Sun Tzu’s The Art of War is a 2000-year-old textbook on warfare principles. It is one of the most widely used books on military strategy. This article aims to compare the practice of urology to the campaign of war.

Sun Tzu says, “Military action is measured in 5 things: the way, the weather, the terrain, the leadership, and discipline.” These 5 factors can be applied to surgery. In surgery, the battlefield can be likened to the operating room; the surgeon is the general, flanked by a team of soldiers. The enemy is the procedure, whether it be routine or complicated. The battle is the struggle to complete that task expeditiously without complications.

The “way” refers to motivating people to have the same aim as the leader. The way also refers to humaneness and justice. A confident urologist who has a full grasp of the surgical procedure will confirm that all those assisting have the same goal of enhancing the patient’s well-being.

The “weather” represents the timing of surgery. Just as a general would try to avoid fighting a battle during severe conditions, the surgeon must choose the right time for any surgical procedure. Questions to be considered before initiating surgery can include the following: Have preoperative laboratory and imaging studies been reviewed? Does the patient need preoperative antibiotics? Are any consultations needed?

The “terrain” refers to an assessment of the battleground. The surgeon must always accurately determine the state of the tissues approaching the target to be removed or repaired. The urologist can review imaging to select the approach that is ideal. If a surgeon chooses the wrong path through bad terrain, difficulties or a surgical complication may be lurking.

“Leadership” is the ability of the general to motivate and control his forces. The urologic surgeon must realize that complex tasks require the skilled cooperation of the entire team in the operating room.

“Discipline” is the attitude of the soldiers. Sun Tzu says, “When there is effective leadership, there will be good discipline among the troops.” Similarly, a good surgeon should garner his subordinates’ unfailing cooperation and attention for the entire operation.

If any of these 5 elements are absent before making the incision, Sun Tzu would likely suggest that you defer any surgery until these conditions can be improved.

Sun Tzu believed that skilled military operations should be short as there is rarely any benefit in a protracted campaign. Prolonged surgeries may be the norm in operations such as cystectomy, stricture repair, or renal transplant, but moving expeditiously is almost always a benefit. Let’s remember that as the day and the case draw longer, their assistants and their own hands may fatigue, affecting concentration and team efficiency. Ultimately, exhaustion sets in, mistakes are made, and the chances for success can become more challenging. Many of us have experienced this and have learned to schedule complex cases to be the first case of the day, when the urologist and the assistants are at their best.

Overly enthusiastic and overconfident urologists can be careless. The strict, inflexible urologist may regret taking on a specific procedure. Another trap occurs when the compassionate, sympathetic urologist is troubled by their emotions. If a urologist is too emotionally involved with a patient or a procedure, it may be prudent to bring in a different team (ie, a new “general” to be the commander).

Sun Tzu emphasizes the importance of being adaptable and flexible to the situation. A strategic-minded surgeon knows when to exercise caution, when to be eager, when to be strict, and when to show restraint. Bringing a new, unsettling, and unexpected diagnosis or prognosis to an unsuspecting patient and family can require a unique set of skills that every urologist must develop.

Knowing yourself refers to identifying and acknowledging one’s limits and performing surgery only within one’s capabilities. Knowing others becomes essential when the urologist finds themselves treading in unfamiliar territory. Urologists cannot practice in isolation; the surgeon should not allow pride to get in the way of enlisting assistance from others. The urologist should never be ashamed to request the help of other colleagues who may be better equipped to handle various challenges.

Sun Tzu says, “There are only two kinds of charges in battle: the unorthodox surprise attack and the orthodox direct attack, but variations of the unorthodox and the orthodox are endless.” Sun Tzu encourages his generals to keep their minds open and explore various ways of attack, from traditional methods to unconventional ones. Likewise, surgeons must realize that multiple options may exist to achieve an objective. Regarding surgical management decisions, surgical approaches, suture material, and even nonsurgical considerations should be the palette from which the urologist selects.

Sun Tzu wishes to stimulate his generals to invent and generate fresh methodologies. The wave of research and innovation is constantly advancing. With it, we have benefitted from stem cell therapies, advances in robotics, minimally invasive techniques, sophisticated pharmacological agents, and now the application of artificial intelligence to the urologist’s armamentarium. Urologists will continue to think “outside the box” and open new frontiers of surgical managements.

Sun Tzu teaches that to be genuinely skillful, one should win battles without direct confrontation. Just as modern warfare has evolved with stealth weapons, indirect “warfare” is also prevalent in urology. The use of robots has revolutionized urologic surgery. Minimally invasive tools and sophisticated imaging techniques have been developed to view prostate cancer in its earliest stages. And now, computer-aided navigation has introduced yet another formidable tool to fight our surgical battles from afar. In urologic surgery, Sun Tzu’s words portend an age where modern technology has enhanced the capabilities of the urologic surgeon to a level never imagined just a decade ago.

Bottom Line: By adopting the principles from The Art of War, urologists can navigate the complexities of the health care landscape more effectively, leading to improved patient care and overall success in their practices.

Dr Mobley and Dr Baum are the authors of Prostate Cancer: Expert Advice for Helping Your Loved One (Johns Hopkins Press, 2023).