- Email: [email protected]
Abdominal and Genitourinary Complications Following Ventriculoperitoneal Shunts
0022-5347/78/1192-0295$02. 00/0 The Journal of Urology Copyright © 1978 by The Williams & Wilkins Co.
Vol. 119, February Printed in U.SA.
ABDOMINAL AND GENITOURINARY COMPLICATIONS FOLLOWING VENTRICULOPERITONEAL SHUNTS JOHN F. REDMAN
JOANNA J. SEIBERT
AND
From the Departments of Urology and Radiology, University of Arkansas College of Medicine, Little Rock, Arkansas
ABSTRACT
Three patients with complications secondary to ventriculoperitoneal shunts for the management of hydrocephalus are described. Abdominal and genitourinary complications that may occur after the shunting procedure usually are owing to abnormal accumulation of cerebrospinal fluid or perforation by the shunting catheter tip. The ventriculoperitoneal shunt is used frequently for shunting cerebrospinal fluid in children with hydrocephalus. 1 Although the complication rate is relatively low abdominal and, occasionally, genitourinary problems do occur.2-5 Reports of abdominal complications have appeared most frequently in the neurosurgical and pediatric literature. Herein we discuss the abdominal and genitourinary complications that may occur after ventriculoperitoneal shunting. CASE REPORTS
Case 1. L. P., 73-65-76, a 5-year-old girl, was seen initially in February 1976. At birth she had undergone closure of a meningomyelocele. In 1972 a ventriculoperitoneal shunt was
vealed a large midline abdominal mass (fig 1, A). Ultrasound examination demonstrated a fluid-filled space, which was believed to be a pseudocyst of cerebrospinal fluid (fig. 1, B). With the revision of the shunt to the atrium the distension resolved within 3 days. Case 2. C.H., 58-13943, a 16-year-old girl with hydrocephalus and a ventriculoperitoneal shunt, was evaluated because of epigastric and right lower quadrant pain. The pain was described as constant but no emesis was present. There were no neurological deficits and the shunt seemed to pump well. Abdominal radiograms and ultrasound examination demonstrated a fluid mass in the mid abdomen (fig. 2). Exploration revealed an omental cyst around the tip of the catheter.
Fm. 1. Case 1. A, abdominal radiogram with patient in supine position shows shunt tubing coiled in mid abdomen with large mass displacing large bowel to right and stomach cephalad. B, transverse B-mode ultrasound at level of umbilicus reveals large echo-free mass.
inserted and urinary diversion by an ileal conduit was done. The patient had an enormous ileal conduit segment with concomitant upper tract dilatation. The head circumference had remained stable. Because of the dilatation and history of repeated symptomatic urinary tract infections a new ileal segment was constructed in March 1976. At operation the shunt was bound in dense fibrous tissue and, when freed, copious amounts of fluid began to drip from the shunt. Also, there was a considerable degree of intestinal adhesions. The operation was uneventful. Approximately 6 weeks postoperatively the patient was vomiting, and had abdominal pain and distension. Partial intestinal obstruction was suspected because of the previously noted intestinal adhesions. However, the abdominal radiograms showed no evidence of obstruction but, instead, re-
Case 3. M. K., 73-49-17, a 6-month-old male infant with hydrocephalus and a ventriculoperitoneal shunt, was evaluated because of a bulging right hemiscrotum. A plain film demonstrated the shunt tubing to be coiled in the scrotum (fig. 3). At operation the catheter was. coiled within a patent processus vaginalis. DISCUSSION
Generally, the abdominal and genitourinary complications are those related to accumulation of cerebrospinal fluid or to perforation by the tip of the shunting catheter. Collection of cerebrospinal fluid may be localized to form a cyst-like structure or may involve all of the peritoneal cavity causing ascites. 6 A child with a cerebrospinal fluid pseudocyst or ascites may present with symptoms of an acute abdomen with abdominal pain, vomiting, distension and/or a mass. 6
Accepted for publication May 27, 1977. 295
296
REDMAN AND SEIBERT
Fm. 2. Longitudinal B-mode ultrasound in midline of abdomen in case 2 shows fluid-filled mass anteriorly and caudal to liver.
A further complication related to the cerebrospinal fluid is the appearance of inguinal hernias when none has been noted previously. The incidence has been reported as high as 15 per cent. 1 Contralateral exploration in cases of unilateral clinical inguinal hernias in ventriculoperitoneal shunt patients has been advised. 1 The appearance of the abdominal catheter in the scrotum and the appearance of hydroceles secondary to cerebrospinal fluid have been reported. 1 , 5 , 10, 11 Simulated testicular torsion 12 and torsion of omental cysts secondary to ventriculoperitoneal shunts also have been described. 13 Complications caused by perforation by the tip of the shunt catheter have been reported with numerous unusual presentations. Perforation of the small bowel, colon and rectum have been noted. 4 , 14, 15 Extrusion of the catheter tip through the umbilicus16 and also the vagina17 has been reported. Grosfeld and associates have reported 2 instances of perforations of the bladder by a shunt catheter tip that required surgical repair. 4 Additional abdominal complications not related to the cerebrospinal fluid or perforations have been volvulus around the adhesive bands around the catheter and ileus related to blood from a subarachnoid hemorrhage draining into the peritoneal cavity. 18' 19 A unilateral ureteral obstruction secondary to extrinsic compression by a shunt catheter also has been described. Obstruction was relieved by displacement of the catheter and ureterolysis from the surrounding fibrous tissue. 20 REFERENCES
1. Grosfeld, J. L. and Cooney, D.R.: Inguinal hernia after ventri-
2. 3. 4. 5. 6.
7. 8. 9. 10. 11. 12. Fm. 3. Abdominal radiogram of case 3 demonstrates shunt tubing coiled in right hemiscrotum. Other cases may have symptoms of increased intracranial pressure or a deteriorating neurological status. 7 The diagnosis may be confirmed by injection of the shunt system by contrast medium. 4, 8 Since shunts that do poorly in the peritoneal cavity continue to do so even after revision it is recommended that a further abdominal procedure be avoided by conversion to a ventriculoatrial or other form of shunt. 7• 9
13. 14.
15. 16.
culoperitoneal shunt for hydrocephalus. J. Pediat. Surg., 9: 311, 1974. Little, J. R., Rhoton, A. L., Jr. and Mellinger, J. F.: Comparison of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus in children. Mayo Clin. Proc., 47: 396, 1972. Ames, M. D. and Schut, L.: Results of treatment of171 consecutive myelomeningoceles, 1963 to 1968. Pediatrics, 50: 466, 1972. Grosfeld, J. L., Cooney, D. R., Smith, J. and Campbell, R. L.: Intra-abdominal complications following ventriculoperitoneal shunt procedures. Pediatrics, 54: 791, 1974. Ramani, P. S.: Extrusion of abdominal catheter ofventriculoperitoneal shunt into the scrotum. Case report. J. Neurosurg., 40: 772, 1974. Parry, S. W., Schuhmacher, J. R. and Llewellyn, R. C.: Abdominal pseudocysts and ascites formation after ventriculoperitoneal shunt procedures. Report of four cases. J. Neurosurg., 43: 476, 1975. Fischer, E. G. and Shillito, J., Jr.: Large abdominal cysts: a complication of peritoneal shunts. Report of three cases. J. Neurosurg., 31: 441, 1969. Gifford, R. R. M. and Plaut, M. R.: Contrast radiography of abdominal cyst from ventriculo-peritoneal shunt. J. South Carolina Med. Ass., 69: 335, 1973. Sivalingam, S., Corkill, G., Getzen, L. and Matolo, N.: Recurrent abdominal cyst: a complication of ventriculoperitoneal shunt and its management. J. Pediat. Surg., 11: 1029, 1976. Murtagh, F. and Lehman, R.: Peritoneal shunts in the management of hydrocephalus. J.A.M.A., 202: 1010, 1967. Scherzer, A. L.: Hydrocele following placement of a ventriculoperitoneal shunt (letter). J. Pediatr., 86: 811, 1975. Levey, S. H., Cooper, P. and Schiffman, D.: Simulated testicular torsion in a neonate. Complication of ventriculoperitoneal shunt. Urology, 9: 174, 1977. Parrish, R. A. and Potts, J. M.: Torsion of omental cysts-a rare complication of ventriculoperitoneal shunt. J. Pediat. Surg., 8: 969, 1973. Rubin, R. C., Ghatak, N. R. and Visudhipan, P.: Asymptomatic perforated viscus and gram-negative ventriculitis as a complication of valve-regulated ventriculoperitoneal shunts. Report of two cases. J. Neurosurg., 37: 616, 1972. Sells, C. J. and Loeser, J. D.: Peritonitis following perforation of the bowel: a rare complication of a ventriculoperitoneal shunt. J. Pediatr., 83: 823, 1973. Adeloye, A.: Spontaneous extrusion of the abdominal tube
ABDOMINAL AND GENITOURINARY COMPUCATIONS FOLLOWING VENTRICULOPERITONEAL SHUNTS
through the umbilicus complicating peritoneal shunt for hydrocephalus. Case report. J. Neurosurg., 38: 758, 1973. C. D. and Matloub, H.: Vaginal perforation as a compli17. of ventriculoperitoneal shunt. Case report. J. Neurosurg., 38: 761, 1973. 18. Sakoda, T. H., Maxwell, J. A. and Brackett, C. tinal volvulus secondary to a ventriculoperitoneal report. J. Neurosurg., 35: 95, 1971.
297
19. Forrest, P. D., Lesser, R. M. and Corkill, G.: Subarachnoid hemorrhage manifested by intestinal ileus in a patient with a ventriculoperitoneal shunt. Case report. J. Neurosurg., 4I: 499, 1974. 20. Sullivan, M. J., Banowsky, L. H. and Lackner, L. H.: A urological complication of lumbar subarachnoid shunt. Ureteral obstruction by extrinsic compression. Amer. J. Dis. Child., :123: 597, 1972.
Vol. 119, February Printed in U.SA.
ABDOMINAL AND GENITOURINARY COMPLICATIONS FOLLOWING VENTRICULOPERITONEAL SHUNTS JOHN F. REDMAN
JOANNA J. SEIBERT
AND
From the Departments of Urology and Radiology, University of Arkansas College of Medicine, Little Rock, Arkansas
ABSTRACT
Three patients with complications secondary to ventriculoperitoneal shunts for the management of hydrocephalus are described. Abdominal and genitourinary complications that may occur after the shunting procedure usually are owing to abnormal accumulation of cerebrospinal fluid or perforation by the shunting catheter tip. The ventriculoperitoneal shunt is used frequently for shunting cerebrospinal fluid in children with hydrocephalus. 1 Although the complication rate is relatively low abdominal and, occasionally, genitourinary problems do occur.2-5 Reports of abdominal complications have appeared most frequently in the neurosurgical and pediatric literature. Herein we discuss the abdominal and genitourinary complications that may occur after ventriculoperitoneal shunting. CASE REPORTS
Case 1. L. P., 73-65-76, a 5-year-old girl, was seen initially in February 1976. At birth she had undergone closure of a meningomyelocele. In 1972 a ventriculoperitoneal shunt was
vealed a large midline abdominal mass (fig 1, A). Ultrasound examination demonstrated a fluid-filled space, which was believed to be a pseudocyst of cerebrospinal fluid (fig. 1, B). With the revision of the shunt to the atrium the distension resolved within 3 days. Case 2. C.H., 58-13943, a 16-year-old girl with hydrocephalus and a ventriculoperitoneal shunt, was evaluated because of epigastric and right lower quadrant pain. The pain was described as constant but no emesis was present. There were no neurological deficits and the shunt seemed to pump well. Abdominal radiograms and ultrasound examination demonstrated a fluid mass in the mid abdomen (fig. 2). Exploration revealed an omental cyst around the tip of the catheter.
Fm. 1. Case 1. A, abdominal radiogram with patient in supine position shows shunt tubing coiled in mid abdomen with large mass displacing large bowel to right and stomach cephalad. B, transverse B-mode ultrasound at level of umbilicus reveals large echo-free mass.
inserted and urinary diversion by an ileal conduit was done. The patient had an enormous ileal conduit segment with concomitant upper tract dilatation. The head circumference had remained stable. Because of the dilatation and history of repeated symptomatic urinary tract infections a new ileal segment was constructed in March 1976. At operation the shunt was bound in dense fibrous tissue and, when freed, copious amounts of fluid began to drip from the shunt. Also, there was a considerable degree of intestinal adhesions. The operation was uneventful. Approximately 6 weeks postoperatively the patient was vomiting, and had abdominal pain and distension. Partial intestinal obstruction was suspected because of the previously noted intestinal adhesions. However, the abdominal radiograms showed no evidence of obstruction but, instead, re-
Case 3. M. K., 73-49-17, a 6-month-old male infant with hydrocephalus and a ventriculoperitoneal shunt, was evaluated because of a bulging right hemiscrotum. A plain film demonstrated the shunt tubing to be coiled in the scrotum (fig. 3). At operation the catheter was. coiled within a patent processus vaginalis. DISCUSSION
Generally, the abdominal and genitourinary complications are those related to accumulation of cerebrospinal fluid or to perforation by the tip of the shunting catheter. Collection of cerebrospinal fluid may be localized to form a cyst-like structure or may involve all of the peritoneal cavity causing ascites. 6 A child with a cerebrospinal fluid pseudocyst or ascites may present with symptoms of an acute abdomen with abdominal pain, vomiting, distension and/or a mass. 6
Accepted for publication May 27, 1977. 295
296
REDMAN AND SEIBERT
Fm. 2. Longitudinal B-mode ultrasound in midline of abdomen in case 2 shows fluid-filled mass anteriorly and caudal to liver.
A further complication related to the cerebrospinal fluid is the appearance of inguinal hernias when none has been noted previously. The incidence has been reported as high as 15 per cent. 1 Contralateral exploration in cases of unilateral clinical inguinal hernias in ventriculoperitoneal shunt patients has been advised. 1 The appearance of the abdominal catheter in the scrotum and the appearance of hydroceles secondary to cerebrospinal fluid have been reported. 1 , 5 , 10, 11 Simulated testicular torsion 12 and torsion of omental cysts secondary to ventriculoperitoneal shunts also have been described. 13 Complications caused by perforation by the tip of the shunt catheter have been reported with numerous unusual presentations. Perforation of the small bowel, colon and rectum have been noted. 4 , 14, 15 Extrusion of the catheter tip through the umbilicus16 and also the vagina17 has been reported. Grosfeld and associates have reported 2 instances of perforations of the bladder by a shunt catheter tip that required surgical repair. 4 Additional abdominal complications not related to the cerebrospinal fluid or perforations have been volvulus around the adhesive bands around the catheter and ileus related to blood from a subarachnoid hemorrhage draining into the peritoneal cavity. 18' 19 A unilateral ureteral obstruction secondary to extrinsic compression by a shunt catheter also has been described. Obstruction was relieved by displacement of the catheter and ureterolysis from the surrounding fibrous tissue. 20 REFERENCES
1. Grosfeld, J. L. and Cooney, D.R.: Inguinal hernia after ventri-
2. 3. 4. 5. 6.
7. 8. 9. 10. 11. 12. Fm. 3. Abdominal radiogram of case 3 demonstrates shunt tubing coiled in right hemiscrotum. Other cases may have symptoms of increased intracranial pressure or a deteriorating neurological status. 7 The diagnosis may be confirmed by injection of the shunt system by contrast medium. 4, 8 Since shunts that do poorly in the peritoneal cavity continue to do so even after revision it is recommended that a further abdominal procedure be avoided by conversion to a ventriculoatrial or other form of shunt. 7• 9
13. 14.
15. 16.
culoperitoneal shunt for hydrocephalus. J. Pediat. Surg., 9: 311, 1974. Little, J. R., Rhoton, A. L., Jr. and Mellinger, J. F.: Comparison of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus in children. Mayo Clin. Proc., 47: 396, 1972. Ames, M. D. and Schut, L.: Results of treatment of171 consecutive myelomeningoceles, 1963 to 1968. Pediatrics, 50: 466, 1972. Grosfeld, J. L., Cooney, D. R., Smith, J. and Campbell, R. L.: Intra-abdominal complications following ventriculoperitoneal shunt procedures. Pediatrics, 54: 791, 1974. Ramani, P. S.: Extrusion of abdominal catheter ofventriculoperitoneal shunt into the scrotum. Case report. J. Neurosurg., 40: 772, 1974. Parry, S. W., Schuhmacher, J. R. and Llewellyn, R. C.: Abdominal pseudocysts and ascites formation after ventriculoperitoneal shunt procedures. Report of four cases. J. Neurosurg., 43: 476, 1975. Fischer, E. G. and Shillito, J., Jr.: Large abdominal cysts: a complication of peritoneal shunts. Report of three cases. J. Neurosurg., 31: 441, 1969. Gifford, R. R. M. and Plaut, M. R.: Contrast radiography of abdominal cyst from ventriculo-peritoneal shunt. J. South Carolina Med. Ass., 69: 335, 1973. Sivalingam, S., Corkill, G., Getzen, L. and Matolo, N.: Recurrent abdominal cyst: a complication of ventriculoperitoneal shunt and its management. J. Pediat. Surg., 11: 1029, 1976. Murtagh, F. and Lehman, R.: Peritoneal shunts in the management of hydrocephalus. J.A.M.A., 202: 1010, 1967. Scherzer, A. L.: Hydrocele following placement of a ventriculoperitoneal shunt (letter). J. Pediatr., 86: 811, 1975. Levey, S. H., Cooper, P. and Schiffman, D.: Simulated testicular torsion in a neonate. Complication of ventriculoperitoneal shunt. Urology, 9: 174, 1977. Parrish, R. A. and Potts, J. M.: Torsion of omental cysts-a rare complication of ventriculoperitoneal shunt. J. Pediat. Surg., 8: 969, 1973. Rubin, R. C., Ghatak, N. R. and Visudhipan, P.: Asymptomatic perforated viscus and gram-negative ventriculitis as a complication of valve-regulated ventriculoperitoneal shunts. Report of two cases. J. Neurosurg., 37: 616, 1972. Sells, C. J. and Loeser, J. D.: Peritonitis following perforation of the bowel: a rare complication of a ventriculoperitoneal shunt. J. Pediatr., 83: 823, 1973. Adeloye, A.: Spontaneous extrusion of the abdominal tube
ABDOMINAL AND GENITOURINARY COMPUCATIONS FOLLOWING VENTRICULOPERITONEAL SHUNTS
through the umbilicus complicating peritoneal shunt for hydrocephalus. Case report. J. Neurosurg., 38: 758, 1973. C. D. and Matloub, H.: Vaginal perforation as a compli17. of ventriculoperitoneal shunt. Case report. J. Neurosurg., 38: 761, 1973. 18. Sakoda, T. H., Maxwell, J. A. and Brackett, C. tinal volvulus secondary to a ventriculoperitoneal report. J. Neurosurg., 35: 95, 1971.
297
19. Forrest, P. D., Lesser, R. M. and Corkill, G.: Subarachnoid hemorrhage manifested by intestinal ileus in a patient with a ventriculoperitoneal shunt. Case report. J. Neurosurg., 4I: 499, 1974. 20. Sullivan, M. J., Banowsky, L. H. and Lackner, L. H.: A urological complication of lumbar subarachnoid shunt. Ureteral obstruction by extrinsic compression. Amer. J. Dis. Child., :123: 597, 1972.