The COVID-19 pandemic has led to the reshaping of health care systems and simultaneous shifting of economic resources to treat critically ill COVID-19 patients. In many countries, patients treated and followed up in urological settings are facing a significant delay of their appointments since the tertiary centers either became hospitals dedicated to COVID-19 patients or face-to-face consultations have been postponed in accordance with curfew requirements.

Telemedicine is defined as the “provision of healthcare services over physically separate environments via Information and Communications Technology.”¹ Telemedicine has been implemented to facilitate access to health care services for patients living in remote or rural areas or in settings with limited availability of services, such as in military camps or prisons.

Kidney stone disease is a highly prevalent clinical condition associated with modern lifestyle and metabolic syndrome, with a lifetime prevalence of nearly 10%.² Considering the high probability of recurrence, with more than 50% of patients experiencing another episode within the next 5 to 10 years and the possibility of surgical intervention rising up to 26.6%,³ the followup of these patients seems imperative. Recent reports point out the promising functionality of telemedicine in the field of urolithiasis (see Appendix).

The experience of setting up a virtual stone telephone clinic during the span of a 6-year period has shown that telemedicine is applicable and cost-effective for the followup of both asymptomatic patients with renal calculi and high risk stone formers.⁴ Patients underwent imaging prior to telemedicine consultations, which was held with a specially trained stone nurse, for a duration of 5 to 10 minutes each. Dietary measures, fluid intake and secondary prevention measures were also provided along with review of imaging examinations and assessment of new symptoms, while for emergent situations or worsening of clinical condition, appropriate referral was made either for a face-to-face consultation or intervention.

During a median followup duration of 12 months, 290 patients were enrolled in the virtual clinic, with only 2 (0.7%) choosing to return to face-to-face consultations, while only 8 (2.8%) patients did not attend the arranged appointments.⁴ The direct savings form salaries were calculated at nearly £26 per appointment (93%) compared to face-to-face meeting, without considering work days lost or travel and parking expenses.

Dietary modifications and medical treatment tailored to specific metabolic abnormalities of recurrent stone formers can drastically reduce recurrence, but both initial 24-hour urine metabolic assessment and compliance with prescribed regimen are surprisingly low.^5,6 Gasparini et al evaluated the feasibility of telemedicine services to enhance the compliance and followup in patients under medical treatment for recurrent stone disease and found that 11.8% of patients did not comply with the telephone based program at 12 months and another 12.4% for duration more than 12 months.⁷ More interestingly, 80% of patients completed a followup 24-hour test at 1 year of followup, with most of patients experiencing improvement in the urinary parameters affecting stone recurrence after complying with most of dietary modifications suggested during the telemedicine consultations.⁷

Telemedicine, either via telephone consultations or through virtual meetings using relevant technology, proved to be effective in several circumstances regarding stone disease, such as remote assessment of computerized tomography (CT) scan images for identification of hydronephrosis⁸ or for postpercutaneous nephrolithotripsy followup using the Skype application with both physicians and patients reporting high levels of satisfaction.⁹ Ong et al evaluated the efficacy of telemedicine in patients with ureteric colic without complications such as infection/fever, severe pain or hydronephrosis.¹⁰ Consultations were performed via telephone instead of face-to-face meetings over a 3-year period. Most patients (93.1%) were satisfied with the service provided, while the need for direct meeting was reduced by 71.1%, either due to normal CT scan (46.2%) or missing scan appointments (24.9%).¹⁰

The application of telemedicine has been studied before the occurrence of COVID-19 pandemic. Limited technological infrastructure and appropriate medical staff experience, high costs of implementation and reluctance of both patients and physicians in fear of losing direct contact resulted in scarce use from a few centers. However, more than 1 year has passed since encountering the novel coronavirus and the potentials of telemedicine now seem very enticing. Avoidance of direct contact not only drastically reduces the risk of virus contamination, but also saves time and monetary resources both for patients and health care systems. The risk of disease progression is also diminished since when the indication exists patients are referred for face-to-face consultation and receive appropriate management.

A major drawback of this type of patient encounter is the inability to perform proper physical examination, which is essential in many circumstances. However, applications are under validation for caregivers to perform basic clinical examination under physician guidance. The easier access to personal sensitive data and the need for implementing secure algorithms and software in order to protect patient data should also be overemphasized during use of telemedicine services, especially when performing medical examination.

In conclusion, the use of telemedicine regarding stone disease has gained wider attention in the post-COVID-19 era and is feasible, cost-effective and acceptable both by patients and physicians. As long as appropriate protective measures are implemented, patients with kidney stone disease could benefit from such virtual encounters, saving time and money and thereby optimizing health care resources.