As the COVID-19 pandemic led to a global crisis, contact restrictions were imposed, and medical measures were reduced to the minimum to contain the virus’ rapid dissemination (1, 2). These restrictions did not only concern hospital staff, increasing intensive care capacities and postponing elective surgical procedures, but the outpatient sector was also intensively affected (3–5).

A cross-sectional study based on nearly four million consultations evaluated the number of healthcare services during the first pandemic wave, demonstrating a 65% decline in face-to-face consultations (6). The healthcare services provided in the ambulatory sector also significantly decreased during the first wave, especially when the protective measures were imposed in March 2020, affecting mainly elective consultations (7).

At the beginning of the pandemic, urologists from the outpatient sector were not adequately prepared to deal with the new situation in their practices, causing considerable concern and fear among physicians (8–10). During the first COVID-19 wave, 24% of all urologists felt high, and 48% felt a moderate threat level (8). A German observational study revealed that hospital admissions, recognized incident diseases, and consultations significantly decreased throughout the pandemic in primary care (11). However, it is unknown whether and, if so, to what extent the reduced provision of urologist services was compensated at the end of the pandemic.

The negative impact of the pandemic on the mental health of healthcare professionals strongly influences work-life (12). A prior survey- and interview-based study revealed significant physical and psychological burden associated with the pandemic, with a high prevalence of burnout (57.7%) among physicians (13). Especially studies from Asia demonstrated high stress, depression, and anxiety symptoms with severe degrees in 2.2 to 14.5% at the pandemic’s beginning (14). However, data are lacking regarding the stress experienced by urologists during the pandemic.

This analysis’s objectives were to evaluate the impact of the COVID-19 pandemic on the daily work routine and medical service provision of urologists and their perceived stress during the first four pandemic waves in Germany.

Our study was the first to evaluate the long-term effect of the COVID-19 pandemic on work-related and personal aspects among urologists in the German ambulatory sector. The decline in consultations, drug prescriptions, hospital admissions, and cancer diagnosis detection during the pandemic was in line with previous studies, showing a significantly decreased number of cancer screenings and diagnoses during the early phase of the COVID-19 pandemic (15).

However, data evaluating its longitudinal change was lacking. A German survey assessed the provision of medical care services during the first and second waves of the COVID-19 pandemic (16). Congruent to our data, the urologic outpatient sector described a 50% reduction in consultation during the first wave. This is also in line with studies reporting a strong impact of the pandemic on German urologists’ daily work (8). An international cohort study with more than 20,000 cancer patients confirmed that cancer surgery systems were worldwide fragile to lockdowns, as 14% of all patients awaiting surgery did not undergo planned surgery and experienced longer preoperative delays during lockdowns (17). This is in line with the high number of cancelations of preventive medical examinations (40%) in our study. Our study revealed that consultations, hospital admissions, and cancer diagnoses decreased massively, not reaching pre-pandemic levels throughout the study period. A previously published analysis supports our findings regarding prostate cancer, as fewer prostate cancer patients were surgically treated during the first two waves of the pandemic, which did not reach pre-pandemic levels (18).

Nine out of ten urologists in our study fear that the reduced detection rate of incident disease will harm patients’ outcomes. French studies aroused suspicion that a reduced consultation and detection rate of cancer diagnoses during the pandemic might lead to a higher tumor burden, number of advanced tumors (pT3b: 11.2 vs. 25.6%; nodal positive: 14.8 vs. 46.1%) and metastatic disease (5.9 vs. 9.3%) of prostate cancer patients (19, 20). However, long-term data is missing so far but is urgently needed. Thus, the fine line between a shutdown and a potential negative impact on the healthcare system should be intensively evaluated in future pandemic waves.

During the pandemic’s beginning, German urologists awarded telehealth for having a high relevance. Still, only 25,5% of all urologists from the ambulatory sector already included telemedical approaches in their daily routine (8). In the survey two years later, telemedical approaches were used by 58% of all urologists from the outpatient sector, showing that telemedicine has steply risen during the pandemic (5). Although telemedicine incorporates advantages in a pandemic, our study participants stated that it might have complicated the identification of incident diagnoses, indicating a loss of vital clinical information and that physical examination and face-to-face consultations might not be replaceable. Consequently, healthcare professionals and patients must be trained in telemedical approaches before widespread uptake, and accurate electronic patient notes must be available. Especially follow-up consultations seem to be ideal for telemedical procedures (21).

Almost 60% of all urologists reported COVID-19-related absences from employees. One in four practices had to close temporarily during the pandemic, underlining the COVID-19 pandemic impact on health systems and social and economic structures (22). The observations of the pandemic’s influence can be used as a call for dynamic systemic transformation and improved resilience of healthcare workers. The World Health Organization also expounds on the potential negative impact of the COVID-19 pandemic on mental health of healthcare professionals, strongly impacting the work-life balance (12). In our study, urologists reported higher anxiety, stress, and need for support during the pandemic than in the pre-pandemic period. Anxiety and the need for support were highest during the first wave of the pandemic, which is in line with prior studies from China and Europe performed at the beginning of the pandemic revealed a high psychological burden among healthcare workers, especially in the outpatient sector (8, 23–26).

Our analysis revealed that urologists in individual practices and those treating more patients experienced the highest stress level in the third and/or fourth waves. The higher anxiety level in female urologists during the fourth wave is in line with the results of a German and French survey that evaluated mental health issues in healthcare workers during the beginning of the pandemic (8, 27). However, a previous analysis examining the pandemic-related stress experience of psychiatrists revealed that anxiety was dependent on feeling restricted (OR = 5.52) and risk of infection (OR = 5.74) but not on gender (28). The physical and psychological burden healthcare workers experienced during the COVID-19 pandemic is high, as the prevalence of burnout among physicians was nearly 60% (13). Further analysis of potential risk factors for developing mental health problems is paramount. Mental health and resilience could be supported by specific interventions and psychological support (29), which can be classified into four main categories: social/structural support, work environment, communication/information, and mental health support. However, systematic reviews revealed lacking evidence regarding selecting interventions beneficial to frontline workers’ resilience and mental health (29, 30). Future research is needed to promote mental well-being and resilience strategies in healthcare professionals during and after pandemics. Limitations of our study include the descriptive design of the analyses of consultations, drug prescriptions, hospital admission or incident cancer diagnoses over the pandemic periods, which did not account for the analyses of statistical significances. Furthermore, we used a non-validated survey, potentially leading to non-sampling errors which might negatively impact the accuracy and reliability of the results. Additionally, the low response rate of 5% of our survey could have negatively impacted the reliability and validity of the results.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

The survey was approved by the Ethical Committee of the Chamber of Physicians of Mecklenburg-Western Pomerania (registry number (BB 127/21) and was conducted in accordance with Good Clinical Practice Guidelines: all participants agreed on the conditions of the survey before taking part.

PP: Data curation, Formal analysis, Writing – original draft, Writing – review & editing. MP: Formal analysis, Methodology, Writing – review & editing. KK: Formal analysis, Writing – review & editing. SL: Writing – review & editing. JB: Methodology, Writing – review & editing. BM: Formal analysis, Methodology, Writing – review & editing.