The objective of this study is to evaluate the impact of intraprocedural Virtual Reality (VR) as a non-pharmacological intervention for mitigating anxiety and pain during Extracorporeal Shock Wave Lithotripsy (ESWL). The hypothesis is that VR can effectively reduce both pain and anxiety levels in patients by diverting their cognitive focus, potentially leading to a decrease in pharmacological intervention requirements.

The primary outcome is pain at energy level 900 during ESWL for the intervention and the control group.

The secondary outcomes are as follows:

• Type and dose of analgesia
• Conductance scores/values
• Anxiety levels
• Patient satisfaction
• Procedure duration
• Adverse events

Participants will be randomized into either the intervention or control group. Both groups will undergo ESWL according to standard treatment; however, the intervention group will wear a Virtual Reality headset and noise-cancelling headphones during the procedure, while the control group will not

The objective of this study is to evaluate the impact of intraprocedural Virtual Reality (VR) as a non-pharmacological intervention for mitigating anxiety and pain during Extracorporeal Shockwave Lithotripsy (ESWL). The hypothesis is that VR can effectively reduce both pain and anxiety levels in patients by diverting their cognitive focus, potentially leading to a decrease in pharmacological intervention requirements.

Furthermore, the study aims to gather data on patients' perspectives regarding the functionality and efficacy of VR technology in enhancing their intraprocedural experience. This includes an evaluation of VR's role in contribution to the overall procedural experience.

Introduction: According to the European Association of Urology (EAU) guidelines, urolithiasis is treated with ESWL, Ureteroscopy (URS), Percutaneous Nephrolithotomy (PNL), or other surgical treatments that may relieve the obstructive symptoms of the urinary tract. EAU recommends ESWL as the primary treatment for renal pelvic and proximal ureteral stones of <20 mm. The success of ESWL is closely related to factors such as the experience of the urologist using the machine, localization of the stone, urinary system anatomy, and the patient's compliance with the procedure. To ensure compliance, it is important to minimize patients' pain and anxiety. To handle pain and anxiety, various ways including both pharmacological and non-pharmacological approaches are in use today. Pharmacological control of pain and anxiety, including the use of sedation, is a complex decision that consider both benefits and potential risks. While not highly recommended due to the side effects associated with these agents, such as hypotension, respiratory depression, confusion, and limitations in ability to operate machines, sedation medication can be an effective means of managing pain and anxiety when used judiciously.

Non-pharmacological alternatives have been recommended for decreasing pain and anxiety during ESWL, as for example music which have been found beneficial in several studies. VR can immerse patients into a virtual environment and distract patients from e.g., unpleasant sounds, sights, and feelings. Integrating VR into hospital settings, has shown the potential to offer several advantages, such as promoting patients' distraction, knowledge, and information. The advantage lies in the engagement of multiple sensory perceptions, including hearing and vision, which can be beneficial in enhancing the potential for reduced experiences of pain and anxiety, as these perceptions typically strengthen humans' cognitive memory. The hypothesis is that distraction from VR can lower pain perception and reduce anxiety for patient undergoing EWSL compared with standard care.

Virtual Reality (VR) has been widely used in psychiatry and for children when they need to have a peripheral venous catheter inserted. Many studies show that VR has a distracting effect, and this distraction can be used to reduce both pain and anxiety. The novelty of this research study lies in using VR during ESWL so that the patient experiences less pain and anxiety. There is only one study from 2023, conducted in Belgium, which investigates whether VR is effective in reducing pain in kidney stone patients during ESWL. This study is a randomized controlled trial (RCT), and its results support the use of VR as a method for pain relief during ESWL.

There is a significant need for more evidence-based research studies in this area. With more research, it will be possible to better assess whether VR has the desired effect and relevance within medical procedures.

Method: The trial will be designed as a randomized controlled clinical trial while being adequately powered for the primary outcome. The randomization will be computer-generated randomization by the statistic programme R studio with sequence 1:1 by a colleague not associated to the study. The sample size estimation showed that 72 participants are needed with a 15% drop rate. The participants will be randomized into one of two groups. There will be randomization on the day of inclusion by REDcap which also store the data about the patients.

Because of VR's nature, it is impossible to blind the participants. The outcome assessors, investigators, data analysts, and manuscript writers will be blinded. The participants are patients undergoing urological procedure at Zealand University Hospital, Roskilde. All ASA scores are accepted.

All patients scheduled for ESWL will be screened based on the inclusion and exclusion criteria. Patients are eligible if they meet all inclusion criteria and none of the exclusion criteria. Intervention Group: Patients will receive ESWL using the EDAP-TMS model Sonolith i-sys machine with standard medication, supplemented by a Virtual Reality headset and Active-Noise-Cancelling (ANC) headphones, which will play a video of the patient's choice. Control Group: Patients will receive ESWL with standard medication, without the addition of VR or ANC-headphones. Participation in this trial will not result in prolonged admission or require additional follow-up visits.

The four different videos of what the patient can choose from, are developed specific for intraprocedural use and have been established in cooperation with people older than 65 years of age, private company Khora and Zealand University Hospital, Denmark and Lund University. The videos are created to fit different personalities and needs when persons undergo painful procedures. The development of the videos has focused on comprehending videos that have movement, colours, sound and pixels quality to prevent cyber sickness.

Standard intraprocedural management: All patients will follow the traditional standard treatment which includes Paracetamol and Ibuprofen as premedication with the possibility of receiving sublingual fentanyl during procedure to comfort the patient.

Inclusion Criteria:

• Scheduled for ESWL at Region Zealand
• Age of 18 or above
• Ability to understand the trial protocol, risks, and benefits and provide signed informed consent

Exclusion Criteria:

• Inability to read and understand Danish.
• Uncooperativeness (as judged by investigators)
• Claustrophobia or fear of small spaces
• Disorders that prevent the person from wearing a VR device
• Highly visually or auditive impaired

Due to the nature of VR, it is impossible to mask the patients and the healthcare providers administering the shockwave treatment.