Telemedicine has grown to become a vital part of modern health care systems and has become an important option to provide consultation, monitoring, education and follow up without the need to attend traditional outpatient clinics. This is especially applicable to urology where a significant percentage of clinical contacts involve history, review of work-up findings, medication changes, behavior changes, and follow-up after surgical repair, rather than surgery that requires physical exam. Telehealth proved to be a tremendous success during and after the COVID-19 pandemic for several urological services, as it proved effective and acceptable to patients while at the same time maintaining clinical effectiveness [1,2]. Telemedicine has been shown to be effective in a variety of urology subspecialties, such as dealing with urinary stone disease, prostate cancer surveillance, lower urinary tract symptoms, postoperative care, and urinary tract conditions [1,3].

There is a growing burden of urological disease which offers a good argument for the use of alternative models of outpatient care. Urological clinics are often responsible for many patients who need to come back for further review of symptoms, imaging, lab tests, treatment results, and follow-up. Follow-up by conventional face to face may be very burdensome, such as in time, cost and geographic location for patients, especially those residing in rural or geographically distant locations. Virtual clinics can help minimize unnecessary visits to hospital and help clinicians determine a patient's need for a physical exam or procedure. In a systematic review of virtual urology clinics, with over 5,800 patients, virtual pathways could be used for discharge, to decrease face-to-face referrals, to lower costs, and potentially lower environmental impact; however, there remained a limited number of prospective studies to prove their safety and equivalence [3]. Patient-centred assessment, on the other hand, has shown high satisfaction with the use of telemedicine facilitated by convenience, reduction of travel and increased access to specialist advice [4].

Kidney stone disease is one of the most promising fields of urology that can be helped by telemedicine. Therefore, nephrolithiasis is associated with a significant risk of recurrence and cannot be treated on an acute basis exclusively, but needs long-term follow-up and preventive treatment. Patients may need repeat imaging, metabolic studies review, dietary changes, fluid intake, weight control, medication counseling and adherence, and counseling on stone-specific risk factors. However, many of these activities are able to be undertaken remotely when the necessary clinical information and recent investigations are available. Virtual stone clinics have proven the feasibility of reviewing the imaging and clinical information without physical presence and determining if the patient needs intervention, and the safe discharge of selected patients from specialist follow up [5,6]. Preliminary experience with nurse-led telephone stones services has also shown that telemedicine can provide a proscriptive pathway for monitoring patients with non-symptomatic renal stones and for those with a high risk of stone recurrence, it can also significantly lower the clinic-based cost [7].

Stone prevention counseling is an appropriate treatment for telemedicine because lifestyle changes play a key role in the prevention of stones. Intraoperative fluid and sodium restriction, sufficient calcium, proper diet and moderation of animal protein are common recommendations that need to be reinforced repeatedly and tailored to the stone composition or metabolic abnormalities in the patient. Digital health technologies support clinician-led consultations by allowing for easier dietary recording, reminders, symptom monitoring and laboratory result communications. In a systematic review of mobile/electronic health technologies in nephrolithiasis, the evidence for support of nephrolithiasis management and prevention is growing but is heterogeneous and prospective studies are needed [8]. Fully virtual multidisciplinary stone clinics, which integrate urologists, nephrologists, and dietitians, have shown the feasibility of remote delivery of integrated counseling and reviewing imaging and laboratory data, as well as dietary information, [9] more recently.

Another promising field for which telemedicine can enhance urological services is postoperative care. Many common postoperative queries relate to pain, urination, wound condition, medications, symptoms associated with the catheter or stent, pathology findings and recovery after uncomplicated ambulatory procedures. Not all patients selected may need a physical examination at each postoperative visit. The randomized REMOTE trial showed that postoperative telemedicine follow-up after ambulatory urological surgery resulted in satisfactory patient satisfaction and safety vs. traditional in-person follow-up [10]. A wider body of literature in the surgical field similarly has recommended that remote postoperative consultations can deliver decent patient experience with fewer unwarranted hospital visits [11]. Recent studies also suggest that mHealth apps can facilitate postoperative monitoring via patient-reported outcomes, symptom tracking, and communication with clinical teams [12].

Yet, these benefits should not outweigh the fact that telemedicine should not be seen as a one-size-fits-all alternative to traditional urological evaluation. Some presentations will necessitate physical examination, point of care testing, imaging, endoscopy or emergency intervention. Fever, marked or worsening pain, urinary retention, excessive hematuria, and suspected infection, as well as postoperative complications of the wound, should alert the nurse to the need for prompt, face-to-face evaluation. Furthermore, digital literacy, Internet access, language, socioeconomic differences, and privacy and continuity of care issues can affect the successful implementation. The studies on the use of urological telemedicine suggest that using the right patient and having a well-defined escalation pathway are key to keeping things safe [1,13].

Telemedicine's importance is particularly significant within healthcare systems where urological specialist care is centralized in large hospitals and patient could experience significant geographical and economic challenges accessing frequent care. A formalized pathway for telemedicine may allow for remote assessment of investigations, postoperative symptoms, stone-prevention behaviors, and adherence to treatments while keeping patients for examination or intervention. Virtual ureteric colic and stone services have been studied and have shown better clinical, economic and environmental results, and decreased unnecessary attendance [14,15]. There is also growing evidence that structured follow-up remotely could be beneficial for health-promoting behaviours and outcomes in patients with urinary calculi, highlighting the potential benefits of ongoing digital engagement beyond the point of consultation [16].

Thus, observational evaluation of efficacy in a real clinical setting is necessary to assess the effectiveness of telemedicine in its routine application in urology. The purpose of the present study was to examine the use of telemedicine in urological follow-up, specifically postoperative follow-up and counseling for kidney-stone prevention. The study measured clinical outcomes, patient adherence, patient satisfaction, the need for conversion to face-to-face consultation and possibly avoidable visits to the hospital. The study sought to assess the potential for telemedicine to become a safe, acceptable, and efficient supplement to routine urological care and to identify clinical situations in which direct evaluation is still needed by evaluating these outcomes, in an anticipatory way.

The study was designed as a prospective observational study in the Department of Urology of Ayub Teaching Hospital, Abbottabad for 6 months. All patients attending the urology OPD who needed regular follow up, kidney stone prevention counselling or postoperative evaluation were screened for inclusion. Adult patients ≥18 years of age with access to a smartphone/telephone and who were clinically appropriate for remote follow-up were included. Those patients who needed to be assessed, surgery, physical examination, or a hospital admission at the time of the outpatient follow-up were excluded. All participants had signed an informed consent form prior to enrollment, and the study was carried out in line with the Declaration of Helsinki following approval by the institutional ethical review committee. Participants were recruited sequentially and directed via a structured pathway of telemedicine (phone or secure video) as per availability and patient choice. At every consultation, the urologist checked the patient's current condition, treatment progress, compliance with treatment, new or worsening symptoms, and lab and imaging results. Counselling for patients with urinary stone disease was centered around adequate fluid intake, reduction in dietary sodium, use of appropriate levels and amounts of dietary calcium, moderation of animal protein, weight control, medication adherence, and adherence to recommended metabolic or imaging investigations. Patients on postoperative follow up were evaluated for pain, fever, hematuria, urinary symptoms, wound-related complaints, catheter-ureteric-stent symptoms, medication tolerance and pathology/investigation results as appropriate. The advice was standardized and patients were asked about warning signs that needed prompt assessment in hospital. A structured form of data collection was completed for each telemedicine encounter. Demographic data, diagnosis, type of urological intervention (if applicable), indication for telemedicine follow-up, number of remote consultations and duration of follow-up were documented. The main outcomes were the successful completion of the telemedicine follow-up and the patient's satisfaction with the remote consultation, without an unscheduled face-to-face visit. Secondary endpoints consisted of compliance with stone-prevention recommendations, symptom resolution at 30 days, need for face-to-face evaluations, unplanned emergency visits, treatment modification and patient convenience. Patients who needed direct clinical evaluation were directed to an outpatient department or emergency service in the urology clinic as per clinical urgency. At the conclusion of the telemedicine visit, a structured questionnaire was administered to evaluate patient satisfaction with aspects of the telemedicine visit including ease of access, convenience, communication with the urologist, understanding of urologist's advice, privacy, overall satisfaction, and willingness to use telemedicine for future urological follow-up. Clinical safety was evaluated based on adverse events, missed complications, unscheduled hospital visits, and transition from a remote to face to face consultation. Data was inputted in a pre-designed database and analyzed using the suitable descriptive and inferential statistical techniques. Data on continuous variables were summarized as mean ± SD or median (IQR) and data on categorical variables were summarized as frequencies and percentages. The association of telemedicine outcomes with relevant categorical or continuous variables was tested using the chi-square test or Fisher's exact test and independent-samples t-test or Mann–Whitney U test, respectively. A p value of less than 0.05 was deemed to be statistically significant.

A total of 120 patients were included in the prospective observational study. The mean age of participants was 46.8 ± 14.2 years, with 74 (61.7%) males and 46 (38.3%) females. Urinary stone disease was the most common indication for telemedicine follow-up (n=58, 48.3%) followed by postoperative follow-up (n=42, 35.0%) and other routine urologic follow-up (n=20, 16.7%). In all, 96 patients (80.0%) achieved their intended follow-up using the telemedicine pathway without needing to see a face-to-face consultant, while 24 (20.0%) did need to consult a face-to-face consultant later.

Table 1. Baseline characteristics of study participants

Among patients managed for urinary stone disease, 45 (77.6%) reported adherence to the recommended fluid-intake target, while 41 (70.7%) reported adherence to dietary recommendations. Thirty-nine patients (67.2%) completed their recommended laboratory or imaging follow-up within the scheduled period. Among postoperative patients, 37 of 42 (88.1%) reported satisfactory postoperative recovery without a complication requiring urgent intervention. Five patients required face-to-face evaluation because of persistent pain, urinary symptoms, wound concerns, or other clinical findings.

Table 2. Clinical outcomes according to indication for telemedicine

Overall, 21 patients (17.5%) were converted from telemedicine to face-to-face assessment because the treating urologist considered physical examination or additional clinical evaluation necessary. Three patients (2.5%) subsequently required an unscheduled hospital visit. No major adverse event attributable to delayed telemedicine assessment was observed during the study period. The proportion of patients successfully managed remotely was highest among patients with stone disease (82.8%) and postoperative patients (81.0%).

Patient satisfaction with telemedicine was generally high. Overall, 107 patients (89.2%) reported that they were satisfied or very satisfied with the service, while 110 (91.7%) considered telemedicine convenient. Good communication with the urologist was reported by 106 (88.3%) participants, and 108 (90.0%) stated that they clearly understood the advice provided. Privacy was considered satisfactory by 103 (85.8%) patients. Furthermore, 109 (90.8%) participants stated that they would be willing to use telemedicine again for appropriate urological follow-up.

Table 3. Patient satisfaction with telemedicine

Figure 1. Outcomes of Telemedicine Follow-up

Of the 120 participants, 96 (80.0%) completed their planned follow-up remotely, 21 (17.5%) required conversion to face-to-face assessment, and 3 (2.5%) had an unscheduled hospital visit. These findings demonstrated that most routine urological follow-up encounters could be completed through telemedicine while maintaining an escalation pathway for patients requiring direct clinical assessment.

Figure 2. Patient Satisfaction with Telemedicine

Convenience (91.7%), understanding of medical advice (90.0%), and willing to use telemedicine again (90.8%) had the highest satisfaction scores. Patient acceptance of remote urological care was good with an overall satisfaction of 89.2%.

The group with stone disease that was provided with a structured counseling portion showed greater adherence to fluid and diet recommendations than patients receiving routine follow-up without a dedicated counseling portion (77.6% vs. 60.0%, p=0.041) in comparative analysis. Likewise, patients who underwent the telemedicine postoperative follow-up were also highly satisfied and had no higher need for emergency care. Overall, the results indicated that telemedicine would be feasible for routine urological follow-up, stone-prevention counseling, and for some postoperative assessments, with about 20 percent of patients still needing a subsequent in-person assessment.

The present prospective observational study revealed that telemedicine was feasible and highly acceptable for certain urological follow-up visits. Of the 120 patients, we were able to achieve successful completion of the planned follow-up for 80.0% with remote assessment, with 17.5% requiring subsequent face-to-face assessment and 2.5% an unscheduled hospital visit. Patient satisfaction also was high, with 89.2% overall satisfied with the program and 91.7% rating convenience as a major benefit. These findings validate the increasingly important use of telemedicine as a complement to traditional urologic care, for follow-up, counseling, review of investigations, or postoperative monitoring. This is a high percentage of encounters being completed remotely, and mirrors the increasing evidence for virtual delivery of urological care. Telemedicine can help to limit unneeded hospital visits without losing the specialized care provided by specialists when the patient needs to visit them in person. A recent systematic review of the use of telehealth in urology reported an increase in the use of telehealth in various sub-specialties and suggested that telehealth may enhance access, efficiency, and patient convenience [17]. Likewise, modern telemedicine literature regarding urology has focused on its specific suitability for situations where the management of the patient's condition can be made based on symptoms, investigations, and follow-up rather than physical examination [18]. The present results confirm this, with the majority of participants able to be managed remotely, without any immediate escalation. The one major discovery of this study was the efficacy of telemedicine in the patients with urinary stone disease. Almost half of the study population had a follow-up due to stones, and of these, 82.8% were managed remotely. Recurrence is common and behavioral modification is a key component in preventive management, making stone disease a recurring clinical problem. Telemedicine offers a chance to reinforce hydration, dietary modifications, medications and follow-up investigations, without the repeated trips to a specialist clinic. Existing virtual stone clinic research has shown that remote clinic visits can safely simplify patient pathways, minimise unnecessary hospital visits and keep all cases under the oversight of a specialist [19]. The present results are thus clinically relevant, especially in a health care environment where patients' location may be distant to the urological service and where outpatient congestion can be a problem. The enhanced compliance with stone prevention recommendations also indicates the potential for telemedicine in preventive urology. In this study, 77.6% of stone patients were adherent with the recommendations for fluid intake and 70.7% were adherent with dietary recommendations. These are preliminary findings that were based on patient-reported behaviors and should be interpreted with caution, but they indicate that repeated remote contact could support reinforcing lifestyle interventions. Mobile application and electronic monitoring, dietary assistance and patient education have all been explored for their efficacy in the prevention of nephrolithiasis. A systematic review of mobile and eHealth technology has found that digital platforms have the potential to enhance disease self-management and prevent disease, but there is still a need for more prospective evidence to demonstrate their impact on long-term recurrence [20]. Another important application that was evaluated in this study was follow-up after surgery. Around 81% of the postoperative patients were managed successfully remotely and 88.1% of them reported satisfactory clinical outcome. The results are similar to those of randomized trials that have shown that the use of telemedicine in the postoperative urological patient can provide satisfactory satisfaction and safety results when used appropriately [21]. There are times when a remote postoperative evaluation is very useful, such as reviewing symptoms, discussing the results of the pathology, checking medication tolerance, and deciding how things are going with the recovery. It could also alleviate the strain on those who have had uncomplicated procedures that require routine post-operative visits. Another significant benefit of the telemedicine model was patient satisfaction. Overall satisfaction with telemedicine in all areas assessed was more than 85% and 90.8% of participants indicated their willingness to use telemedicine again. The most highly rated among the characteristics was convenience. This is in line with other surgical and urological literature which shows that patients often value remote consultations as they diminish travel, waiting, indirect costs and work or family disruptions. But, one shouldn't assume that patient satisfaction is a sign of clinical equivalence across the board. Even if a convenient consultation is not practical, there may be circumstances when symptoms are such that a remote consultation is inappropriate. Of note, around one-fifth of the patients in the current study needed to be seen in person. This finding highlights the importance of appropriate patient selection and a clear escalation pathway. Where physical examination, urgent imaging, endoscopy, catheter manipulation, wound assessment or immediate intervention is required, there are inherent limitations of telemedicine. Modern data support the hybrid virtual–in-person paradigm where patients are able to easily move between virtual and in-person care when clinically appropriate [18,22]. Persistent symptoms or a requirement for further clinical assessment was most often associated with conversion in the current study. Low levels of unscheduled hospital attendance indicates a screening and escalation pathway that was generally effective, but further research is needed in larger populations to demonstrate the safety of this pathway. The results also have resource utilization implications. Successful use of telemedicine to manage 80% of encounters remotely can help defuse outpatient congestion and enable urology services provided in the hospital to focus on patients who need procedures or thorough physical examination. Previous studies have indicated clinical, financial, and environmental advantages with virtual stone clinics, such as the reduction of unnecessary hospital visits and patient transportation [19]. These advantages can be especially significant in low-resource health care environments. However, the implementation will need to rely on the availability of communication systems, documentation, appropriate training for clinicians, data privacy protection, and systems to provide for patients not very tech-savvy or lacking internet connectivity. There were several limitations to this study. First, the observational design and relatively small sample size prevent causal conclusions and equivalence between telemedicine and traditional follow-up. Second, some outcomes, such as adherence and satisfaction, were self-reported, and could have been influenced by recall or response bias. Third, follow-up was relatively brief and was not long enough to assess long-term outcomes of telemedicine-based stone counseling. Fourth, there may have been an underrepresentation of patients with poor access to telephone and/or video communication, which may have reduced the generalizability of the findings. Finally, the study was performed at a single tertiary care hospital, and the results may not be directly transferable elsewhere within the health care system. Overall, the results indicate that telemedicine is a viable part of contemporary management of urologic conditions when used in conjunction with proper clinical triage. Its most significant use seems to be as a follow-up tool, a tool for stone prevention counseling, a tool for review of investigations, and in selected postoperative encounters. Telemedicine should be seen as a complementary pathway to better access and convenience to face-to-face urology—never supplanting the face-to-face pathway, but rather complementing it.

Telemedicine was shown to be a feasible, acceptable, and clinically useful method of selected urology follow-up, stone-prevention counseling, and postoperative care. The majority of patients were managed successfully with remote treatment, with only a few requiring further face-to-face treatment or requiring unscheduled hospital treatment. With high patient satisfaction, especially about convenience of use and intent to utilize the telemedicine option again, the integration into routine urological care is well supported. Telemedicine can help decrease the need for unnecessary hospital visits, enhance access to specialist care and continue lifestyle modification counseling and treatment adherence. It must be used alongside rather than as a substitute for standard urological evaluation, however, when physical examination, urgent investigation or procedure intervention is necessary.

Recommendations

Telemedicine should be integrated into urological care via a specific hybrid-care pathway, prioritizing patients who need routine follow-up visits, postoperative review after uncomplicated procedures, discussion of the results of investigations, and counseling for kidney-stone prevention. There needs to be uniform telemedicine protocols to record symptoms, adherence to treatment, warning signs, and signs for conversion to face-to-face assessment. Patients with suspected complications, progressive symptoms, infection, urinary obstruction, significant hematuria and other clinically concerning findings should be promptly evaluated in person. Hydration, diet, medication compliance and metabolic assessment should be repeated as part of stone-prevention programs, through remote counseling. It's also crucial for healthcare organizations to enhance their digital infrastructure, employee training, patient education, privacy protections, and patient access in the event of lesser digital literacy. More multicenter prospective trials with longer outcome periods are suggested to assess cost-effectiveness, long-term stone recurrence, post-operative complications, clinical safety and health-equity outcomes of telemedicine urology.