<%server.execute "isdev.asp"%> Urethral protrusion of the abdominal catheter of ventriculoperitoneal shunt: Case report of extremely rare complication Yazar U, Kanat A, Akca N, Gazioglu G, Arda IS, Kazdal H - J Pediatr Neurosci
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CASE REPORT
Year : 2012  |  Volume : 7  |  Issue : 2  |  Page : 111-113
 

Urethral protrusion of the abdominal catheter of ventriculoperitoneal shunt: Case report of extremely rare complication


1 Department of Neurosurgery, Karadeniz Technical University, Trabzon, Turkey
2 Department of Neurosurgery, Recep Tayyip Erdogan University, Rize, Turkey
3 Department of Urology, Recep Tayyip Erdogan University, Rize, Turkey
4 Department of Pediatric Surgery, Yildizli Guven Hospital, Trabzon, Turkey
5 Department of Anestesiology, Sar Hospital, Rize, Turkey

Date of Web Publication17-Oct-2012

Correspondence Address:
Ayhan Kanat
Department of Neurosurgery, University Medical Faculty, Rize
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1817-1745.102571

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   Abstract 

Hydrocephalus in its various forms constitutes one of the major problems in pediatric neurosurgical practice. The placement of a ventriculoperitoneal (VP) shunt is the most common form of treatment for hydrocephalus, so that all neurosurgeons struggle with shunt malfunctions and their complications. Well-known complications are connected with the use of the valve systems (malfunction, infectious, overdrainage, secondary craniosynostosis, etc.). We report an unusual case of protruding abdominal catheter from the urethra. This girl had received a VP shunt for hydrocephalus following surgery of posterior fossa medulloblastoma 4 years ago. After admission, the entire system was removed, antibiotic treatment was administered for 2 weeks, and a new VP shunt was placed. The postoperative course was uneventful. This complication is extremely rare.


Keywords: Hydrocephalus, ventriculoperitoneal shunt, urethral protrusion


How to cite this article:
Yazar U, Kanat A, Akca N, Gazioglu G, Arda IS, Kazdal H. Urethral protrusion of the abdominal catheter of ventriculoperitoneal shunt: Case report of extremely rare complication. J Pediatr Neurosci 2012;7:111-3

How to cite this URL:
Yazar U, Kanat A, Akca N, Gazioglu G, Arda IS, Kazdal H. Urethral protrusion of the abdominal catheter of ventriculoperitoneal shunt: Case report of extremely rare complication. J Pediatr Neurosci [serial online] 2012 [cited 2017 Oct 20];7:111-3. Available from: http://www.pediatricneurosciences.com/text.asp?2012/7/2/111/102571



   Introduction Top


Hydrocephalus is a common clinical problem seen in pediatric neurosurgical practice. [1] At present, neurosurgical practice is confronted by an explosion of technology. [2],[3] In spite of all advances in neuroendoscopic surgery, [4] the placement of a ventriculoperitoneal (VP) shunt, from its first realization in 1908 by Kausch till our days, [5] is still amongst the most frequently performed operations in the management of hydrocephalus. [6] Well-known complications are connected with the use of the valve systems (malfunction, infectious, overdrainage, secondary craniosynostosis, etc.). [7],[8],[9],[10],[11],[12],[13] Perforation of the bladder by an abdominal catheter of a VP shunt is extremely rare. We report an unusual case of protruding abdominal catheter from the urethra. We investigated the literature and found seven similar cases. [6],[8],[14],[15],[16],[17],[18] Three of them were recently published, [16],[17],[18] so our case is eighth reported case with this complication in the literature.


   Case Report Top


A 5-year-old girl, who had received a VP shunt for hydrocephalus following surgery of posterior fossa medulloblastoma 4 years ago, readmitted to our hospital with protruding abdominal catheter from the urethra. On admission, the child was in a poor condition, afebrile, and alert but rather flaccid. Cerebrospinal fluid (CSF) analysis was done. CSF parameters showed high white blood cell (WBC) count 110 cell/mm 3 , low glucose level 39 mg/dl, and high protein 227/dl. The CSF sample was obtained for culture. The tip of the abdominal catheter was protruded from the urethra. The patient underwent plain X-rays of cranium, thorax and abdomen, cerebral, and abdominal CT scan. Abdominal X-ray showed an abnormal distal location of catheter distal tip [Figure 1]. Cranial CT scan showed overdrainage of ventricles. Laparotomy, performed jointly by neurosurgeons and pediatric surgeons, exposed the catheter and removed it and repaired the bladder. After the entire shunt system was removed, antibiotic treatment was administered for 2 weeks. Under treatment with antibiotics the child showed clinical improvement and progressive normalization of the CSF parameters, and a new VP shunt was placed. The postoperative course was uneventful.
Figure 1: X- ray of patient shows the tip of the abdominal catheter protruding from the urethra

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   Discussion Top


VP shunting in a patient with medulloblastoma can be considered in progressive symptomatic hydrocephalus. [19] Ventriculo peritoneal shunt is also carried out in hydrocephalus in a patient with medulloblastoma. Our case with medulloblastoma had received a VP shunt 4 years ago. VP shunt-related complications may occur anywhere along its course from the ventricle cranially to the peritoneal cavity caudally. [12] The distal end of the VP shunt had been placed in the peritoneal cavity, but this procedure is also associated with several complications, [7],[8],[9],[20] as can be seen in our case. The incidence of VP shunt-related abdominal complications has been reported to be from 5% to 47%. The most common distal VP shunt complications include shunt infection, subcutaneous collection of CSF, peritoneal pseudocyst, bowel perforation, intestinal volvulus, [21] catheter disconnection; and extraperitoneal retraction of the catheter through the mouth, umbilicus, bladder, vagina, anus, scrotum. [9],[22],[23],[24] In our case, physical examination, abdominal X-ray, CT scan helped us establish the diagnosis rapidly. The abdominal X-ray [Figure 1] and CT scan showed a foreign body inside of bladder and urethra [Figure 2], [Figure 3] and cranial CT scan showed overdrainage of ventricles. This migration of peritoneal catheter may be attributed to inspirations and expirations with a Valsalva effect, but no positive demonstration of this hypotheses has ever been published, so the real mechanism causing this urethral protrusion remains unclear. Our etiological speculations could be better explained by an experimental animal model. That would give us better knowledge of hydrodynamic happenings during CSF drainage. These distal VP shunt complications can be effectively managed surgically, and we operated this case. During surgery, we inspected peritoneal cavity, found protruded the distal catheter from the urethra. We repaired the defect of bladder and placed a new distal catheter into the peritoneal cavity. Previously, seven cases with protruding abdominal catheter of VP shunt from the urethra were reported [Table 1]. [6],[8],[14],[15],[16],[17],[18] Three of these seven cases were recently reported. [16],[17],[18] As can be seen from table, this complication is very rare. Our case is the eighth reported case in the literature. We treated this patient as an emergency because protruding the abdominal catheter from the urethra can lead to dysfunction of shunt or overdrainage, and infection such as meningitis.
Figure 2: Abdominal CT shows an abdominal catheter entering the urinary bladder

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Figure 3: Abdominal CT shows an abdominal catheter protruding from urethra

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Table 1: Published cases with urethral protrusion of the abdominal catheter VP shunt

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   Conclusion Top


VP shunt procedures are still in use despite recent technologic advances such as endoscopic third ventriculostomy. Care should be taken to prevent complications. This case report highlights a point of practical interest: pediatric neurosurgeon and parents must always be alert for possible urethral protrusion in children having a VP shunt because if the catheter is protruded it might lead to serious outcome.

 
   References Top

1.Venkataramana NK.Hydrocephalus Indian scenario - A review. J Pediatr Neurosci 2011;6(Suppl 1):11-22.  Back to cited text no. 1
    
2.Kanat A, Yazar U, Kazdal H, Yilmaz A, Musluman M. Neurosurgery is a profession. Neurol Neurochir Pol 2009;43:286-8.  Back to cited text no. 2
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3.Kanat A, Epstein CR. Challenges to neurosurgical professionalism. Clin Neurol Neurosurg 2010;112:839-43.  Back to cited text no. 3
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4.Popa F, Grigorean VT, Onose G, Popescu M, Strambu V, Sandu AM. Laparoscopic treatment of abdominal complications following ventriculoperitoneal shunt. J Med Life 2009;2:426-36.  Back to cited text no. 4
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5.Kausch W. Die behandlung des hydrocephalus der kleinen Kinder. Arch Kiln Chir 1908;87:709-96.  Back to cited text no. 5
    
6.Surchev J, Georgiev K, Enchev Y, Avramov R. Extremely rare complications in cerebrospinal fluid shunt operations. J Neurosurg Sci 2002;46:100-2.  Back to cited text no. 6
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7.Sekerci Z, Iyigun O, Rizalar R, Bozkurt G, Cokluk C, Rakunt C, et al. Migration of the distal catheter of a ventriculoperitoneal shunt into the abdominal wall. Turk Neurosurg 1993;3:125-7.  Back to cited text no. 7
    
8.Bavbek M, Simsek S. Urethral extrusion of distal shunt catheter. Turk Norosirurji Dergisi 1996;6:130-2.  Back to cited text no. 8
    
9.Ozveren MF, Kazez A, Cetin H, Ziyal IM. Migration of the abdominal catheter of a ventriculoperitoneal shunt into the scrotum-case report. Neurol Med Chir (Tokyo) 1999;39:313-5.  Back to cited text no. 9
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10.Baradkar VP, Mathur M, Sonavane A, Kumar S. Candidal infections of ventriculoperitoneal shunts. J Pediatr Neurosci 2009;4:73-5.  Back to cited text no. 10
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11.Taha MM, Hassanain S. Subtentorial subdural empyema: Report of two cases and review of the literatures. Turk Neurosurg 2011;21:669-73.  Back to cited text no. 11
    
12.Borkar SA, Satyarthee GD, Khan RN, Sharma BS, Matapatra AK. Spontaneous extrusion of migrated ventriculoperitoneal shunt catheter through chest wall: A case report. Turk Neurosurg 2008;18:95-8.  Back to cited text no. 12
    
13.Chong JY, Kim JM, Cho DC, Kim CH. Upward migration of distal ventriculoperitoneal shunt catheter into the heart: case report. J Korean Neurosurg Soc 2008;44:170-3.  Back to cited text no. 13
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14.Prasad VS, Krishna AM, Gupta PK. Extrusion of peritoneal catheter of ventriculoperitoneal shunt through the urethra. Br J Neurosurg 1995;9:209-10.  Back to cited text no. 14
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15.Ueda Y, Kakino S, Hashimoto O, Imoto K: Perforation of the bladder by a peritoneal catheter: An unusual late complication of ventriculo-peritoneal shunt. No Shinkei Geka 1998;26:413-6.  Back to cited text no. 15
    
16.de Aguiar GB, Mizrahi C, Aquino JH, Tavares CM, Telles C, Nigri F, et al. Urethral extrusion of a peritoneal catheter in a patient with a neobladder: A rare complication ofshunt insertion. Neuropediatrics 2011;42:124-7.  Back to cited text no. 16
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17.Chen TH, Lin MS, Kung WM, Hung KS, Chiang YH, Chen CH. Combined ventriculoperitoneal shunt blockage, viscus perforation and migration into urethra, presenting with repeated urinary tract infection. Ann R Coll Surg Engl 2011;93:151-3.  Back to cited text no. 17
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18.Pohlman GD, Wilcox DT, Hankinson TC. Erosive bladder perforation as a complication of ventriculoperitoneal shunt with extrusion from the urethral meatus: case report and literature review. Pediatr Neurosurg 2011;47:223-6.  Back to cited text no. 18
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19.Muzumdar D, Deshpande A, Kumar R, Sharma A, Goel N, Dange N, et al. Medulloblastoma in childhood-King Edward Memorial hospital surgical experience and review: Comparative analysis of the case series of 365 patients. J Pediatr Neurosci 2011;6(Suppl 1):S78-85.  Back to cited text no. 19
    
20.Fransen PF, Kevenk U, Thauvoy C. Subcutaneous cranial migratian of a ventricula-peritoneal shunt: Case report. Turkish Neurosurg 1994;4:38- 40.  Back to cited text no. 20
    
21.Blount JP, Campbell JA, Haines SJ. Complications in ventricular cerebrospinal fluid shunting. Neurosurg Clin N Am 1993;4:633-56.  Back to cited text no. 21
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22.Gocer AI, Bagdatlioglu H, Cetinalp E, Uzuneyupoglu Z, Karadayi A. An unusual complication of the ventriculo-peritoenal shunt: migration of distal end into the scrotum through the inguinal canal. Turk Neurosurg 1990;1:176-7.  Back to cited text no. 22
    
23.Vuyyuru S, Ravuri SR, Tandra VR, Panigrahi MK. Anal extrusion of a ventriculo peritoneal shunt tube: Endoscopic removal. J Pediatr Neurosci 2009;4:124-6.  Back to cited text no. 23
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24.Agarwal T, Pandey S, Niranjan A, Jain V, Mishra S, Agarwal V. Unusual complication of ventriculoperitoneal shunt surgery. J Pediatr Neurosci 2009;4:122.  Back to cited text no. 24
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]


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    Abstract
   Introduction
   Case Report
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