During the hardest phase of the pandemic, in each single country, the majority of the population encountered restrictions, affecting their daily routines. In particular, the avoidance of physical contact was stressed following the #stayathome trend. Focusing on health services, the follow-up ambulatory visits for benign pathology were postponed or cancelled, also in Italy .
In this context, to cope with the COVID-19 pandemic, the use of telemedicine for patients’ health management steps into the limelight, even in urology. Telemedicine represents a peculiar instrument which, when used for selected populations of patients, can be compared to traditional counseling, as stated by Novara et al . Thanks to this instrument, physicians can offer effective and high-quality clinical consultations.
In order to fill the blank of official guidelines concerning the correct execution of a telemedicine counseling, Socarrás et al  outlined its main principles and characteristics, highlighting some crucial aspects such the maintenance of professionalism, privacy, confidentiality whilst reaching satisfying levels of data transmission and comprehension.
Our study reported the data of more than 600 phone counselling for urological benign pathology: notwithstanding the simple call may seem an obsolete approach for telemedicine and may even seem inadequate for clinical visits, it perfectly matches the recommendations of the European Association of Urology . In fact, the phone call, performed by using hospital phones, can be considered the first and easiest approach for telemedicine, as reported in previously published experiences, for the management of prostate cancer , hematuria , stones [13, 14], urinary incontinence [15, 16] and urinary tract infections .
Focusing on clinical findings of our study, it is worth noticing that all patients presented a benign disease (mostly BPH), and only in 8% of the cases a worsening of the clinical condition was recorded, and in 12.5% of the cases a traditional visit within two weeks was recommended. No patients required to go to ER for an urgent visit. On the contrary, most of the interviewers reported stability of the symptoms. Thus, phone counselling made by medical staff allowed to perform a triage to discriminate the patient's clinical condition with a subsequent optimization of the hospital resources, allowing the access to patients with a real need.
Another important finding was that more than 80% of the patients were more worried about the viral infections than their urological diseases. Moreover, 66% of patients stated their intention to postpone their visit due to COVID-19 emergency. These percentage was very high probably because the patients were affected by benign diseases, with a clinical stability in 85% of the cases. On the contrary, in our series for oncological disease, only 20% of the patients would postpone their treatment ; whilst in Rodler et al experience, 56% of the patients were more anxious about their malignant disease than about COVID-19 .
However, the most interesting findings of our study concerns the evaluation of patients’ perception on telemedicine approach. In 88% of the cases the appreciation for this telematic approach was rated 5/5 (“absolutely appreciated” by using the five-point Likert scale). These findings are in line with our previous experiences evaluating the perceptions of patients waiting for urological procedures during COVID-19 lockdown at our center, which reported a high appreciation for telemedicine in 72% of the cases . As expected, this value decreased to 46% when we evaluated its potential application in post-pandemic era, probably due to the scarce knowledge about this kind of approach by the patients.
Notwithstanding these encouraging findings, our analysis showed that the patients are not ready for a more modern telemedicine approach, such as tele-visiting. In fact, the 53% did not have an adequate support (PC, tablet, smartphone); moreover 68% of patients declared that, even if available, they would not have the instruments to perform an online visit. A 2019 survey reported by Cacciamani et al investigating the popularity of telemedicine in the US, showed that lack of access (34.6%) and poor awareness (39.7%) of telehealth options represent the main limitations to the spreading of this instrument , with an estimated 10% of Americans to have experienced a telehealth visit. In fact, the most popular tools for virtual communication resulted to be, in decreasing order of preference, phone call (76.9%), e-mail (56.7%), patient-reported outcome applications (22.0%), and video call (14.3%), as reported by Rodler et al .
It is important to note that telemedicine represents a new area for both physicians and patients. The latter, particularly when elderly, may be unable to effectively use electronic devices, making an electronic consultation hard to perform. As suggested by Sosnowski et al , the urologist can play an essential role in offering the patient the best option, choosing the most appropriate communication tool, and considering all the variables and the patient’s needs and preferences. The role of caregivers should also be maximized and integrated inside this context, since they can be helpful in the communication process. Moreover, in this setting, patients should be able to get in touch with the physician as soon as a new problem arise, in order to promptly schedule a follow-up visit.
The main limitation of the present study should be mentioned. Phone-counselling allowed to perform a triage visit without the chance to adequately evaluate blood tests or radiological exams, and no change in pharmacological therapy was suggested, intrinsically limiting the in-depth analysis of clinical investigation of this kind of approach.
However, taking together all of these findings, one can argue that even if telemedicine is highly appreciated both by doctors and patients, current health care infrastructures remain inadequate and low access to computers of the patients represent the main challenges for a real transition to telemedicine in current daily clinical practice. Therefore, health practitioners should become increasingly familiar with telemedicine and, at the same time, national and regional initiatives to improve patients’ digital “literacy” should be implemented.