Virtual Reality for Pain, Anxiety, and Patient Experience in Awake Urological Procedures: A Systematic Review and Meta-Analysis of Randomised Controlled Trials.

Awake urological procedures, including cystoscopy, transrectal ultrasound-guided prostate biopsy (TRUS-Bx), extracorporeal shock wave lithotripsy, vasectomy, and urodynamic studies, are consistently associated with procedural pain and anxiety, with downstream consequences for surveillance compliance and patient experience. Head-mounted display (HMD) virtual reality (VR) has emerged as a non-pharmacological adjunct, but existing reviews have been narrative or restricted to a single procedure type. This systematic review and meta-analysis evaluated head-mounted display VR across the full breadth of awake urological procedures. PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to April 2026. Eligible studies were randomised controlled trials (RCTs) of HMD VR compared with standard care in adults undergoing office-based urological procedures under local anaesthesia. Two reviewers independently performed study selection, data extraction, and risk of bias assessment using the revised Cochrane risk of bias tool (RoB 2). Random-effects meta-analyses used the standardised mean difference (SMD) with Hedges' g. Certainty of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Eleven RCTs encompassing 1,557 participants across eight countries were included. The VR was associated with statistically significant reductions in procedural pain (SMD -0.68, 95% CI -1.25 to -0.11) and anxiety (SMD -1.39, 95% CI -2.64 to -0.14), although both estimates carried substantial heterogeneity (I² = 91.7% and 89%, respectively). Subgroup analysis of pain by procedure type revealed marked divergence: VR produced negligible benefit during cystoscopy (SMD -0.16, 95% CI -0.32 to 0.00) but a large reduction during TRUS-Bx (SMD -1.84, 95% CI -2.82 to -0.85), the latter based on only two studies with substantial heterogeneity. Narrative synthesis showed consistent improvements in patient satisfaction and procedural comfort and attenuation of physiological stress markers. No serious VR-related adverse events were identified across approximately 900 patients. The certainty of evidence was low for all outcomes. The HMD VR may offer meaningful reductions in procedural pain and anxiety during selected awake urological procedures, particularly those characterised by sustained nociceptive stimulation and high anticipatory distress, with a consistent safety profile. However, the very high between-study heterogeneity means these pooled averages should be interpreted cautiously, and the benefit appears procedure-specific rather than uniform. The benefit appears procedure-specific and is unlikely to exceed established pharmacological standards during routine cystoscopy. Adequately powered procedure-specific trials are needed before VR can be considered a standard adjunct.