There are different modalities of how to apply telemedicine effectively, always keeping in mind the final objective that will be to provide a quality medical consultation at a distance. The most used format is video consultation, and it consists of a live face-to-face electronic audiovisual interaction between the physician and patients. Despite the limitations of not being able to perform a proper physical examination, video visits have proven to be a reasonable alternative to traditional in-person visits (3).

In a survey published by Chu et al., of more than 1000 patients in the United States, 95% rated satisfaction with video consultations from very good to excellent, and 80% of urologists rated the encounters as excellent. Among the advantages that patients list for this type of modality are: equal consultation times, less waiting time, reduced time off work for the patient, and no travel expenses (7).

In another study done by Bohem et al. 84.7% of interviewed patients wished for a telemedicine consultation in urology rather than a face-to-face consultation, while physicians considered that most patients (63.2%) of their regular clinical practice were judged suitable for telemedicine (8).

Other possible methods for teleconsultation include email, text messages, and other specific software platforms for instant messaging. In the case of older patients, less used to modern technologies and software, the use of telephone calls is a valid and very accepted practice that allows fluent communication between the health care professional and the patient (44).

There are three main types of telehealth applications: synchronous, asynchronous or store forward, and remote patient monitoring (9, 10). Synchronous telehealth applications (in real-time) are carried out through remote visits. Asynchronous applications involve the collection and storage of health information for later review, these include electronic consultations and communication with patients through a health portal. Remote patient monitoring is a type of asynchronous telehealth that involves the regular collection of patient health data, such as vital signs, and transmission to a provider for monitoring or response. Finally, telehealth can provide education and training activities for residents and urologists (telementoring), and surgical procedures can be transmitted live to distant audiences. In recent years, urology training has undergone gradual modifications according to the escalation of the alter level in each country for COVID-19 (11, 34). In general, interhospital training instances were suspended, residency admission exams were delayed and face-to-face academic activities were stopped, initiating a new stage in scientific dissemination where software like Zoom Meeting, Skype, Webex Cisco, among others, play a fundamental role (11, 28, 44, 45). In the article by Claps et al., the residents provided a perspective on the potential educational value of smart learning, defined as any modality of teaching activity carried out through virtual platforms or online communication channels. The acceptance and impact on the training of residents was considered positive in each of the educational platforms (46). In a survey developed by Amparone et al. on 351 residents, the negative impact on both clinical and surgical activities was evidenced, highlighting the importance of telehealth with virtual training platforms as a fundamental ally in the training of residents in the pandemic and the first years of the post pandemic by COVID-19 (47).

The new virtual courses and lectures produced during the pandemic allowed urology residents to tailor courses to their interests (29). These courses prompted discussion of a shift towards standardized virtual-based curriculums for programs (30, 31). Though virtual didactics may facilitate ease of attendance, that does not always translate into increased participation. Several virtual sessions per day may lead to fatigue, and the ability to attend didactics remotely has created an expectation that residents attend all meetings, regardless of their location or scheduled.

The current literature indicates that telemedicine in urology has proven to be useful in a variety of clinical scenarios within a urological practice, from benign disease to advance cancers, and from the initial diagnosis to follow-up. In the review published by Novara et al., clinical scenarios ranging from decision-making process to follow-up in prostate cancer, uncomplicated urinary stones, and urinary incontinence have enough evidence in the literature to be highly recommended to be managed safely and efficiently by teleconsultations (14).

Telemedicine not only complies with the current demand of social distancing in order to avoid possible outbreaks in the hospital waiting rooms, public transportation or other places related to health care providers and patients' mobilization. In some rural and underserved areas, with notable workforce shortages, specialized teleconsultations play an important role, improving patients access to care in a more time efficient, safer way (6, 44). Most of the regular follow-up visits of chronic, well-controlled disease can be safely managed with a short video or telephone consultation in which the physician or nurse has access to laboratory or imaging tests (44).

Most of the initial limitations of this practice have been removed and allow personal and patients to gain experience and become used to schedule video consultations or telephone consultations. Telemedicine is yet to be widely accepted in the urological community due to several limitations pertaining to patient and physician acceptance, licensure and liability, costs, safety, ethical considerations, and changes in workflow (37).

Some health care authorities and professionals worried initially that telemedicine technologies will result in an unequal distribution of health care resources, as telehealth companies are focused on providing software for well-resourced patients in order to expand their presence. But the truth is that in low income communities, some easier and less sophisticated methods of telemedicine such as telephone calls, can help these population to get access to specialized care (6, 38).

Telemedicine activities should be carried out using a secure and robust internet-based network, which generally involves the use of a virtual private network combined with end-to-end encryption software that meets recognized standards. The goal should be to transmit and store data securely at all times. There are several internet-based video conferencing software programs that are commercially available for synchronous applications, but the electronic medical record is all that is required for asynchronous applications. Currently, there are commercially available platforms like EPIC ® medical record system and NHS Attend Anywhere ®. But Zoom, Doxy.me, WhatsApp, and Skype are also used with great frequency. Technological failures can cause interruptions during the practice of teleconsultation, and therefore a plan should be ready in this case, health care providers and patients should have contact information for technical support at all times for case troubleshooting (3, 48).

At the patient level, there are some important possible barriers in the practice of telemedicine. While telehealth is intended to greatly improve patient access to medical care, access to technology remains a limiting factor. In older patients, there can be troubles in adopting the technology and devices needed for telemedicine (15, 49).

On the other hand, difficulties have also been identified in implementing telemedicine at the provider level. While most physicians are familiar with telemedicine, many report limited experience with its use. Carrying out telehealth, particularly those modalities that use newer technologies, requires more than medical training (16, 17).

The lack of experience in teleworking and telehealth could precipitate challenges for health care providers, which include scheduling teleconsultations, attending remote team meetings, maintaining self-discipline, keeping away distractions, avoiding feelings of loneliness, and creating a professional work environment (50).

In a survey developed by Dubin et al., 620 urologists from 58 countries on five different continents showed that approximately half of the urologists surveyed have never used telemedicine in their life. When addressing the key barriers to telemedicine use for those that had experienced, the top three reasons were: patients' lack of technological understanding, patients' lack of access to the required technology, and concerns about reimbursement. Another major barrier found was the lack of administrative support, which was the fourth most mentioned barrier to the use of telemedicine (18).

Another interesting point against telemedicine, from another study, was that some clinicians felt that increased reliance on telehealth could disrupt the patient-provider relationships (10).

Adherence to security policies for patient data is essential, as is carried out in face-to-face visits and telemedicine support programs, in any of their modalities should guarantee them.

The differences in the regulations of each country directly impact the reimbursement models for telehealth services, providing a significant barrier to their implementation. Collective strategies vary even in the same country (10). A common restriction is on the applicable technology. Since many countries or states specifically restrict their definition of telemedicine to real-time technologies, asynchronous technologies and remote patient monitoring are rarely reimbursed. Similarly, email, fax, and telephone, while frequently used to provide continuing medical care, are rarely accepted forms of telemedicine for reimbursement (19).

Patients with urological malignancies have a greater number of risk factors for a severe course of COVID-19 than patients with non-oncological diseases (8). The emergence of the pandemic resulted in rapid and widespread adoption of telemedicine. Urologists quickly adopted telemedicine to facilitate social distancing, continue to care for their patients and keep practices economically viable. During the annual 2020 AUA census, as much as 71.5% of urologists reported engaging using these practices during the COVID public health emergency (32, 51).

Thus, in most of the published studies, there is evidence of high assimilation of telemedicine by both patients and professionals. There are publications related to the use of telemedicine in the different subspecialties of urology, such as pediatric urology, andrology, urogynecology, and oncology. Although the main limitation is the impossibility of performing a physical examination, all the studies evaluated in this review highlight the high rate of patient and professional satisfaction (20–22, 33, 52).

Given its proper use and always being aware of its limitations, telemedicine has an opportunity as a safe and efficient alternative for the management of uro-oncological patients in many situations. Health care in this setting should be personalized according to patient and disease characteristics as much as possible and an initial basic triage is mandatory to identify those patients who require to go to the hospital for a physical examination, procedure, or admission to the emergency department (23). Although the use of telemedicine in urology has been successfully implemented even in acute management pathologies such as ureteral colic, reducing face-to-face consultations during the pandemic (24).

As explained before, the key limitation is adequate access to technology, especially in the older patients. This disparity in technology is underlined by a recent study in Italy showing that more than half of patients contacted regarding benign urological conditions did not have access to the technology required for a telemedicine visit. As telemedicine continues to grow, it needs to do so while addressing the needs of vulnerable groups (25, 35). Telemedicine is better suited for long-term follow-up as well as reports on chronic illnesses (36).

Regarding the modality, one study compared patient satisfaction between teleconsultation (TC) and videoconsultation (VC). Forty-eight urology patients who were managed by TC and 66 VC patients were included. The differences between the two groups of patients were small but tended to favor VC. Patient satisfaction was higher with VC compared to TC. Both modalities were associated with many cost benefits for patients (26).

The European Association of Urology (EAU) published a series of recommendations in order to promote best practices in telemedicine use (27).

Here we provide a summary of the key recommendations:

- Stay up to date on innovative strategies and learn to use platforms and tools that enable communication with patients, communication with team members, and secure data exchange.

The spread of telemedicine is reliant on health policy as it would allow and encourage the use of telemedicine to improve the cost, quality, and access (39). The characteristics of telemedicine are clearly in favor of the patient in terms of comfort and privacy; however, the reimbursement and incentives do not align with this modality (40).

You want it then you get it; important computer systems are not always necessary when developing telemedicine protocols to facilitate public health access to the entire population. Interventions of the Simple Messaging System (SMS) can occur even without data service. A simple protocol has been carried out and has shown great promise in developing countries (41). Telemedicine allows providers to reach remote areas of developing countries where broadband is not strong, but a cellular network exists. This protocol does not require a data network, but instead transmits small message packets over a cellular network (42). But the telemedicine modality is not free. There are significant costs up front and some basic training for both vendors and staff to use the technology safely and effectively. Ongoing costs are typically negligible, certainly less than the incremental cost associated with expanding clinic space. The initial costs for patients are almost negligible if the patient already has the technology with which he will be able to access the telemedicine system (43).

Telemedicine continues to increase in prevalence around the world but there are barriers to the adoption of telemedicine and its correlation with health policy. The barriers consist of current health policy that limits providers within states, the cost of implementation, ethical concerns, limited resources, the digital age divide, and the current reimbursement model. As this new modality of care becomes more widely accepted and preferred, nations health policy will need to adjust and expand to govern and monitor it while incentivizing providers and patients to use it (40).

The present study is not devoid of limitations. Although this review was carried out in detail and the available works were of good methodological quality, since it is a narrative review, the selection of articles may be biased according to the criteria of each of the authors when including or excluding articles for this review.