Virtual Reality in ESWL: A Novel Approach to Pain Management

Extracorporeal shock wave lithotripsy (ESWL) is a well-established treatment for kidney and ureteric stone disease, employing high-energy shock waves to fragment stones into smaller pieces for passage through the urinary tract. This article explores the application of virtual reality (VR) for pain management during ESWL.

Pain during ESWL procedures

Pain during ESWL arises from the shock waves, causing discomfort in the flank, back, or pelvis (for ureteric stones). Pain intensity varies considerably among individuals, likely influenced by factors such as stone size and location, individual pain tolerance, and procedure-related anxiety. 1-3

Pain can lead to several negative consequences:

* Reduced patient compliance: Pain can hinder patients' ability to remain still, crucial for effective stone fragmentation. Movement can misdirect shock waves, reducing efficacy and potentially increasing the number of treatments required.
* Increased anxiety: Anticipation and experience of pain can elevate anxiety, further impacting the patient's experience and potentially exacerbating pain perception. 1
* Suboptimal treatment outcomes: Pain can result in suboptimal stone fragmentation, necessitating additional procedures or alternative treatments, such as ureteroscopy or percutaneous nephrolithotomy.3

Traditional pain management during ESWL includes medications like diclofenac suppositories, short-acting opioid analgesics, and smooth muscle relaxants such as tamsulosin. Analgesics are often administered before and/or during the procedure.

The Emergence of Virtual Reality (VR)

VR has emerged as a promising non-pharmacological approach to pain management. By immersing individuals in a computer-generated environment, VR offers a compelling sensory experience that can effectively distract patients from pain and anxiety. 4-6

Two randomized controlled trials (RCTs) have investigated the acceptability of VR during ESWL. Candela et al. assessed the feasibility and effectiveness of the HypnoVR® device for pain and anxiety management during ESWL. 30 patients with upper urinary tract stones were offered VR during their procedure. Results showed the device was safe and well- tolerated, with only one patient experiencing mild side effects. Pain and anxiety levels were significantly lower post-procedure. The study concluded that HypnoVR® is a clinically feasible and safe tool for pain and anxiety management during ESWL, warranting further comparative studies. 7

In a subsequent larger RCT, Weynants et al. 8 used the Oncomfort Sedakit VR device (now part of HypnoVR®), 9 immersing patients in an underwater environment following a whale. Patients undergoing ESWL with VR experienced less pain despite receiving significantly higher energy delivery to their stones via more powerful shockwaves. Neither study demonstrated a significant improvement in clinical success of stone clearance. 7-8

Practical Experience of VR in ESWL sessions

At University Hospitals Birmingham NHS Foundation Trust, we have implemented VR for ESWL using commercially available, off-the-shelf technology (Meta Quest 3). 10 We tested various meditation software options available from the Meta Horizon Store. Patients receive diclofenac 100mg PR prior to ESWL. After fluoroscopic stone targeting, the VR headset is fitted while the patient lies supine on the ESWL table.

Software selection proved challenging. Most VR environments are designed for seated or standing use, while ESWL requires a supine position. Identifying a stationary, engaging, and immersive environment that avoids motion sickness and involuntary movements was an unexpected hurdle.

Our early experience mirrors Weynants’ findings, showing that patients generally tolerate higher total energy with lower perceived pain. This effect is particularly noticeable in patients undergoing repeat ESWL sessions, who were able to compare experiences with and without the VR device.

Expanding VR Applications in Urology

VR has potential for various other urological applications, particularly in patient distraction and pain management:

Minimally invasive procedures: VR can distract patients during procedures like flexible cystoscopy, 11 prostate biopsies, 12 and potentially all minimally invasive surgical therapies under local anaesthesia.
Pelvic floor muscle training: VR can provide immersive biofeedback, enhancing patient engagement and effectiveness. 13
* Preoperative anxiety reduction: VR can alleviate preoperative anxiety by immersing patients in calming environments. 14
* Postoperative pain management: VR can manage postoperative pain and discomfort, potentially reducing analgesic requirements. 15

Future Directions

While initial findings are promising, further research, including multi-center studies, is needed. Given the heterogeneity of VR headsets and software, research should focus on identifying the most effective content and delivery methods for patient distraction. Cost- effectiveness evaluations compared to traditional pain management are also crucial to determine clinical and economic benefits beyond improved patient experience.

Conclusion

VR shows significant promise as a novel approach to pain management and distraction during ESWL. By providing a captivating and immersive experience, VR can effectively reduce pain and anxiety during the procedure.

Published: 15/2/2025

Mr Ivo Dukic is an experienced consultant urologist and high-volume stone surgeon in Birmingham, United Kingdom. You can schedule an appointment with him for expert, bespoke advice through his Top Doctors profile or book an appointment through the Harborne Hospital, HCA Healthcare or the Priory Hospital, Edgbaston, Circle Health Group.

References

1. Tamalvanan V, Rajandram R, Kuppusamy S. Reduction of pre-procedural anxiety for
   repeat sessions in extracorporeal shockwave lithotripsy (ESWL) reduces pain
   intensity: A prospective observational study. Medicine (Baltimore).
   2022;101(37):e30425.

2. Bovelander E, Weltings S, Rad M, et al. The Influence of Pain on the Outcome of
   Extracorporeal Shockwave Lithotripsy. Curr Urol. 2019;12(2):81–7.

3. Daly KM, Chaker K, Rhouma SB, et al. Evaluation des protocoles analgésiques pour la
   prise en charge de la douleur au cours de la lithotripsie extra corporelle. Pan Afr Med
   J. 2019;32:109.

4. Hoffman HG, Doctor JN, Patterson DR, et al. Virtual reality as an adjunctive pain
   control during burn wound care in adolescent patients. Pain. 2000;85(1–2):305–9.

5. Malloy KM, Milling LS. The effectiveness of virtual reality distraction for pain
   reduction: A systematic review. Clin Psychol Rev. 2010;30(8):1011–8.

6. Morris LD, Louw QA, Grimmer-Somers K. The Effectiveness of Virtual Reality on
   Reducing Pain and Anxiety in Burn Injury Patients: A Systematic Review. Clin J Pain.
   2009;25(9):815.

7. Candela L, Ventimiglia E, Corrales M, et al. The Use of a Virtual Reality Device
   (HypnoVR) During Extracorporeal Shockwave Lithotripsy for Treatment of Urinary
   Stones: Initial Results of a Clinical Protocol. Urology. 2023;175:13–7.

8. Weynants L, Chys B, D’hulst P, et al. Virtual reality for pain control during shock wave
   lithotripsy: a randomized controlled study. World J Urol. 2023;41(2):589–94.

9. https://hypnovr.io/en/ (Accessed February 3, 2025)

10. https://www.meta.com/gb/quest/quest-3/ (Accessed February 3, 2025)

11. Ketsuwan C, Matang W, Ratanapornsompong W, et al. Prospective randomized
    controlled trial to evaluate effectiveness of virtual reality to decrease anxiety in
    office-based flexible cystoscopy patients. World J Urol. 2022;40(10):2575–81.

12. Kim P, Dall’era M. Mp06-15 virtual reality immersion for reducing anxiety and pain
    during transperineal prostate biopsy: a prospective, randomized clinical trial. J Urol.
    2023;[Epub ahead of print]. (Please add actual publication details when available)

13. Payton S. Using a virtual reality dance game to improve mixed incontinence. Nat Rev
    Urol. 2014;11(3):128.

14. Chiu PL, Li H, Yap KYL, et al. Virtual Reality–Based Intervention to Reduce
    Preoperative Anxiety in Adults Undergoing Elective Surgery. JAMA Netw Open.
    2023;6(10):e2340588.

15. Ding L, Hua H, Zhu H, et al. Effects of virtual reality on relieving postoperative pain in
    surgical patients: A systematic review and meta-analysis. Int J Surg. 2020;82:87–94.