Immersive Virtual Reality for Pain and Anxiety Reduction During Transrectal Ultrasound-Guided Prostate Biopsy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Transrectal ultrasound (TRUS) guided prostate biopsy is a distressing procedure associated with significant pain and anxiety, even with routine local anesthesia. Immersive virtual reality (VR) has emerged as a promising non-pharmacological distraction strategy, aiming to modulate pain perception via sensory overload and attentional shift. Methods: A comprehensive search of five databases, including PubMed, Web of Science, CENTRAL, Scopus, and Embase, was conducted up to April 2026. RCTs comparing intra-procedural immersive VR to standard care were included. Primary outcomes were biopsy-related pain and anxiety. Secondary outcomes included patient satisfaction and procedure-related adverse events. Standardized mean differences (SMD) were pooled using a random-effects model. Results: Four RCTs involving 454 patients were included. There was no significant difference between the two groups regarding biopsy-related pain (N = 355 patients, SMD: -1.24, 95% CI [-2.53, 0.04]; p = 0.06) and biopsy-related anxiety (N = 361 patients, SMD: -1.37, 95% CI [-2.76, 0.02]; p = 0.054). These analyses demonstrated significant inter-study heterogeneity (I² > 95%), and leave-one-out sensitivity analyses revealed instability in the pooled estimates. Nevertheless, VR appeared feasible and well tolerated, with no major device-related adverse events reported in the available trials. Conclusions: The available evidence remains very uncertain regarding the effect of immersive VR on pain and anxiety during TRUS-guided prostate biopsy. Substantial clinical and statistical heterogeneity and instability of the pooled estimates limit definitive interpretation, and the current evidence is insufficient to support routine implementation. Larger, adequately powered, and standardized RCTs are warranted.