for a fee, just because you have to have some skin in the game. We feel that, but at a very nominal one. And we want people who are interested in collaborating with us to reach out to us because we are more than happy to extend our hand to do that. Now, I think SLICE is the future of surgical training, and we're hoping that we can standardize that.

Zachary Klaassen: That's great. Thanks so much for your expertise, your time. And congratulations on the work so far. It's exciting to see how things are going to play out over the next few years, so thank you.

Ahmed Ghazi: Thank you very much, Zach. And thank you for this opportunity.

Zachary Klaassen: Fantastic.