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Understanding virtual urology clinics: a systematic
review
Marie Alexandra Edison
1
, Martin John Connor
1,2
, Saiful Miah
3
, Tamer El-Husseiny
1
,
Mathias Winkler
1,2
, Ranan Dasgupta
1
, Hashim Uddin Ahmed
1,2
and David Hrouda
1
1
Imperial Urology, Imperial College Healthcare NHS Trust, Charing Cross Hospital,
2
Division of Surgery, Imperial Prostate
I Department of Surgery and Cancer, Imperial College London, London, and
3
Department of Urology, Wycombe
Hospital, Buckinghamshire Healthcare NHS Trust, Amersham, UK
Objectives
To perform a systematic review to identify the clinical, fiscal and environmental evidence on the use of urological telehealth
and/or virtual clinic (VC) strategies, and to highlight research gaps in this rapidly evolving field.
Methods
Our PROSPERO-registered (CRD42019151946) systematic search of Embase, Medline and the Cochrane Review Database
was performed to identify original research articles pertaining to adult urology telehealth or VC strategies. Risk-of-bias
(RoB) assessment was performed according to the Cochrane 2.0 RoB tool or the Joanna Briggs Institute Checklist for non-
randomized studies.
Results
A total of 5813 participants were included from 18 original articles (two randomized controlled trials [RCTs], 10 prospective
studies, six retrospective studies). Urology sub-specialities comprised: uro-oncology (n=6); general urology (n=8); endo-
urology (n=2); and lower urinary tract symptoms and/or incontinence (n=2). Across all sub-specialties, prospective studies
using VCs reported a primary median (interquartile range [IQR]) VC discharge rate of 16.6 (14.7–29.8)% and a primary
median (IQR) face-to-face (FTF) clinic referral rate of 32.4 (15.5–53.3)%. Direct cost analysis demonstrated median (IQR)
annual cost savings of £56 232 (£46 260–£61 116). Grade II and IIIb complications were reported in two acute ureteric colic
studies, with rates of 0.20% (3/1534) and 0.13% (2/1534), respectively. The annual carbon footprint avoided ranged from 0.7
to 4.35 metric tonnes of CO
2
emissions, depending on the mode of transport used. Patient satisfaction was inconsistently
reported, and assessments lacked prospective evaluation using validated questionnaires.
Conclusion
Urology VCs are a promising new platform which can offer clinical, financial and environmental benefits to support an
increasing urological referral burden. Further prospective evidence is required across urological sub-specialties to confirm
equivalency and safety against traditional FTF assessment.
Keywords
urology virtual clinic, telehealth, carbon footprint, telemedicine, ureteric colic, prostate cancer, #ProstateCancer, #PCSM,
#Urology
Introduction
Telemedicine is defined as ‘the provision of remote healthcare
by means of electronic communication tools’[1]. Its rapid
expansion has been underpinned by technological advances,
particularly in improvements to and availability of electronic
health records (EHR). A virtual clinic (VC) is a form of
telemedicine whereby contact between healthcare
professionals and patients occurs without a traditional face-
to-face (FTF) consultation [2].
In urology, common conditions can rapidly create high
service demands, and the recent Getting it Right First Time
(GIRFT) urology report has specifically highlighted a need
to improve secondary care pathways [3]. Annually, more
than 750 000 care episodes are absorbed by
urological services, however, only 10–12% required
surgical intervention [3,4]. Whilst other conditions may not
be immediately life-threatening, they often have a
significant negative impact on quality of life if left
untreated.
© 2020 The Authors
BJU International
published by John Wiley & Sons Ltd on behalf of BJU International. www.bjui.org wileyonlinelibrary.com
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
BJU Int 2020 doi:10.1111/bju.15125
Review
In the UK, urology secondary care referrals have increased by
nearly 20% over a 20-year period [4], and demands from an
expanding older population are increasing this burden [3].
This has negatively impacted on wait-time targets [3,5]. In
2016, only 10.2% (15/147) of UK NHS trusts met time-to-
treatment targets for patients undergoing urological
procedures. Definitive treatment delays may increase
complication risks, in addition to specific concerns regarding
uro-oncology wait-time targets [3].
Virtual clinics have been proposed as effective methods to
accommodate increased urological service demands clinically
and financially, whilst maintaining patient-centred care [6,7].
The primary aim of the present systematic review was to
present current clinical, fiscal and environmental evidence on
using urological telehealth and/or VCs. The secondary aim
was to highlight research gaps in this rapidly evolving field.
Methods
A systematic literature search was performed of the Medline,
Embase, and Cochrane Review databases, according to
Preferred Reporting Items for Systematic Reviews and Meta-
analyses (PRISMA) guidelines (Fig. 1). The search included
the period from 1 October 2010 to 1 October 2019 and was
for original articles meeting prespecified inclusion/exclusion
criteria. The minimum study number required for formal
narrative synthesis was 10.
Inclusion and Exclusion Criteria
All articles on clinical, fiscal or environmental outcomes in
adult patients exposed to VCs using telehealth strategies were
included, with particular focus on safety and/or
complications. Studies were excluded if not urology-specific,
or if they were reviews, letters, bulletins, comments, or
conference abstracts. Additionally, case series of <10 patients
were excluded to reduce publication and reporting bias.
Search Strategy
Articles were identified using the full search strategy listed
(Appendix S1). Further relevant articles were identified by
manually reviewing references of included articles.
Titles and abstracts were reviewed by two authors
independently (M.A.E. and M.J.C.) and adjudicated by a third
author (S.M.). Prespecified eligibility criteria were applied.
Any disparities were discussed with all co-authors until
sufficient agreement. Full texts of remaining articles were
reviewed independently by M.A.E. and M.J.C.
Data Extraction
Where reported, the following data were extracted: author,
publication year, reference, study design, patient population,
demographics, time to VC (days), VC discharge rate (%), VC
tariff (£/$), patient satisfaction, other primary/secondary
outcomes, fiscal analysis, environmental analysis, statistical
analysis (univariate, multivariate, Pvalues), complications
(Clavien–Dindo classification) and safety profile.
Risk of Bias Assessment
A risk-of-bias (RoB) assessment for non-randomized studies
was undertaken independently by two authors (M.A.E and
M.J.C) using the Cochrane 2.0 RoB tool or validated Joanna
Briggs Institute Critical Appraisal Checklist for non-
randomized studies (Appendix S2).
Statistical Analysis
All data were collected using SPSS (version 26.0). A meta-
analysis was not performed because of the heterogeneity of
reported results and the lack of comparative RCT evidence.
Results
Overview
The search identified 18 original articles [6–23] containing
5813 participants: two RCTs [8,13], 10 prospective studies, and
six retrospective studies (Table 1). Urology sub-specialities
comprised: uro-oncology (n=6); general urology (n=8);
endo-urology (n=2); and LUTS/incontinence (n=2).
Across all sub-specialties, prospective VC studies reported a
primary median (IQR) VC discharge rate of 16.6 (14.7–29.8)%
and a primary median (IQR) FTF clinic referral rate of 32.4
(15.5–53.3)%. Furthermore, direct cost analysis demonstrated
median (IQR) annual cost savings of £56 232 (£46 260–
£61 116). Grade II and IIIb complications were reported in
two acute ureteric colic studies, with rates of 0.20% (3/1534)
and 0.13% (2/1534). Annual carbon footprint avoided ranged
from 0.7 to 4.35 metric tonnes of CO
2
emissions (Table 2).
Uro-Oncology
Six studies reported on uro-oncology (Table 1) and could be
further sub-divided into postoperative care (n=3) and
haematuria clinics (n=3).
Postoperative Care
Stable Disease Clinics
Viers et al. [13] conducted an RCT assessing VCs compared to
FTF clinics in patients who had undergone radical
prostatectomy. In total, 70 patients were randomized, with 78.6%
reaching endpoint; final numbers were 28 in the VC group and
27 in the FTF group. The authors reported equivalent efficiency
of VCs vs FTF clinics, determined by no difference in total time
2
© 2020 The Authors
BJU International published by John Wiley & Sons Ltd on behalf of BJU International
Review
spent on care (mean 17.9 vs 17.8 min, 95% CI 5.9 to 5.6; P=
0.97), total clinicianpatient contact time (12.1 vs 11.8 min,
95% CI 4.2 to 3.5; P=0.85), or patient wait-time (18.4 vs
13.0 min, 95% CI 13.7 to 3.0; P=0.20).
Furthermore, there was no difference in patient satisfaction in
the VC group (n=21/24, 88%) compared to the FTF group
(n=20/22, 91%; P=0.70). Uniquely, Viers et al. also
recorded clinician satisfaction, with 88% of VC and 90% of
FTF clinic urologists reporting ‘very good’or ‘excellent’
ratings.
Interestingly, 88% of the VC patients (21/24) and 73% of
patients in the FTF group (16/22) strongly agreed (Likert
scale 1–7) that they could be seen without physical
examination for every appointment, addressing a common
VC concern. However, as well as power limitations, there was
a risk of selection bias, as only 24% (70/295) of screened men
were randomized. After pre-screening, potentially significant
reasons for non-eligibility included 70/155 patients (45%)
who declined (reasons unstated), 25 patients (16%) lacking
capable technologies, 15 patients (10%) uncomfortable with a
VC, and 15 patients (8%) requesting FTF consultation for
medical reasons, limiting its generalizability. Finally, the end-
totals for the VC and FTF groups decreased to 24 and 22,
respectively (i.e. nine men were not included); ideally the
authors could have adopted an intention-to-treat analysis.
In Scotland, in a study of a nurse-led prostate cancer follow-
up VC by Robertson et al. [9], surveys were sent to 302 men.
The men were eligible if they had PSA-stable disease, were a
minimum of 2 years post-radiotherapy and had been seen
already in an FTF clinic for ≥6 months. No patient
demographics were available. Follow-up protocols were 6-
monthly for 3 years, annually for 5 years, then reviewed at
10 years if there were no consecutive PSA rises. The clinical
nurse specialist met weekly with an oncologist to discuss
patients with PSA rises. Patients visited their GP for blood
tests every 6 months, and were informed of results by letter
from the reviewing clinical nurse specialists (along with their
GP).
Robertson et al. report that 50 consultant FTF appointments
were saved per month following introduction of the VC.
However, it is not clear how this was calculated. Regarding
satisfaction, a total of 191 surveys (63.2%) were returned.
These showed that 98.4% of men were happy with the new
service, and 98.8% felt ‘well supported’; however, broader
generalizability of the findings is limited, given that eligibility
was restricted to a low-risk cohort in a rural setting.
Records identied through
database searching
(n = 480)
Records after duplicates removed
(n = 321)
ScreeningEligibilityIncluded
Records screened
(n = 322) Full-text articles excluded, with
reasons
(n = 304)
Abstract only (n = 6)
Other surgical specialty (n = 99)
Review articles (n = 23)
Non-virtual clinic urology topic
(n = 46)
Letters/comments/perspectives
(n = 13)
Conference abstracts (n = 100)
Paediatric population (n = 9)
Proposals/grants/contracts
(n = 2)
Full-text articles
screened for eligibility
(n = 18)
Studies included in
narrative synthesis
(n = 18)
Additional records identied
through other sources
discharging duplicates
(n = 1)
Identication
Fig. 1 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow chart.
© 2020 The Authors
BJU International published by John Wiley & Sons Ltd on behalf of BJU International 3
A systematic review of virtual urology clinics
Table 1 Overview of all studies included in the narrative synthesis, including patient demographics and associated urology subspecialty.
Author
(year)
Study
direction
End number
participants
Patient
demographics
Associated urology subspecialty Study endpoint
Uro-
oncology
& RAC
General
urology
Endo-
urology
Male/
female
LUTS
Tele-nursing Primary Secondary
Viers et al.
(2015a) [13]
Prospective RCT 55 Men post-radical
prostatectomy
X Efficiency of VC (time
studies including
patient waiting time,
consultation time)
Patient/provider
satisfaction and
costs
Robertson et al.
(2013) [9]
Prospective 191 Men 2 years post-
radiotherapy with
PSA-stable history
of prostate cancer
X X Patient perception of
support and
satisfaction
(questionnaire)
–
Jensen et al.
(2011) [8]
Prospective RCT 95 Men 3 days post
radical
prostatectomy
XXEfficacy of
postoperative
educational
telephone calls in
optimizing
rehabilitation (Likert
and visual analogue
scales)
Patient satisfaction
and sense of
security
Safir et al.
(2016) [12]
Prospective 150 Haematuria referrals
seen by VC
X Time to access
clinician (time to
VC consultation,
time to subsequent
cystoscopy)
Patient satisfaction
(visual analogue
scales, yes/no
questions)
Safir et al.
(2018) [11]
Prospective 450* Haematuria referrals
seen by VC and
FTF
X Patient satisfaction,
time to access
clinician
–
Zholudev et al.
(2018) [10]
Retrospective 400 Haematuria referrals
seen by VC and
FTF
X VC cost-effectiveness Patient-incurred
costs ($)
Browne et al.
(2018) [15]
Prospective 385 General urology
clinic referrals
X VC outcome Cost analysis
(saved OPD
visits)
Miah et al.
(2019) [6]
Prospective 409 General urology
clinic follow-up
X VC outcome, cost and
environmental
analysis (£, carbon
footprint)
Patient satisfaction
Sherwood et al.
(2018a) [17]
Retrospective 376 Male prisoner
population with
general urological
complaints
XVCefficiency,
diagnostic
concordance
comparative to FTF
(EHR record), saved
FTF visits
Safety
Sherwood et al.
(2018b) [16]
Retrospective 376
†
Male prisoner
population
presenting with
testicular pain
XVCefficiency,
diagnostic
concordance
comparative to FTF
(EHR record), saved
FTF visits
Safety
Andino et al.
(2017) [19]
Prospective 108 FTF clinic patients X Patient VC interest
and concern levels
–
4
© 2020 The Authors
BJU International published by John Wiley & Sons Ltd on behalf of BJU International
Review
Table -0001 (continued)
Author
(year)
Study
direction
End number
participants
Patient
demographics
Associated urology subspecialty Study endpoint
Uro-
oncology
& RAC
General
urology
Endo-
urology
Male/
female
LUTS
Tele-nursing Primary Secondary
Viers et al.
(2015b) [14]
Retrospective 1378 FTF clinic patients X Likelihood of VC
acceptance by
patients
Patient travel and
cost savings
(miles, $)
Chu et al.
(2015) [20]
Retrospective 97 VC clinic patients X VC safety
(readmissions),
Patient satisfaction
Patient travel and
cost savings
(miles, $)
Glassman et al.
(2018) [18]
Retrospective 289 VC clinic patients X Patient satisfaction Patient travel
distance (miles)
Smith et al.
(2018) [23]
Prospective 526 Acute ureteric colic
patients
X VC outcome Urgent and
routine wait list
numbers and
time to
consultation,
cost analysis
Connor et al.
(2019) [7]
Prospective 1008 Acute ureteric colic
patients
X X Time to definitive
treatment (days),
discharge rate from
primary VC (%)
Cost and
environmental
analysis (£,
carbon
footprint)
De-Souza et al.
(2017) [22]
Prospective 15 Patients requiring
CISC
X X Acceptability and
usability of
telenursing remote
assistance for CISC
–
Yu et al. (2014)
[21]
Prospective 31 Nursing home
residents with
degrees of
incontinence
X X Volume urine voided
into incontinence
pad, actual and
successful toileting
visits
Staff compliance
with plans
CISC, clean intermittent self-catheterization; EHR, electronic health records; FTF, face-to-face; LUTS, Lower urinary tract symptoms; OPD, outpatient department; RAC, rapid access clinic; RCT, randomized controlled trial;
VC, virtual clinic. Total participant numbers 5813 (excluding duplication populations as listed below).
*
Safir et al. [11] used convenience sampling and adds 150 cases and 150 controls to the participants of Safir et al. [12].
†
Sherwood et al. [16] used the same population as that used in Sherwood et al. [17] that presented with testicular pain or pathology.
© 2020 The Authors
BJU International published by John Wiley & Sons Ltd on behalf of BJU International 5
A systematic review of virtual urology clinics
Patient Education
Jensen et al. [8] conducted an RCT to investigate the efficacy
of nurse-led educational telephone calls in the immediate
post-prostatectomy period. Over 13 months, 142 men were
referred in a single centre for either open retropubic radical
prostatectomy (RRP) or robot-assisted laparoscopic radical
prostatectomy (RALP). The standardized discharge education
programme covered catheter care, bowel function/nutrition,
urine infection prevention/recognition, pain control, and
wound care. The intervention was an extra 15-min clinical
nurse specialist telephone call 3 days post-discharge to
reinforce this information.
In total, 95 men were included: an intervention group of 46
men (15 RRP, 31 RALP) and a control group of 49 men (17
RRP, 32 RALP). A total of 47 men were excluded because
they declined to participate or had postoperative hospital
stays >4 days. The two groups were well matched, with the
mean age of the intervention group being 64.1 years (95% CI
62.5–65.8) and the control group 62.5 years (95% CI 60.9–
64.2).
The authors reported that the additional clinical nurse
specialist telephone call was able to better meet post-radical
prostatectomy needs in the limited domain of bowel function
rehabilitation (n=39/49; odds ratio 0.76, 95% CI 0.60–0.98;
P=0.03), but not of postoperative discomfort and limitations
in activities of daily living. They reported no significant
differences between the VC and FTF groups in patient
satisfaction and sense of security.
The sample size limited power in this study. Furthermore,
patient reasons for declining participation were not explored.
Finally, data were collected relatively soon postoperatively
(2 weeks) and, if given longer follow-up, more complications
may have occurred.
Haematuria Clinic
In the USA, Safir et al. [12] first reported a pilot study of 150
VCs for haematuria in a veteran population, and later added
150 more with 150 FTF clinic controls [11] (totals: 300 VCs,
150 FTF consultations). Men were referred by primary care
with microscopic (≥3 red blood cells/microscopy field) or
macroscopic haematuria. At scheduled telephone encounters,
clinicians completed standardized templates. The participants
were predominantly male (VC group 94%, FTF group 95%; P
=0.83), with the median age in the VC group being 63 years
and in the FTF group 64 years (P=0.19). Non-visible
haematuria was present in 71% of those in the VC group and
66% of those in the FTF group (P=0.19).
Time-to-be-seen was significantly shorter in the VC
compared to the FTF group (12 vs 72 days; P<0.001), as
was median time to cystoscopy after initial consultation (16
Table 2 Summary of studies assessing wider impact on national economy and carbon footprint.
Study Study direction Travel distance saved by
VC
Patient travel costs saved
by VC
Patient time costs saved by
VC
Other relevant outcomes
Viers et al. (2015a) [13] Prospective RCT Median travel distance saved 95
miles (P<0.001)
Median travel time saved 95 min (P
<0.001)
Median $47.5 travel costs per
encounter (P<0.001)
Median patient time cost saving 1
working day
High level of urologist satisfaction
for both VCs (88%) and FTFs
(90%)
Zholudev et al. (2018) [10] Retrospective Median travel distance saved 4
miles (P=0.19)
Median travel time saved 12 min (P
=0.09)
Mean saving $83.47 per encounter,
of which $24.62 was non-
reimbursable cost to patient
Mean patient time cost saving
$24.41/encounter
Total patient cost savings $49.03
Miah et al. (2019) [6] Prospective Total 4 623 miles saved
Median travel distance saved 3.8
miles/patient
NR NR 1.05–4.35 metric tonnes of CO
2e
annual saving
Chu et al. (2015) [20] Retrospective Mean travel distance saved 277
miles
Mean travel time saved 290 min
Mean $67 travel costs per
encounter
Mean patient time cost saving
$126/encounter
-
Connor et al. (2019) [7] Prospective Total 9 374 miles saved
Median travel distance saved 4.3
miles/patient
NR NR 0.7–2.93 metric tonnes of CO
2e
saved
NR, not reported; RCT, randomized controlled trial; VC, virtual clinic.
6
© 2020 The Authors
BJU International published by John Wiley & Sons Ltd on behalf of BJU International
Review
vs 141 days; P<0.001) [11]. Initial appointment ‘did not
attend’rates were higher in the FTF group compared to the
VC group (n=24, 16.0% vs n=17, 5.7%; P<0.001).
Importantly, there were no group differences in bladder
cancer incidence (P=0.386).
Patient satisfaction level was higher in the VC compared to
the FTF group (mean SD score 9.2/10 1.22 vs 8.4/10
1.83; P<0.001), and 98.0% (294/300) preferred the VC
consultation. Potential limitations are selection and recall
bias, given that the voluntary survey was offered post-
cystoscopy, which occurred at variable time lengths from
initial consultations.
Zholudev et al. [10] studied 400 patients referred to the
haematuria clinic (300 VC; 100 FTF) The median age was 63
and 64 years in the VC and FTF groups, respectively (P=
0.48). FTF costs were significantly higher than VC costs with
regard to administration ($9.96 vs $2.49; P<0.001) and
nursing costs ($8.72 vs $0; P<0.001). VC provider costs
were not calculated owing to heterogeneous staff numbers
across encounters. With this exclusion, the average VC costs
were still significantly lower than the FTF costs ($10.95 vs
$135.02; P<0.001). Overall, the mean savings per
consultation were reported as $124.07 (Table 2).
General Urology
Eight studies reported on general urology (Table 1). A
prospective pilot study by Browne et al. [15] recruited 385
patients for general urology VCs run alongside FTF clinics
over a 10-month period: 260 men and 125 women, with a
mean SD (range) age of 59 16(17–96) years, participated.
Patients were referred from general outpatient departments,
GPs, and other specialities. Of 385 patients, 39 (10.1%) were
discharged directly from the VC, 6% needed radiological
investigations (n=23, 6%), and 2% were allocated further
VCs. Whilst 262/385 (68%) still required FTF review, 5% had
another VC outcome (e.g. referral to multidisciplinary team/
another specialty).
The authors report that, after EHR review of enrolled
patients, VCs avoided 217 outpatient department visits, with
an estimated €17 360 cost saving, but it is not clear how this
was calculated. Furthermore, the authors suggest that saved
FTF appointments would result in further cost savings for
hospitals and patients, including transport cost savings and
avoidance of time taken off work, but this was not quantified.
All investigation results were accounted for in the study,
however, the VC failed for two patients (0.5%) who did not
receive FTF appointments as intended. No specific further
safety data were offered.
In another prospective study, Miah et al. [6] reported higher
VC primary discharge rates. Their cohort of 409 patients
included 281 men (mean age 60 years) and 128 women
(mean age 61.5 years). Over 4 months, 68.5% (n=280/409)
were discharged from general urology follow-up VCs, and
16.1% (n=66) had further VCs booked, meaning FTF
appointments were avoided in 84.6% of patients (n=346/
409). Only 13% (n=53/409) required FTF consultations. The
authors reported cost savings of £18 744 in 4 months (VC
cost £8250, FTF clinic opportunity cost £26 994), giving
predicted 12-month savings of £56 232. Patient satisfaction
was reported at >90%, defined as ‘happy’or ‘very happy’
with VCs. There were no adverse events or complaints with
minimum 4-month follow-up.
In studies of a male prisoner population, Sherwood et al. [17]
retrospectively reviewed potential VC use as the primary
contact, not purely as follow-up. Urological VC encounters
over 7 years since implementation of full prisoner EHRs were
analysed to estimate how many could have been managed by
VC alone. A total of 376 unique and 154 repeat VCs were
identified. The mean SD age was 42.3 13.2 years. It must
be taken into account that the goal of these VCs when
undertaken was not to replace FTF clinics but to maximize
their effectiveness, which was defined by VC diagnosis
concordance with confirmed FTF diagnosis, and compliance
with VC-requested investigations.
The study reported that 100/376 patients (27%) were
managed by VC encounter(s) alone, whilst 210/376 (56%)
were followed up FTF. Furthermore, 66/376 patients (18%)
were lost to follow-up, potentially yielding bias. Of the 210
patients seen in FTF consultations after a VC, 188 (90%) had
a concordant diagnosis. It was deemed a safe service as no
patients required emergency department visits and, in the 22
non-concordant diagnoses, there were no missed
malignancies. Reviewing EHRs, the authors estimated that
195/376 patients (52%) could have been managed by VC
alone. However, this was on the basis that basic laboratory
and radiological testing was available to the VC, and that VC
specialists could have access to a primary care provider’s
examination through video if desired. Thus, it does not
address a primary concern with diagnostic VCs, namely, lack
of examination. Finally, whilst the authors state that VCs
would have reduced costs, there was no formal cost analysis.
A second paper by Sherwood et al. [16] included the same
retrospective patient cohort, focusing on testicular pain
complaints (n=110/376; 29%). VC diagnosis was confirmed
in 53/54 patients (98%) continuing to FTF visits, reducing the
need for prisoner transfers to emergency departments. Whilst
the authors report no patients had torsion or malignancy,
there are ethical and legal considerations with the potential
for lack of physical examination in prisoner populations, and
acceptance of deviation from routine standard of care
examinations.
Four studies focused on general urology patient acceptance
and satisfaction with VCs [14,18–20]. Andino et al. [19]
© 2020 The Authors
BJU International published by John Wiley & Sons Ltd on behalf of BJU International 7
A systematic review of virtual urology clinics
conducted a prospective survey of 119 patients in FTF clinics
over 3 months, and asked them whether they would have an
interest in VCs. A total of 108 patients completed surveys
and were eligible for analysis (predominantly aged >51 years
[55%; 59/108]). Using a Likert scale of 1–100, the median
(IQR) score for interest level in a VC was 72 (51.25). When
participants were asked to rate concern on a similar 1–100
scale, the median (IQR) concern level was 18.5 (51.75).
Viers et al. [14] surveyed all adult urology outpatients over
6 months. They identified 19 155 patients, of whom 5524
(29%) were eligible for inclusion (English-speaking, EHR and
e-mail address available). In total, 1378 (25%) completed
online surveys with a mean SD age of 63 12 years.
Responses were: 63% (868/1378) ’likely’, 12% (172/1378)
’neutral’, and 25% (338/1378) ’unlikely’to accept VC. The
’likely’group were marginally younger on average, more often
had a college education, and had previous VC experience (P
≤0.001).
Chu et al. [20] carried out a retrospective study of 97 VC
encounters over a 6-month period. The majority of patients
were men (n=93; 96%). On a Likert scale of 1–5, ≥80% of
patients rated both the assisted remote site and clinician
interaction as ‘excellent’. With regard to safety profile, one
patient was seen in the accident and emergency department
with hydronephrosis following VC.
It should be noted that this telehealth consultation took place
between clinicians in a tertiary centre with patients in
community-based clinics (not at home), where a nurse and
technician were available for assistance, as well as bladder-
scanning facilities. Of 60 patients seen for LUTS-based
complaints, 21 (35%) were assessed using the bladder
scanner, and 13 (22%) used the IPSS questionnaire. VCs
conducted wholly remotely and unassisted may have different
clinical results and satisfaction scores.
Finally, Glassman et al. [18] retrospectively reviewed 611
consecutive VC encounters over 15 months. A total of 289
patients (47.2%) completed surveys, with a mean (range) age
of 54.4 (18–89) years. Using Likert scales of 1–5, they report
high patient satisfaction scores: mean SD clinician
satisfaction rating 4.94 0.32, and mean SD system
satisfaction 4.63 0.97. They found a small significant
negative correlation between age and system satisfaction
(Spearman’s correlation coefficient 0.14; P=0.014), but the
reasons why were not formally evaluated.
Endo-urology
Two prospective studies reported on endourology (Table 1).
Smith et al. [23] prospectively reported on an acute
ureteric colic VC in 526 patients. VC implementation,
alongside introduction of an online accident and emergency
referral system, cleared stone waiting lists within a 2-month
period. This created additional clinic capacity which
reduced 6-month waiting times for new urology FTF
appointments. Furthermore, 89/365 patients (24%) were
able to be discharged direct from primary VC, and of
those re-reviewed in second VCs (after investigations), 96/
144 (66.7%) were discharged without another. Only 86 of
331 needing follow-up (26%) required an FTF consultation.
Surgical management was offered to 101/526 patients
(19.2%).
The authors estimated savings of £5500 per month (£66 000
per annum). Regarding safety profile, there were six re-
presentations after the VC: three were seen in the accident
and emergency department and discharged (reasons not
declared) and three required admission (two for pain, one for
sepsis). Of these, one required emergency stenting for an
infected obstructed system. Patient feedback was not formally
qualified but was reported as ‘good’, with only one patient
complaint (0.2%).
Connor et al. [7] conducted the largest prospective VC cohort
to date. In total, 1008 patients presenting to emergency
departments with acute uncomplicated ureteric colic, and
subsequently discharged against prespecified criteria, were
included. After accident and emergency referrals, made via an
EHR system, patients were reviewed in real time. The median
(IQR) time-to-treatment decision was reduced from 28 to 2
(1–5) days. In total, 34.5% of patients (n=347) were
discharged from primary VC or follow-up VC. A further
17.2% (n=173) were streamlined rapidly to definitive
interventions (extracorporeal shockwave lithotripsy,
percutaneous nephrolithotomy or ureterorenoscopy). Fewer
than half the patients (48.4%; n=488) required traditional
FTF consultations. Over the 4-year period this generated
savings of £145 152 for the respective NHS clinical
commissioning groups.
They reported only two adverse events, one was incorrectly
entered onto the pathway, the other presented for undeclared
reasons to another centre. However, this study was limited by
lack of formally evaluated patient feedback.
Lower Urinary Tract Symptoms and Incontinence
Two studies assessed LUTS (Table 1). De Souza-Junior et al.
[22] described a Brazilian telenursing intervention in Brazil
assessing the acceptability and usability of telenursing
assistance for patients with chronic LUTS undertaking clean
intermittent self-catheterization. This pilot study identified 25
eligible patients (exclusions of complete physical immobility,
advanced senile disease, or severe psychological conditions).
Fifteen patients (nine female, six male), with a wide age range
(<10–80 years), met the inclusion criteria. Twenty-one
consultations occurred over 5 weeks (13 telephone calls, eight
e-mails). Only two patients requested a subsequent FTF
consultation: one for personal training, and one for training
8
© 2020 The Authors
BJU International published by John Wiley & Sons Ltd on behalf of BJU International
Review
other health professionals in clean intermittent self-
catheterization.
Yu et al. [21] report on the introduction of a telemonitoring
system for continence assessments in a nursing home.
Personalized incontinence plans were made for 32 residents
after 72 h of telemonitoring (via sensors in continence aids to
detect wetness). For the 31 residents reaching study
completion, the volume of urine voided into continence pads
significantly reduced from 2.069 (SD 1523) mg to 1.529
(SD 1795) mg (P=0.015). It is unclear to what extent this
may be attributable to a significant increase in the median
number of actual and successful toilet visits (P<0.001 and P
=0.011).
Environmental Impact
Annual carbon footprint avoided ranged from 0.7 to 4.35
metric tonnes of CO
2
emissions, depending on transport
mode. Details of per study environmental savings are
presented in Table 2.
Risk of Bias of Included Studies
Risk of bias was tabulated using the Joanna Briggs Institute
checklist (Appendix S2). With regard to the two RCTs
included in this systematic review, both were deemed to be of
‘some concern’when assessed using the Cochrane 2.0 RoB
tool (Appendix S3) [8,13].
Discussion
The principle findings of this systematic review are that
employing telehealth or VC strategies leads to reductions in
requirement for FTF appointments and median time to
clinical review, and may promote financial and environmental
savings.
Accumulating prospective evidence supports VC integration
in acute urological settings. Firstly, the high specificity and
sensitivity of low-dose non-contrast CT lends itself to
confident virtual imaging review, which can guide ongoing
management [24]. Secondly, the emergence of online direct
referral systems streamlines cases directly from the accident
and emergency department, without acute specialty review.
The GIRFT programme has specifically highlighted both the
need to standardize national care of urinary tract stones, and
lack of structures for clinical nurse specialists to be utilized in
‘new and challenging roles’[3]. VCs may offer an exciting
opportunity to address both these inconsistencies in
healthcare provision.
Advances in minimally invasive surgery have reduced lengths
of inpatient stays significantly [25], with a median (IQR)
length of stay of 1 (1–2) days for RALP [25]. This presents a
challenge for clinicians in the delivery of postoperative
education and providing outpatient review within shorter
clinical windows. Evidence from RCTs now supports
postoperative clinical nurse specialist-led telephone calls and
post-RALP VC follow-up. These strategies may offer an
efficient method by which to consolidate patient education
and help patients feel supported.
Encouragingly, it would appear patients and staff find VCs an
acceptable alternative to FTF appointments. Far from being
concerned, patients welcomed the offer for VCs and felt it
was safe, thorough and professional. Moreover, VCs
dramatically cut patient-incurred costs, most significantly in
travel expenses (Table 2). Thus, particularly in rural settings,
VCs could help break down potential socio-economic barriers
to care.
The studies demonstrated a significant heterogeneity in design
and approaches that were all considered under the umbrella
term ‘telehealth’. The question of which forms of urology
clinics are best suited to nurse-led, urologist-led clinics, or the
two combined, or require routine integration with primary
care telehealth remains unanswered.
Overall, the patient-reported outcome findings are
encouraging, and a particularly pertinent evidence base given
the present COVID-19 pandemic. The pandemic has been a
catalyst for VC utilization in urology, with multiple
applications across all sub-specialties. At present many
urologists are using VC to maintain high-risk cancer referral
pathways. This is of vital importance in encouraging patients
with red flag symptoms to present for investigation and may
help to mitigate the risk of a rise in unintended non-COVD-
19-related morbidity and mortality from under-detection and
delays in treatment [26,27].
In addition to direct cost savings, follow-up VCs create
additional FTF capacity which, when used for new patients,
creates unique opportunities to generate income at
departmental levels, as new-patient FTF appointments receive
higher tariffs than follow-ups.
Using NHS tariffs and the current market forces factor, Miah
et al. [6] reported additional tariff generations of £24 042
(predicted 12-month generation £72 072), for their
department. In their clinical commissioning group a new FTF
could be charged at a tariff £107 higher than a follow-up FTF
consultation [28]. With a 30% reduction in urology tariffs in
the past year alone [28], VC pathways now offer a model to
offset potential departmental income losses.
For countries with private medical systems, there is similar
provider benefit in increased patients per clinic and increased
time to spend with complex patients [29]. In a 2020 AUA
white paper, 72% of urologists, who were surveyed (n=243)
before the COVID-19 pandemic, reported that the most
common barrier to VC use was the inability to bill for service
effectively [30].
© 2020 The Authors
BJU International published by John Wiley & Sons Ltd on behalf of BJU International 9
A systematic review of virtual urology clinics
It could be assumed that the lasting impact of increasingly
widespread VC use during the COVID-19 pandemic will aid
countries such as the USA to break down current prohibitive
telemedicine barriers, such as state-specific differences in
Medicaid reimbursement, and lead to permanent revision of
regulations whereby VCs must still occur in approved
medical facilities [29].
It is important, however, to highlight that reported economic
benefits need robust formal prospective confirmation. Fiscal
evaluation to date has been limited by studies’sizable
variability in economic analyses, including time length
denominators and private vs national tariffs.
The environmental impact of healthcare services is
increasingly at the forefront of new policies. Healthcare
systems have been criticised for being ill prepared for the
clinical risks posed by climate change [31], and are looking
unlikely to meet ongoing targets for reducing greenhouse gas
emissions [32]. Currently, the NHS is responsible for 5% of
all UK road transport emissions [33]. Integrating
environmentally positive VCs may help redress imbalances.
Several key research gaps must be explored prior to routine
acceptance of urological VCs. Firstly, better understanding of
patients’experiences of VCs using validated methods of
assessment is required. Secondly, supportive evidence for the
economic arguments for VCs is lacking. Formal health
economic studies, beyond current ad hoc analyses, would
benefit many healthcare systems, including the NHS. If the
expected economic benefits were confirmed, this may
significantly impact on local provider engagement with
urology VCs. Finally, there is a lack of evidence from RCTs
to support routine urology VCs. Individual areas where VCs
demonstrate significant early promise, such as acute ureteric
colic referrals, require multicentre confirmatory prospective
evaluation.
Whilst this systematic review has encouraging initial findings,
a major limitation was lack of standardization of primary and
secondary outcomes across included studies. Further, evidence
synthesis contained only two randomized studies with the
majority of studies either prospective or retrospective case
series. Such an evidence base is limited by inherent selection
bias. In addition, there was significant heterogeneity in the
design and reporting of included studies; this limited
statistical comparisons and the generalizability of combined
conclusions.
In conclusion, VCs are a promising new platform offering
clinical, financial and environmental support for the
management of an increasing urological referral burden,
without compromising patient safety. Further prospective
evidence is required across urological sub-specialties to
confirm equivalency and safety against traditional FTF
assessment. I am
Conflicts of Interest
Martin J. Connor receives grant funding from the Wellcome
Trust and University College London Hospitals Charity.
Hashim U. Ahmed receives grant funding and personal fees
from SonaCare Medical Inc, grant funding from Trod
Medical, and grant funding and personal fees from Sophiris
Bio Inc. Hashim U. Ahmed also receives grant funding from
the Wellcome Trust, MRC (UK), UK National Institute for
Health Research Imperial Biomedical Research Centre,
Prostate Cancer UK, The Urology Foundation and Imperial
Healthcare Charity. Marie Edison, Saiful Miah, Mathias
Winkler, Ranan Dasgupta, Taimur El-Husseiny and David
Hrouda have no conflicts of interest to declare.
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Correspondence: Martin John Connor, Division of Surgery,
Imperial Prostate, Department of Surgery and Cancer,
Imperial College London, Charing Cross Campus, Fulham
Palace Road, London W6 8RF, UK.
e-mail: martin.connor2@nhs.net
Abbreviations: EHR, electronic health records; FTF, face-to-
face; GIRFT, Getting it Right First Time; IQR, interquartile
range; RALP, robot-assisted laparoscopic radical
prostatectomy; RCT, randomized controlled trial; RoB, Risk-
of-bias; RRP, open retropubic radical prostatectomy; VC,
virtual clinic.
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Appendix S1. Database.
Appendix S2. Risk of bias (RoB) Joanna Briggs Institute
checklist non-randomized studies.
Appendix S3. Risk of bias (RoB) Cochrane 2.0 randomized
controlled trials.
© 2020 The Authors
BJU International published by John Wiley & Sons Ltd on behalf of BJU International 11
A systematic review of virtual urology clinics
