Stesura Seveso


375Archivio Italiano di Urologia e Andrologia 2022; 94, 4

ORIGINAL PAPER

No conflict of interest declared.

specifically to remote clinical services and was first adopt-
ed in the 1950’s when an American psychiatrist connected
to a prison through a closed-circuit television to provide
mental health services (3). 
In recent years, with the advancement of mobile technolo-
gies, the adoption and accessibility of telemedicine has sig-
nificantly increased, after COVID-19 pandemic declaration
in several clinical and surgical fields including urology (4-
10). Advantages of remote care include reduction of the
use of resources in health centers, improving access to care
(3). Moreover, telemedicine has the potential to reduce the
risk of direct transmission of infectious agents (11).
Approximately 15 million Americans receive remote med-
ical assistance yearly (2). The urological literature on tele-
health is sparse. The telemedicine experience in urology
spans from new patient consultations to telesurgery to
post-operative rounds and even virtual house calls (12). 
In details, telemedicine has been described in patients with
hematuria, prostate cancer, urinary stones, pelvic organ
prolapse, urinary infections, and urinary incontinence (2).
The aim of the present study was to explore attitudes and
perceptions by urologic patients toward the use of telemed-
icine in the context of patient-physicians communication
during the post-operative follow-up in a large academic
tertiary urology referral department in Italy.

MATERIALS AND METHODS

Questionnaire
An anonymous 15 multiple choice questions (formulated
in Italian with the aim of increasing the response rate)
questionnaire was administered to a total of 955 patients
who had visited the outpatient Department of Urology at
University Federico II, Naples, from September 2020 to
April 2021 The questionnaire was composed of three sec-
tions: a first one to assess respondents’ demographics
(age, sex, urologic disease) a second one to evaluate their
attitudes using telemedicine, and a third to evaluate per-

Introduction: Telemedicine is a most used
tools in various medical and surgical

 scenarios.
The aim of the present study was to explore attitudes and per-
ceptions by urologic patients toward the use of telemedicine in
the context of patient-physicians communication during the
post-operative follow-up in a large academic tertiary urology
referral department in Italy.
Materials and methods: An anonymous questionnaire consisting
of 15 multiple choice questions was designed including three
 sections: respondents’ demographics, attitudes, and perceptions
towards the use of telemedicine. Invitations to participate to this
anonymous questionnaire was given to outpatients attended at
Urology Department, University of Naples Federico II.
Results: In total 697 responses were received (participation rate
73%). The frequency of telemedicine use was described as fre-
quently, occasional, rarely, and never by 41.6%, 30.4%, 15.1%,
and 12.6% of respondents, respectively. WhatsApp messenger
used by 59.5% of respondents and telephone call (34.3%) were
the most common type of tools. Satisfaction in using telemedi-
cine was reported as very satisfied, satisfied, neutral, dissatis-
fied, and very dissatisfied by 39.6%,41.4%,10%,7% and 2% of
respondents respectively. Overall, 43.7%% of participants indi-
viduated limited interaction and risk of misdiagnosis as the
major limit of telemedicine.
Conclusions: Telemedicine represents the future of medical
 practice due to several benefits as well as convenience, increased
access to care and decreased healthcare costs.

KEY WORDS: Telemedicine; Telehealth; Healthcare; Virtual
Healthcare; Urology.

Submitted 28 July 2022; Accepted 2 August 2022   

INTRODUCTION
Telehealth represents a rapidly evolving field of medicine. 
It is defined as the use of information technology and
telecommunications to provide access to health assess-
ment, consultation, diagnosis, intervention, super-vision,
and information across distance (1, 2). Telemedicine refers

Perceptions and attitudes toward the use of telemedicine
for the postoperative outpatient urological care during 
the COVID-19 pandemic in an Academic Hospital 
in Southern Italy

Vincenzo Mirone 1, Giuseppe Celentano 1, Claudia Collà Ruvolo 1, Luigi Cirillo 1, 
Giovanni Maria Fusco 1, Marco Abate 1, Simone Morra 1, Francesco Di Bello 1, Gianluigi Califano 1,
Claudia Mirone 2, Gianluigi Cacace 1, Vincenzo Morgera 1, Roberto La Rocca 1, Marco Capece 1, 
Nicola Longo 1, Luigi Napolitano 1, Massimiliano Creta 1

1 Department of Neurosciences, Reproductive Sciences and Odontostomatology, School of Medicine, University of Naples 
"Federico II", Naples, Italy;
2 Multidisciplinary Department of Medical, Surgical and Dental Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.

DOI: 10.4081/aiua.2022.4.375

Summary



Archivio Italiano di Urologia e Andrologia 2022; 94, 4

V. Mirone, G. Celentano, C. Collà Ruvolo, et al.

376

ceptions towards telemedicine. Questions about
attitudes toward use of telemedicine included:
tools adopted (telephone call, e-mails,
WhatsApp, others), context in which telemedi-
cine was used, content of multimedia data
shared.
Questions about perceptions investigated the
perceived usefulness of telemedicine and the
potential developments. 
Respondents were invited to "strongly agree",
"moderately agree", "slightly agree", "strongly dis-
agree", "moderately disagree", "slightly disagree"
with a series of statements about perceptions.
Some questions required a single answer while
others gave the respondents the choice to select
as many answers as they felt appropriate.

Data analysis
Data were expressed as mean (Standard Deviation)
and raw numbers and percentages of survey
answers. Statistical analyses were two-sided using
a significance level of 0.05. 
All statistical analyses were performed with SPSS
version 17.0 (SPSS, Inc., Chicago, IL) software. 

RESULTS
In total 697 responses were received (participa-
tion rate 73 %). All patients were Caucasian. 
Of them, 572 patients (82%) were male and
125 (18%) were female. Mean (SD) patients’ age
was 67.5 (5.3) years. In details the number of
patients aged between 18-34, 35-54, 55-74,
and those aged > 75 were 12 (1.7%), 16 (2.3%),
466 (66.8%), and 203 (29.1%), respectively. 
Concerning educational level, the number of
patients with elementary school or no title, mid-
dle school diploma, high school diploma, and
university degree were 104 (15%), 139 (20%),
175 (25%), and 279 (40%), respectively. 
As regards the occupational status of respon-
dents, the number of them working, retired and
unemployed were 367 (52.6%), 265 (38.1%),
and 65 (9.3%), respectively. 
The disease for which patients received outpa-
tient post-operative care were bladder cancer
(n = 209, 30%), prostate cancer (n = 160, 23%),
kidney cancer (n = 69, 10%), testis cancer (n =
4, 0.5%), penis cancer (n = 2, 0.3%), obstruc-
tive uropathy (n = 105, 15%), urolithiasis (n =
69, 10%), urinary tract infections (n = 4, 0.5%)
and others (n = 75, 10.7%). Overall, 267
patients (38.3%) were in the early post-opera-
tive follow-up (within 30 days from surgery)
and 430 (61.7%) in the late post-operative fol-
low-up (> 30 days from surgery). 
Table 1 describes attitudes toward the use of
telemedicine. 
Figure 1 describes the frequency of telemedicine
use according to patients’ age. 
Perceptions about the usefulness and limits of
telemedicine in the context of outpatient post-

Table 1. 
Attitudes of patients toward telemedicine.

N (%)

Frequency of telemedicine use 
Frequently 290 (41.6)
Occasionally 212 (30.4)
Rarely 109 (15.7)
Never 86 (12.3)

Use of telemedicine during the COVID-19 pandemic compared to the pre-pandemic period
Increased 387 (63.4)
Remained stable 159 (25.9)
Decreased 65 (10.7)

Purpose of availing telemedicine facility 
Booking and appointment 246 (40.2)
Consultation 322 (52.7)
Treatment 43 (7.1)

Tools adopted 
Telephone call 209 (34.3)
WhatsApp messages 364 (59.5)
Video-call 24 (3.9)
e-mail 2 (0.3)
Other 12 (1)

Media-contents shared 
Video 3 (0.8)
Audio 129 (32.1)
Text 220 (54.7)
Photo 50 (12.4)

Reason for not using telemedicine
I don’t know the existence of this type of medical service 42 (48.9)
I don’t know how to use this type of medical service 19 (22.5)
I don’t trust telemedicine 13 (14.7)
My technical conditions do not allow me to use telemedicine 8 (9.3)
Other reasons 4 (4.6)

Willingness to continue using telemedicine after COVID-19 pandemic
Yes 416 (68.1)
Not 195 (31.9)

Satisfaction with telemedicine use
Very satisfied 242 (39.6)
Satisfied 253 (41.4)
Neutral 61 (10)
Dissatisfied 43 (7)
Very dissatisfied 12 (2)

Figure 1. 
Percentage of telemedicine use according to patients’ age.  



377Archivio Italiano di Urologia e Andrologia 2022; 94, 4

Perceptions and attitudes toward the use of telemedicine for the postoperative outpatient urological care during the COVID-19 pandemic...

operative follow-up are reported in Table 2. Figure 2
describes the percentage of patients reporting specific
challenges in availing telemedicine. 

DISCUSSION
In the last years, several surgeons have incorporated
telemedicine into pre- and post-operative visits and spe-
cialty consultations (13). The use of telemedicine modali-
ties for perioperative care has been reported to represent a
cost-effective strategy and has been associated with a rela-
tively high rate of patient satisfaction (13). 
Urologists described the successful use of telemedicine in
several settings: shared decision-making counseling for
prostate cancer treatment, administration of behavioral
therapies for urinary incontinence, and post-operative fol-
low-up care (13). More recently, The COVID-19 pandem-
ic has radically changed the landscape of health care and
has further stimulated the use of telemedicine (13-14).
Attitudes and perceptions toward the use of telemedicine
by patients varies significantly across the word and accord-

ing to the setting of adoption. To
our knowledge this represents
the first time a survey investigat-
ing the attitudes and perceptions
about telemedicine by urology
patients referring to an outpatient
department in Southern Italy. 
Interestingly, 72% of respon-
dents declared to having fre-
quently or occasionally used
telemedicine during the COVID-
19 pandemic. 
Not surprisingly, the percentage
of patients declaring to use
telemedicine rarely or never
increased with increasing age
with most patients never using

medicine being aged > 75 years. Of note, about half of
patients declaring to have never used telemedicine did
not know the existence of this type of medical service. 
These findings point out the current limits of telemedi-
cine, mainly il old people, for which lack of knowledge
and confidence with telemedicine may represent a sig-
nificant barrier. 
Whatsapp messenger was the most frequently adopted tool
by respondents during remote communication. 
Accordingly, a comprehensive systematic review presented
compelling evidence that WhatsApp Messenger is a prom-
ising system when used as a communication tool between
health care professionals and the general public (15). 
Limited patient-physician interaction and risk of misdi-
agnosis were perceived as limitations of telemedicine by
most respondents. Accordingly, many criticize that tele-
health may adversely affect continuity of care. Online
interactions are perceived as impersonal and dangerous
because the virtual provider does not offer the benefit of
a complete medical history and physical examination
(15-18). Therefore, telehealth should be considered as

Table 2. 
Perceptions about the usefulness and limits of telemedicine in the context of outpatient post-operative follow-up 
of urological patients (n = 697).

Agree strongly Agree moderately Agree slightly Disagree slightly Disagree moderately Disagree strongly
N (%) N (%) N (%) N (%) N (%) N (%)

Telemedicine, in combination with in-person appointments, is useful 
in improving patient- physician communication in the post-operative period 229 (32.9) 264 (38) 75 (10.8) 87 (12.5) 26 (3.7) 16 (2.1)

Telemedicine, in combination with in-person appointments, is useful 
in improving the quality of assistance in the post-operative period 248 (35.6) 196 (28,1) 111 (15,9) 86 (12.3) 35 (5.1) 21(3)

Telemedicine, in combination with in-person appointments, is useful in improving
the interpretation of findings from laboratory and radiological investigations 222 (31.7) 175 (25.1) 139 (20) 139 (20) 15 (2.2) 7 (1)

Telemedicine, in combination with in-person appointments, is useful 
in improving the interpretation of clinical findings 211 (30.3) 158 (22.6) 189 (27.1) 114 (16.4) 18 (2.6) 7 (1)

Telemedicine, in combination with in-person appointments, is helpful 
in reducing unnecessary visits to hospitals 306 (43.9) 175 (25.1) 111 (16) 70 (10) 35 (5) 0 (0)

Telemedicine, in combination with in-person appointments, is helpful 
in reducing costs of post-operative follow-up 258 (37) 141 (20.2) 203 (29.1) 63 (9) 32 (4.7) 0 (0)

Telemedicine, in combination with in-person appointments, is helpful 
in improving patients’ adherence to prescriptions 315 (45.3) 227 (32.6) 72 (10.3) 57 (8.2) 26 (3.6) 0 (0)

Telemedicine, in combination with in-person appointments, is helpful in helps 
in the prompt recognition of complications and side effects 256 (36.8) 154 (22.1) 104 (14.9) 111 (15.9) 72 (10.3) 0 (0)

Figure 2. 
Percentage of patients reporting specific limitations in availing telemedicine (n = 611). 



Archivio Italiano di Urologia e Andrologia 2022; 94, 4

V. Mirone, G. Celentano, C. Collà Ruvolo, et al.

378

an adjunct and best used to supplement in-person visits
(15). Although vulnerable security and privacy was per-
ceived as a limit of telemedicine by only 8.3% of
patients, this issue deserve careful attention. According
to Morris et al., despite the widespread use of WhatsApp,
clinicians are either failing in their ethical, legal, regula-
tory, and clinical responsibility to keep records of
WhatsApp consults, or are not reporting how they do so
or that they do so (19). Unfortunately, the literature does
not report any clear “best practices” for recordkeeping, or
the secure storage of patient information obtained and
there is a need to raise awareness on this issue and to
urgently provide viable guidance (19). Interesting is
patient satisfaction with use of telemedicine. We report-
ed an overall good satisfaction using this technology:
39.6% and 41.4% of respondents reported satisfaction
and very satisfaction respectively. Our data corroborated
results of previous published studies. Holzman et al.
reported high grade of satisfaction with telemedicine
compared to in person visits in pediatric urology outpa-
tient patients (20). A high satisfaction of patients in tele-
health experience compared to in person visit were also
reported by Polinski et al. and by Ambrosini et al. (21-22).
Despite advantages using telemedicine, some disadvan-
tages and barriers as well as performing physical exami-
nations, possibilities for technical difficulties, security
breaches, and regulatory barriers have been reported
(23). Limited interaction and misdiagnosis were the
most reported barriers in our survey, 43.7% and 25.2%
respectively. The topic is very important with several
legal and economic aspects. 
Our data corroborated findings reported in previous
studies: Chandhanayingyong reported an overall misdiag-
nosis rate of 40%, with over-diagnosis of 12% and
under-diagnosis of 27% using teleconsultation using the
mobile phone multimedia messaging service (MMS) in
emergency orthopedic patients (24). Spear at al. in a sur-
vey on 781 patients that experienced telemedicine,
reported as main disadvantages the lack of hands-on
care, the lack of intimacy, and technical difficulties (25). 
Our study has some limitations: first of all, the simple size
represents a small group of the providers in the academ-
ic setting, and it is limited to academic urology experi-
ence. Telemedicine represents the future of medical prac-
tice including several benefits as well as convenience,
increased access to care and decreased healthcare costs.
Further studies are necessary to improve clinical, admin-
istrative, and research aspects to expand the use of
telemedicine among patients.

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Correspondence
Vincenzo Mirone, MD
mirone@unina.it
Department of Neurosciences, Reproductive Sciences and Odontostomatology, 
School of Medicine, University of Naples "Federico II", Naples (Italy)
Giuseppe Celentano, MD
dr.giuseppecelentano@gmail.com
Claudia Collà Ruvolo, MD
c.collaruvolo@gmail.com
Luigi Cirillo, MD
cirilloluigi22@gmail.com
Giovanni Maria Fusco, MD
giom.fusco@gmail.com
Marco Abate, MD
marcoabate5@gmail.com
Simone Morra, MD
simonemorra@outlook.com
Francesco Di Bello, MD
fran.dibello12@gmail.com
Gianluigi Califano, MD
gianl.califano2@gmail.com
Gianluigi Cacace, MD
cacace.gianlu@gmail.com
Vincenzo Morgera, MD
vincemorgera87@gmail.com
Roberto La Rocca, MD
robertolarocca87@gmail.com
Marco Capece, MD
drmarcocapece@gmail.com
Nicola Longo, MD
nicola.longo@unina.it
Massimiliano Creta, MD 
max.creta@gmail.com
Luigi Napolitano, MD (Corresponding Author)
dr.luiginapolitano@gmail.com
Department of Neurosciences, Reproductive Sciences and Odontostomatology, 
Urology Unit, University of Naples "Federico II"
Via Sergio Pansini n 5, Naples (NA), Campania (Italy)

Claudia Mirone, MD
claudiamirone@outlook.it
Multidisciplinary Department of Medical, Surgical and Dental Sciences, 
University of Campania "Luigi Vanvitelli", Naples (Italy)