BACKGROUND: Temporal lobe epilepsy (TLE) is often accompanied by psychiatric manifestations, of which, anxiety is among the most common. While the effects of surgery or ablation on TLE and seizure outcomes, as well as neuropsychological outcomes, have been well studied, anxiety is an exception and has not been systematically examined. Our study aims to systematically review the changes in anxiety before and after TLE surgery. METHODS: We systematically reviewed the existing literature on anxiety in the setting of TLE. Different electronic databases were queried for studies published until 3rd June 2024. RESULTS: Eighteen studies with 1403 patients who had refractory TLE and underwent surgical treatment were included. Eight different anxiety scales were used in the included studies, with baseline anxiety rates of 5.3 % to 35.1 %. A significant reduction in anxiety was observed in studies using the Hamilton Anxiety Rating Scale, with a pooled change of -0.87 (95 % CI: -1.26, -0.48, P <
0.002) after surgery. Conversely, the State-Trait Anxiety Inventory (STAI) scores did not show significant changes, with pooled changes of -0.30 (95 % CI: -1.72, 1.12, P = 0.68) for the State (STAI-S) and 0.10 (95 % CI: -1.56, 1.77, P = 0.90) for Trait (STAI-T) anxiety types. Similarly, significant improvements in anxiety were observed on the Hospital Anxiety and Depression Scale, with a pooled change of -0.87 (95 % CI: -1.62, -0.12, P = 0.02) at the last follow-up. CONCLUSION: Our findings indicate that TLE surgery leads to a significant reduction in anxiety levels, though evidence regarding subgroup differences, such as seizure-free versus non-seizure-free patients, remains limited due to the small number of studies. Additional research is necessary to clarify these findings and further assess the broader effects of surgery on anxiety.