Telehealth in urologic cancer: Lessons learned from the COVID-19 pandemic

As technology evolves, the concept of remote delivery of medical care has been at the forefront of expanding access. During the COVID-19 pandemic, telemedicine became paramount, given the critical need for social distancing and increased demand for medical care despite limited resources for specialty care and oncologic surveillance.¹ Patients embraced the convenience while providers adapted to the new workflow, leading both parties to advocate for this model to be nationally implemented and permanently codified.² In this review, we outline the evolution of telemedicine and analyze how the COVID-19 pandemic propelled the understanding, quality, and delivery of remote medical care in urologic oncology.

Tracey L. Krupski, MD

Teleworking has become increasingly prevalent in many industries over the past decade, with health care specifically focusing on telehealth and telemedicine. Telehealth is a more generic term that references the use of telecommunications and digital technology to expand services beyond traditional clinical settings.³ Examples include the electronic medical record system for scheduling, vital sign monitoring, and patient or provider education and training.⁴ Telemedicine refers to using digital platforms to diagnose, treat, and improve patient outcomes through expanding health care access. This

Jeunice Owens-Walton, MD

includes patient-provider interactions, provider e-consults, multidisciplinary conferences, and telesurgery.⁵ In urologic oncology, telemedicine has proved valuable for initial assessments for hematuria, decision-making for nonmetastatic prostate cancer, and follow-up after prostate cancer treatment.^2,6

Legislative landmarks in the evolution of telehealth are shown in the Figure. The Balanced Budget Act of 1997 allowed payment for outreach to rural areas, thereby incentivizing telemedicine access to geographically remote regions. Medicaid expansion and the 2018 Furthering Access to Stroke Telemedicine Act incrementally moved the needle forward for patients who are indigent or had a stroke. The COVID-19 pandemic, however, created a need for exponential expansion as social distancing became an imperative part of fighting the spread of the virus while still managing underlying health conditions. During this time, urologists were leaders in converting in-person visits to virtual encounters.⁷ This has become particularly essential in our field as we seek to provide urologic care to the country’s most rural and far-reaching corners. Despite the challenges of a physician shortage, patients have expressed satisfaction with their experiences.^8,9 The use of transmitted real-time video has been described as improving access for patients with bladder cancer. This system, termed tele-cystoscopy, entails the interpretation of the cystoscopy by a board-certified urologist while the procedure is performed in a remote location.¹⁰ This example crystalizes how telemedicine allows patients to receive the expertise of an oncologic expert and saves them travel time, travel expenses, and lost wages.¹¹

For surgeons, telemedicine can encompass remote surgery whereby the patient and operating physician are distanced. The first rudimentary operating systems were used in the 1990s and have since evolved. These included the Automated Endoscopic System for Optimal Positioning, Probot, and Zeus, precursors to the da Vinci operating system.^12-14 In 2008, Sterbis et al published an article about performing transcontinental porcine nephrectomies using the da Vinci system across a public internet connection.¹⁵ As urologists, expanding access to lifesaving surgery through telesurgery is exciting. The tools for this to be commonplace are available with growing commercial interest, including using artificial or virtual reality for training platforms. However, secure platforms and licensure issues are pertinent to remote surgery; additional ethical concerns about informed consent, data protection, and physician liability exist. The health informatics and data protection aspects are magnified.^16,17

Although telemedicine has positively addressed several issues, significant hurdles remain. With an aging population comes an increasing digital divide—low digital literacy and limited infrastructure among the patients who need our care the most. Rural areas may have challenges with access to a reliable broadband connection requiring a public computer, or the patient may live across a state border from a urologic oncology provider.^17,18 The most significant challenge may be that of reimbursement. Until the government uniformly reimburses telemedicine via Medicare without site of origin restrictions, widespread investment in developing telemedicine services by the health systems themselves will remain slow.¹⁷ At the time of this writing, parity reimbursement introduced during the pandemic has not been extended beyond September 30, 2025. This leads to hesitancy in investing in platforms that are compliant with privacy regulations. The emergency relaxation of rules is no longer in effect, leading to a high administrative burden in educating patients on how to use their e-devices, codifying the video platform, and the physical location required to initiate the visit, which currently requires separate state licensure across state borders. Thankfully, the American Medical Association and American Urological Association continue to advocate for permanent reimbursement policies, ensuring the long-term sustainability of virtual care in urologic oncology.

Urologists have consistently been pioneers in health care technology, with the COVID-19 pandemic catalyzing the adoption of telemedicine in many forms. However, the use of telemedicine is heavily dependent on supportive legislature. Although regulatory and reimbursement barriers remain, advocacy to support telehealth services is ongoing to ensure equitable access to urologic services for all patients. The future of urologic oncology will likely leverage virtual platforms for consultations and follow-up while preserving in-person care for complex cases and surgery; ultimately, telemedicine will remain a vital component of urologic oncology in the post-pandemic era.

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