Systematic review of telemedicine in pediatric urology (2022)

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Journal of Pediatric Urology

Volume 18, Issue 1,

February 2022

, Pages 17-22

Summary

Introduction

Telemedicine has bridged the distance gap between patients and pediatric urologists for over a decade, yet many pediatric urologists have not embraced it as a major part of their practice. The purpose of this systematic review is to evaluate and clarify the optimal role of telemedicine in pediatric urology, as well as the benefits, barriers, risks, and other important considerations that must be accounted for in its optimal adoption.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this systematic review utilized Medical Subject Headings (MeSH) to search PubMed through April 29, 2021 as follows: (Humans [MeSH]) AND ((Child [MeSH]) OR (Infant [MeSH])) AND ((Remote Consultation [MAJR]) OR (Telemedicine [MAJR]) OR (Videoconferencing [MAJR]) OR (Health Services Accessibility [MAJR])) AND ((Urology [MAJR]) OR (Postoperative Care [MAJR]) OR (Urologic Surgical Procedures [MAJR])). 73 resulting articles, plus 21 from manual searches (e.g. papers too recent to have MeSH terms), were screened. 17 met inclusion criteria by discussing telemedicine in context of pediatric urology in a full manuscript. Non-complete manuscripts and papers not specifically considering pediatric urology, or in which telemedicine was not a major focus, were excluded.

Results

17 papers met inclusion criteria. Varied approaches to the topic included surveys, controlled studies, retrospective studies, and descriptive opinion pieces. Quality of evidence varied, representing at least 1851 virtual encounters, 409 in-person encounters, and 68 clinician opinions. Four papers included a comparison or control group, and none utilized randomization. All 17 papers support expanded application of telemedicine in pediatric urology with varied evidence that telemedicine improves patient access to pediatric urologic care, satisfies both patient families and clinicians, is safe, provides equivalent outcomes, and is practicable.

Conclusions

Implementation of telemedicine in pediatric urology should be expanded as it can practicably and safely improve patient access to pediatric urologic care, satisfy both patient families and clinicians, and maintain outcomes.

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Introduction

The words telehealth and telemedicine denote interactive health care communication via electronic means between patients and providers [1]. Such telemedical communication has been used to expand the reach of health care expertise for roughly half a century [2], and has included text, audio, video, and audio-video technologies in real-time or store-and-forward communications [1]. Technology has obviously been a limiting factor in the comprehensiveness of telemedical care and in its expansion over time, and it goes to reason that the more specialized a sought-after expertise becomes, the more limited in-person access to it may become, especially to those who are in more rural settings. Exemplifying this lack of access to specialized care at a worldwide level, reports indicate that as of the year 2020, 62% of the world's countries do not have even a single urologist [3]. To this end, and for over a decade now, telemedicine has been used to bridge the distance gap between patients and urologists specializing in pediatric care [4]. Nevertheless, many pediatric urologists have yet to embrace telemedicine as a regular part of their practice. Is this due to a lack of its utility among pediatric patients? Is it because its safe implementation is not feasible? Or perhaps there is concern that it will not provide safe care for patients or yield equivalent outcomes? The purpose of this systematic review is to evaluate and clarify the optimal role of telemedicine in pediatric urology and to elucidate the benefits, barriers, risks, and other important considerations that must be accounted for in its optimal adoption.

Section snippets

Materials and methods

This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Initial searches of the literature revealed key Medical Subject Headings (MeSH) of relevant studies, which were then used to search PubMed through April 29, 2021. The following parameters were used for the search: (Humans [MeSH]) AND ((Child [MeSH]) OR (Infant [MeSH])) AND ((Remote Consultation [MAJR]) OR (Telemedicine [MAJR]) OR (Videoconferencing [MAJR]) OR

Results

Of 94 articles screened, 17 met inclusion criteria. Unsurprisingly, as telemedical delivery of pediatric urologic care is rooted in technology and its availability, the number of relevant publications each year has increased, with the first published in 2011, and most of the 17 publications coming out within the last three years (see Fig.2). Included papers represent reports and application from various countries around the world.

Among the 17 included papers, methodologic approach to the topic

Discussion

Adoption of telemedicine has greatly accelerated within all specialties in the wake of the COVID-19 pandemic. Urology is no exception, with the American Urological Association (AUA) reporting a six-fold increase in the percentage of urologists normally using telemedicine programs in 2020 compared to 2019 [3]. Narrowing further to pediatric urologists, it was reported that while 53% were interested in using telemedicine prior to the pandemic, 89% were interest in using it with future patients [5

Conclusions

The literature on telemedicine in pediatric urology varies in quality of evidence but unites in the position that telemedicine can safely and practicably improve patient access to pediatric urologic care, satisfy both patient families and clinicians, and provide equivalent outcomes. This has been demonstrated in post-operative care and in other cases where a skilled physical exam is not essential. No opposing reports were identified. Care needs to be taken in use of telemedicine to continue

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

None.

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  • Cited by (1)

    • Utilization and Adequacy of Telemedicine for Outpatient Pediatric Surgical Care

      2022, Journal of Surgical Research

      Telemedicine (TM) use accelerated out of necessity during the COVID-19 pandemic, but the utility of TM within the pediatric surgery population is unclear. This study measured utilization, adequacy, and disparities in uptake of TM in pediatric surgery during the COVID-19 pandemic.

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      Scheduled outpatient pediatric surgery clinic encounters at a large academic children's hospital from January 2020 through March 2021 were reviewed. Sub-group analysis examined post-operative (PO) visits after appendectomy and umbilical, epigastric, and inguinal hernia repairs.

      Of 9149 scheduled visits, 87.9% were in-person and 12.1% were TM. TM visits were scheduled for PO care (76.9%), new consultations (7.1%), and established patients (16.0%). Although TM visits were more frequently canceled or no shows (P<0.001), most canceled TM visits were PO visits, of which 41.7% were canceled via electronic communication reporting the absence of any PO concerns. TM visits were adequate for accomplishing visit goals in 98.2%, 95.5%, and 96.2% of PO, new, and established patient visits, respectively. Patients utilizing TM visits were more frequently of white race, privately-insured, from less disadvantaged neighborhoods, and living a greater distance from clinic (P<0.001 for all comparisons).

      TM was adequate for the majority of visits in which it was utilized, including the basic PO visits that occurred via TM. TM was used more by patients with greater travel and less by those of minority race, with public insurance, and from more disadvantaged neighborhoods. Future work is necessary to ensure broad access to this useful tool for all children requiring surgical care.

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      1023 boys were included. 273 had glandular, 468 distal, 194 proximal and 88 perineal hypospadias. The mean glans width was 14mm with a range of 8 to 20mm. The mean glans width for glanular hypospadias was 14.0mm (range 9–19mm), 14.0mm (range 10–20mm) for distal hypospadias (p>0.05), 13.1mm (range 9–19mm) for proximal hypospadias (p<0.0001) and 11.1mm (range 8–16mm) for perineal hypospadias (p<0.0001). 460 (45.0%) of all patients presented with a small glans width. In glanular hypospadias it was 99 (36.3%), 167 (35.7%) in distal hypospadias, 111 (57.5%) in proximal hypospadias and 83 (94.3%) in perineal hypospadias. There was no significant difference in the glans size between the age of 6 and 24 months (p>0.2), but there was a difference when compared to patients older than 25 months (p<0.05).

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      Decision for surgery can be challenging in children with AH (Antenatal Hydronephrosis) especially in the setting of supranormal differential renal function (SnDRF).

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      A prospectively collected urinary biomarker database was used for the study. There was a total of 53 patients in the AH group. Nineteen children with no history of AH and a normal urinary ultrasonography were taken as controls. Patients with initial ipsilateral DRF (Differential Renal Function) over 50% were included in the SnDRF group while the remaining were named as non-SnDRF. Patients that didn't undergo surgery were classified as non-obstructive dilation (NOD) in both groups.

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      Pyeloplasty was performed in 6/20 patients in SnDRF group, and in 19/33 patients in non-SnDRF group. Biomarker levels in the pyeloplasty and NOD groups were not affected by the presence or absence of SnDRF (p=1.00, for both). Urinary NGAL, and CA 19–9 could determine the need for surgery in SnDRF group with 83% and 100% sensitivity, 86% and 79% specificity, respectively whereas urinary IP-10 and KIM-1 could with 84% and 83% sensitivity, 57% and 71% specificity, respectively. Urinary MCP-1 could differentiate patients who underwent surgery with 83% sensitivity and 50% specificity in SnDRF groups.

      Our results showed that biomarker levels were not affected whether the kidney has SnDRF. Furthermore, in patients with SnDRF, NGAL and CA 19–9 appear to better estimate requirement for surgical correction before deterioration of renal function.

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      Eighteen male, Wistar albino rats were divided into 3 groups. The sham group which is applied surgical stress. The ischemia/reperfusion group (I/R) which detorsion performed 1h later than testicular torsion application. I/R+NaHS treatment group, NaHS solution was injected intraperitoneally for 1 week. On the 7th day of the detorsion all left testes were fixed in Bouin solution and sent to Pathology Department for histopathological examination. All right testes were washed with normal saline, dried in a sterile way and stored in – 80°C deepfreeze up to the date of biochemical processes. Testicular tissues were obtained for the detection of myeloperoxidase (MPO), malondialdehyde (MDA), AOPP (advanced oxidation protein product) for oxidant markers and ferric reducing antioxidant power (FRAP) levels, superoxide dismutase (SOD),glutathione peroxidase (GSH-Px) activities for antioxidant markers and histopathological exploration.

      The effects of NaHs administration on oxidation were evaluated by determination of testicular MPO, MDA and AOPP levels. Increased testicular MPO (58.6%) activity was observed in the I/R group compared to the sham group. Following NaHS treatment, MPO (26.7%) activity was significantly decreased in rats exposed to I/R injury (Figure1). MDA levels did not alter. Increases in AOPP (20.9%) levels were observed in the I/R group. NaHS treatment resulted in significant decreases in AOPP (25.1%) levels in testes tissues of rats exposed to I/R injury. The effects of NaHS treatment on antioxidant system FRAP, SOD, GSH and GSH-Px activities were evaluated. GSH levels were significantly increased in the IR+NaHS group compared to the I/R group. In histopathological examination degeneration of seminiferous tubules and spermatogenic cells were observed in the I/R group. After NaHS treatment, normal spermatogenic activity with many spermatozoa in the lumen of most seminiferous tubules were observed in the I/R injured rats. According to Johnsen's scoring (JS), the I/R group was significantly decreased compared to the sham group. JS values for the I/R+NaHS group were significantly increased compared to the I/R group.

      Our study supports that ischemia/reperfusion injury plays an important role in the testicular torsion injury, and it is a pioneer study showing that H₂S may have a potential for therapeutic effect. The limitation of this work is this is an experimental study with limited number of animals. According to the results of our study, hydrogen sulfide treatment has beneficial effects on biochemical and histopathological results of testicular injury in testic torsion.

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    © 2021 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

    Most of the articles and recommendations have stressed on the role of telemedicine in the COVID-19 pandemic.. For emergency procedures where patient cannot wait for COVID-19 test results or when COVID test is positive then, these patients are to be admitted in the dedicated COVID ward and surgery is also performed in the dedicated COVID theatre.. In stage 1 and 2, the recommendation is to reduce the surgical cases and perform only urgent and semi-urgent cases.. Certain measures have been recommended to minimise the risk of exposure to the pneumoperitoneum aerosol.. COVID status assessment and screening for flu-like symptoms should be done for the accompanying parent, as well.. In case, there is limited availability of the FFP-3 masks then its use may be prioritised depending on the COVID status of the patients.. The video calling during telemedicine permits virtual inspection of the patient and local pathology.. Separate local guidelines and guidelines suitable for the developing nations are needed.

    The available literature indicates that telemedicine has been adopted successfully in selected patients with several common clinical urological conditions, including prostate cancer, uncomplicated urinary stones, uncomplicated urinary infections, urinary incontinence, or pelvic organ prolapse.. Through telehealth-integrated patient management protocols and payment reforms, telehealth can have a constant effect on urological care delivery even after the pandemic.. The most common urologic conditions evaluated during the initial telehealth meeting (including both general urology and sexual dysfunction clinics) were sexual dysfunction 26.8% (217/811), LUTS 20.6% (167/811), hematuria 15.0% (122/811), prostate cancer 13.3% (108/811), and an elevated PSA 12.1% (98/811) [7].. Future studies should investigate the potential barriers to telemedicine use among rural patients and the impact of rural telemedicine on patient health care utilization and outcomes [12].. It is possible that telemedicine will become completely integrated into urologic training and health care delivery to fulfill the proposition of access and quality of urologic care [13].. References Juan Javier-DesLoges, Margaret Meagher, Shady Soliman, Julia Yuan, Kevin Hakimi, et al. (2021) Disparities in Telemedicine Utilization for Urology Patients During the COVID-19 Pandemic UROLOGY 2021: 1-5.. World Journal of Urology 38: 2377-2384 Adam J. Gadzinski, Chad Ellimoottil (2020) Telehealth in urology after the COVID-19 pandemic.

    Results: Six articles were included in the final review.. Surgical services provided via telehealth may incorporate a pre-surgical consult (to assess and book new patients), as well as post-operative follow-up.. Currently, telehealth paediatric surgical services are relatively common in Australia and play a particularly important role in physically larger states with large rural and remote populations such as Queensland, Western Australia, and the Northern Territory.. This study consists of a systematic review of the literature regarding use of telehealth in paediatric surgery.. Literature searches were performed on 28 October 2018 using Medline (via OvidSP), with MESH search terms (“paediatric surgery” OR “pediatric surgery” OR (surgery or “general surgery” AND paediatric* OR pediatric*) AND (telehealth OR telemedicine)).. Was the exposure(s) assessed more than once over time?. A total of six articles were included in the final review.. Two directly compared initial diagnosis made at telehealth appointments with final pre-operative assessments and diagnoses, and four reviewed the overall service provision and use of telehealth versus Face-To-Face (FTF) assessments, as well as follow-up reviews within the relevant paediatric surgical service.. By contrast, Canon, who studied the use of telemedical follow-up of paediatric urological surgery - including hypospadias review - found that video telemedical follow-up was not associated with poorer outcomes, including for hypospadias which requires a relatively high level of visualisation of the surgical field [12].. Rowell, studying use of telehealth for paediatric orthopaedic surgery in Western Australia, found that 86% of all closed fractures were transferred to a tertiary centre despite 45% of these not requiring manipulation under anaesthesia or surgical fixation, meaning that they could easily have been managed by local staff with adequate radiological imaging supported via telehealth services with orthopaedic specialists at tertiary centres [3].. However, the safety and efficacy of telehealth services can be dependent upon the clinical acumen and procedural skills of the local staff at the remote health centre where the patient is being seen.. Examination of testes requires a relatively significant level of experience with both normal and abnormal anatomy and as a result remote local staff may not have a high enough caseload to ensure clinical accuracy.. J Pediatr Surg 50: 1776-1782.

    Telemedicine articles; Remote Monitoring articles; Cardiovascular Disease articles; Access articles; Healthcare articles. The following review focuses on the currently available data within the telemedicine technologies for CVD patients as preventive or interventional modalities.. In total, six studies reported outcomes focusing on reducing all-cause readmission or all-cause mortality with telehealth interventions among patients with chronic heart failure (CHF).. The other five trials identified a reduction in all-cause readmission and all-cause mortality with telehealth enabled intervene-tions, including self-care behavior with short mess-ages [10], monitoring of pulmonary artery pressure with a wireless hemodynamic monitoring system [11], electronic documenting of vitals [12], combined monitoring of the electrocardiogram, blood pressure, body weight, and oxygen saturation (SpO 2 ) [13], communication about symptoms [14], and home-based exercise program [15].. ACS: Acute coronary syndrome; CVD: Cardiovascular disease; CHF: Chronic heart failure; CHD: Coronary heart disease; EHR: Electronic health record; ER: Emergency room; HF: Heart failure; LDL-C: low-density lipoprotein cholesterol; MI: Myocardial infarction; RCT: Randomized control trial; USA: United States of America.. Studies in our review show that telehealth interventions that focus on remote monitoring also offer some efficacy.. With numer-ous trials underway for the management of CVD, patients may benefit from telehealth monitoring of their health status.. Dendale P, De Keulenaer G, Troisfontaines P, et al. Effect of a telemonitoring-facilitated collaboration between general practitioner and heart failure clinic on mortality and rehospitalization rates in severe heart failure: the TEMA-HF 1 (TElemonitoring in the MAnagement of Heart Failure) study.. Tailored telemonitoring in patients with heart failure: results of a multicentre randomized controlled trial.. Peng X, Su Y, Hu Z, et al. Home-based telehealth exercise training program in Chinese patients with heart failure: a randomized controlled trial.. Text message and internet support for coronary heart disease self-management: results from the Text4Heart randomized controlled trial.. Hawkes AL, Patrao TA, Atherton J, et al. effect of a telephone-delivered coronary heart disease secondary prevention program (proactive heart) on quality of life and health behaviours: primary outcomes of a randomised controlled trial.. Karhula T, Vuorinen A-L, Rääpysjärvi K, et al. Telemonitoring and mobile phone-based health coaching among Finnish diabetic and heart disease patients: randomized controlled trial.

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