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Simulated testicular torsion in a neonate Complication of ventriculoperitoneal shunt
SIMULATED
TESTICULAR TORSION IN
A NEONATE Complication STUART PAUL
H. LEVEY,
COOPER,
DONALD
of Ventriculoperitoneal
Shunt
M.D.
M.D.
SCHIFFMAN,
M.D.
From the Departments of Urology, Neurosurgery, Hackensack Hospital, Hackensack, New Jersey
and Pediatrics,
ABSTRACT - Ventriculoperitoneal shunts are a common form of cerebrospinal @id diversion in treating hydrocephalus. With their use various complications have been noted. Herein is described a shunt complication which simulated an acute scrotal condition. The operative findings and treatment are discussed. A brief review qf the literature is also given.
A full-term male infant was born with a spina bifida and meningomyelocele deformity. Repair of the meningomyelocele was performed on the day of birth. A ventriculoperitoneal shunt was performed twelve days later because of a developing hydrocephalus. Because of a distal shunt obstruction, revision was performed ten days later without incident. Six days after the shunt revision the infant was noted to have an enlarged right hemiscrotum, thought to be a hernia. Later that same day the right hemiscrotum became reddened and indurated with an associated right inguinal swelling. A urologic consultation was obtained. Physical findings included an enlarged reddened and slightly edematous right hemiscrotum with minor involvement of the left side as well (Fig. 1A). The right testicle could not be palpated. The right inguinal canal was also swollen and erythematous. Laboratory findings consisted of an afebrile infant, normal urinalysis, and normal hemogram. The clinical impression at this time was acute torsion of the testicle. Surgical exploration was done within the hour via scrotal incision. A normal-appearing testicle was noted, but on further examination the distal end of the ventriculoperitoneal shunt was iden-
174
tified (Fig. 1B). A second incision was then made in the right inguinal region. The cord structures were identified as well as the ventriculoperitoneal shunt (Fig. 1C). The shunt tube was pushed back into the peritoneal cavity, and the neck of the hernia sac was identified and closed. The remainder of the incisions were closed in the usual manner after wound cultures were obtained. The infant made an uneventful recovery except for the development of a ventriculitis necessitating removal of the shunt. Of significance is the fact that on the day of surgery a baseline intravenous urogram was performed which was to be officially interpreted the following day. The collecting systems and bladder were normal. The most significant finding was the presence of the shunt tubing entering the right inguinal region (Fig. 2A). This should be compared with the postshunt flat plate which demonstrated an intraperitoneal position (Fig. 2B). The postexploratory flat plate again demonstrated an intraperitoneal position (Fig. 2C). It is doubtful whether or not the case would have been managed differently had the findings on the pyelogram been known preoperatively.
UROLOGY
/
FEBRUARY
1977
/
VOLUME IX, NUMBER 2
FIGURE 1. (A) Enlarged, erythematous right hemiscrotum; (B) shunt tube in scrotum; and (C) shunt tube in processus vaginalis in inguinal canal.
Comment Meningomyelocele occurs in nearly two of every one thousand live neonatal births. In approximately 60 per cent of the patients with meningomyelocele hydrocephalus develops; and if not treated, a high mortality in the first year of life 0ccurs.l When hydrocephalus or its development is diagnosed early in the neonatal period, various shunting procedures are used to prevent ventricular enlargement and cerebral atrophy. For many years ventriculoatrial and ventriculojugular shunts were used in children with hydrocephalus, but because of various complications the ventricular peritoneal shunt was de-
vised and has become a popular mode of cerebral spinal fluid diversion.2-4 Currently the ventricular peritoneal shunt involves a Holter valve with either a Pudenz or Raimondi peritoneal catheter. ‘s6 Since the use of the ventricular peritoneal shunt, various complications have been reported, such as fibrous encasement of the peritoneal tip,’ blocking and kinking of the distal tube, extrusion of the tube through the incision,’ postoperative ileuq8 infection, cerebrospinal fluid fistula, and perforation of the bowels and volvulus.‘” Other complications have included extrusion of the catheter into the scrotum or along an unobliterated processus vaginalis, l1 intra-abdominal cerebrospinal fluid
FIGURE 2. (A) Pyelogram demonstrating shunt tube entering right inguinal region. (B) Postoperative flat plate con.ing intraperitoneal position of shunt tubing. (C) Postinguinoscrotal exploration demonstrating intraperitoneal position of shunt tubing.
UROLOGY
/ FEBRUARY
1977 / VOLUME
IX, NUMBER 2
175
cysts, knotted shunts and bladder perforation,12 perforation of peritoneal catheter through umbilicus, l3 and perforation of vagina.r4 It is not uncommon to note the tip of the ventricular peritoneal shunt in the scrotum on a flat plate.15 Grosfeld et al., in 1974,16 described a 16 per cent incidence of previously unrecognized inguinal hernias in a series of 185 patients with ventricular peritoneal shunts, 45 of whom had intra-abdominal complications. The mean interval from shunt procedure to observation of the hernia was 6.8 months, and none was described in an infant one month old. He does mention that x-ray films of the abdomen demonstrated a ventricular peritoneal shunt in the scrotum in 6 otherwise unrecognized cases. In the various case reports no mention has been made of the presence of a ventricular peritoneal shunt catheter in the scrotum associated with an acute inflammatory response. The mechanism for the presence of the shunt tubing in the scrotum is several fold. The shunt tubing is left long deliberately to allow for growth of the child. Thus, if given the opportunity, it could migrate down a patent processus vaginalis. The processus vaginalis remains patent for approximately two years when obliteration takes place spontaneous1y.l’ Prior to this time, however, it is a potential space, and it is believed that the excess cerebrospinal fluid in the peritoneal cavity (either overproduction or diminished absorption) in infancy can convert the potential space to a clinical hernia. This hernia coupled with an increased intraabdominal pressure could account for the migration of an intraperitoneal shunt into the scrotum. la Extravaginal torsion of a testicle is considered high on the list in the differential diagnosis of the acute scrotum in the neonatal period; and when considered, surgical exploration in most cases should be performed. In the case described herein such an exploration was carried out. The negative testicular findings were indeed a surprise. Cultures from both the scrotal contents and peritoneal cavity both grew out Staphylococcus epidermidis. Interestingly enough, this organism has been implicated in shunt complications and no doubt accounted for the scrotal swelling and cellulitis in this case.ls To our knowledge there has been nothing in the urologic literature describing the neurosurgical complication previously outlined. Many urologists are not aware of the possible migrations of a ventriculoperitoneal shunt into the
176
scrotum. This condition should be added to the list of the differential diagnoses of an acute scrotum in patients with ventriculoperitoneal shunts. 445 Prospect Avenue Hackensack, New Jersey 07601 (DR. LEVEY) References 1. RANSOHOFF, J., MATHEWS, E. S.: Neurosurgical management of patients with spina bifida and meningomyelocele, Med. Clin. North Am. 53: 493 (1969). 2. FORREST, D. M., and COOPER, D. G.: Complications of ventriculoatrial shunts: a review of 455 cases, J. Neurosurg. 29: 506 (1968). 3. OVERTON, M. D., III, and SNODGRASS, S. R.: Ventriculovenous shunts for infantile hydrocephalus, ibid. 23: 517 (1965). 4. LITTLE, J. R., RHOTON, A. L., and MELLINGER, J. F.: Comparison of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus in children, Mayo Clin. Proc. 47: 396 (1972). 5. PUDENZ, R. H.: Experimental and clinical observations on the shunting of cerebra-spinal fluid into the circulating system, Clin. Neurosurg. 5: 98 (1957). 6. RAIMONDI,A. J., and MATSUMOTO,S.: A simplified technique for performing the ventriculo-peritoneal shunt, J. Neurosurg. 26: 357 (1967). 7. AMES, R. H.: Ventriculo-peritoneal shunts in the mangement of hydrocephalus, ibid. 27: 525 (1967). 8. MURTAGH, F., and LEHMON, R.: Peritoneal shunts in the management of hydrocephalus, J.A.M.A. 202: 1010(1967). 9. WILSON, C. B., and BERTAN, V.: Perforation of the bowel complicating peritoneal shunts for hydrocephalus, Am. Surg 32: 691 (1966). 10. SAKADA,T. H., MAXWELL, J. A., and BRACKETT,C. E., JR.: Intestinal volvulus secondary to a ventriculo-peritoneal shunt, J. Neurosurg. 35: 95 (1971). 11. ROMANI, P. S.: Extrusion of abdominal catheter of ventriculo-peritoneal shunt into the scrotum, ibid. 40: 772 (1974). 12. GROSFELD, J. L., et al.: Intra-abdominal complications following ventriculo-peritoneal shunt procedures, Pediatrics 54: 791 (1974). 13. ADELAYE, A. : Spontaneous extrusion of the abdominal tube through the umbilicus complicating peritoneal shunts for hydrocephalus, case report, J. Neurosurg. 38: 758 (1973). 14. PATEL, C. D., and MATLAUB, H.: Vaginal perforation as a complication of ventriculo-peritoneal shunts, case report, ibid. 38: 761 (1973). 15. RUBIN, R.: Personal communication, 1975. 16. GROSFELD, J. L., et al. : Op. cit.12 17. ROWE, M. I., et al. : The patent processus vaginalis and the inguinal hernia, J. Pediatr. Surg. 4: 102 (1969). 18. GROSFELD, J. L., and COONEY, D. R.: Inguinal hernia after ventriculo-peritoneal shunt for hydrocephalus, ibid. 9: 311 (1974). 19. IGNELZI, R. J., and KIRSH, W. M. : Follow-up analysis of ventriculo-peritoneal ventriculoatrial shunts for hydrocephalus, J. Neurosurg. 42: 679 (1975).
UROLOGY /
FEBRUARY 1977 / VOLUME IX, NUMBER 2
TESTICULAR TORSION IN
A NEONATE Complication STUART PAUL
H. LEVEY,
COOPER,
DONALD
of Ventriculoperitoneal
Shunt
M.D.
M.D.
SCHIFFMAN,
M.D.
From the Departments of Urology, Neurosurgery, Hackensack Hospital, Hackensack, New Jersey
and Pediatrics,
ABSTRACT - Ventriculoperitoneal shunts are a common form of cerebrospinal @id diversion in treating hydrocephalus. With their use various complications have been noted. Herein is described a shunt complication which simulated an acute scrotal condition. The operative findings and treatment are discussed. A brief review qf the literature is also given.
A full-term male infant was born with a spina bifida and meningomyelocele deformity. Repair of the meningomyelocele was performed on the day of birth. A ventriculoperitoneal shunt was performed twelve days later because of a developing hydrocephalus. Because of a distal shunt obstruction, revision was performed ten days later without incident. Six days after the shunt revision the infant was noted to have an enlarged right hemiscrotum, thought to be a hernia. Later that same day the right hemiscrotum became reddened and indurated with an associated right inguinal swelling. A urologic consultation was obtained. Physical findings included an enlarged reddened and slightly edematous right hemiscrotum with minor involvement of the left side as well (Fig. 1A). The right testicle could not be palpated. The right inguinal canal was also swollen and erythematous. Laboratory findings consisted of an afebrile infant, normal urinalysis, and normal hemogram. The clinical impression at this time was acute torsion of the testicle. Surgical exploration was done within the hour via scrotal incision. A normal-appearing testicle was noted, but on further examination the distal end of the ventriculoperitoneal shunt was iden-
174
tified (Fig. 1B). A second incision was then made in the right inguinal region. The cord structures were identified as well as the ventriculoperitoneal shunt (Fig. 1C). The shunt tube was pushed back into the peritoneal cavity, and the neck of the hernia sac was identified and closed. The remainder of the incisions were closed in the usual manner after wound cultures were obtained. The infant made an uneventful recovery except for the development of a ventriculitis necessitating removal of the shunt. Of significance is the fact that on the day of surgery a baseline intravenous urogram was performed which was to be officially interpreted the following day. The collecting systems and bladder were normal. The most significant finding was the presence of the shunt tubing entering the right inguinal region (Fig. 2A). This should be compared with the postshunt flat plate which demonstrated an intraperitoneal position (Fig. 2B). The postexploratory flat plate again demonstrated an intraperitoneal position (Fig. 2C). It is doubtful whether or not the case would have been managed differently had the findings on the pyelogram been known preoperatively.
UROLOGY
/
FEBRUARY
1977
/
VOLUME IX, NUMBER 2
FIGURE 1. (A) Enlarged, erythematous right hemiscrotum; (B) shunt tube in scrotum; and (C) shunt tube in processus vaginalis in inguinal canal.
Comment Meningomyelocele occurs in nearly two of every one thousand live neonatal births. In approximately 60 per cent of the patients with meningomyelocele hydrocephalus develops; and if not treated, a high mortality in the first year of life 0ccurs.l When hydrocephalus or its development is diagnosed early in the neonatal period, various shunting procedures are used to prevent ventricular enlargement and cerebral atrophy. For many years ventriculoatrial and ventriculojugular shunts were used in children with hydrocephalus, but because of various complications the ventricular peritoneal shunt was de-
vised and has become a popular mode of cerebral spinal fluid diversion.2-4 Currently the ventricular peritoneal shunt involves a Holter valve with either a Pudenz or Raimondi peritoneal catheter. ‘s6 Since the use of the ventricular peritoneal shunt, various complications have been reported, such as fibrous encasement of the peritoneal tip,’ blocking and kinking of the distal tube, extrusion of the tube through the incision,’ postoperative ileuq8 infection, cerebrospinal fluid fistula, and perforation of the bowels and volvulus.‘” Other complications have included extrusion of the catheter into the scrotum or along an unobliterated processus vaginalis, l1 intra-abdominal cerebrospinal fluid
FIGURE 2. (A) Pyelogram demonstrating shunt tube entering right inguinal region. (B) Postoperative flat plate con.ing intraperitoneal position of shunt tubing. (C) Postinguinoscrotal exploration demonstrating intraperitoneal position of shunt tubing.
UROLOGY
/ FEBRUARY
1977 / VOLUME
IX, NUMBER 2
175
cysts, knotted shunts and bladder perforation,12 perforation of peritoneal catheter through umbilicus, l3 and perforation of vagina.r4 It is not uncommon to note the tip of the ventricular peritoneal shunt in the scrotum on a flat plate.15 Grosfeld et al., in 1974,16 described a 16 per cent incidence of previously unrecognized inguinal hernias in a series of 185 patients with ventricular peritoneal shunts, 45 of whom had intra-abdominal complications. The mean interval from shunt procedure to observation of the hernia was 6.8 months, and none was described in an infant one month old. He does mention that x-ray films of the abdomen demonstrated a ventricular peritoneal shunt in the scrotum in 6 otherwise unrecognized cases. In the various case reports no mention has been made of the presence of a ventricular peritoneal shunt catheter in the scrotum associated with an acute inflammatory response. The mechanism for the presence of the shunt tubing in the scrotum is several fold. The shunt tubing is left long deliberately to allow for growth of the child. Thus, if given the opportunity, it could migrate down a patent processus vaginalis. The processus vaginalis remains patent for approximately two years when obliteration takes place spontaneous1y.l’ Prior to this time, however, it is a potential space, and it is believed that the excess cerebrospinal fluid in the peritoneal cavity (either overproduction or diminished absorption) in infancy can convert the potential space to a clinical hernia. This hernia coupled with an increased intraabdominal pressure could account for the migration of an intraperitoneal shunt into the scrotum. la Extravaginal torsion of a testicle is considered high on the list in the differential diagnosis of the acute scrotum in the neonatal period; and when considered, surgical exploration in most cases should be performed. In the case described herein such an exploration was carried out. The negative testicular findings were indeed a surprise. Cultures from both the scrotal contents and peritoneal cavity both grew out Staphylococcus epidermidis. Interestingly enough, this organism has been implicated in shunt complications and no doubt accounted for the scrotal swelling and cellulitis in this case.ls To our knowledge there has been nothing in the urologic literature describing the neurosurgical complication previously outlined. Many urologists are not aware of the possible migrations of a ventriculoperitoneal shunt into the
176
scrotum. This condition should be added to the list of the differential diagnoses of an acute scrotum in patients with ventriculoperitoneal shunts. 445 Prospect Avenue Hackensack, New Jersey 07601 (DR. LEVEY) References 1. RANSOHOFF, J., MATHEWS, E. S.: Neurosurgical management of patients with spina bifida and meningomyelocele, Med. Clin. North Am. 53: 493 (1969). 2. FORREST, D. M., and COOPER, D. G.: Complications of ventriculoatrial shunts: a review of 455 cases, J. Neurosurg. 29: 506 (1968). 3. OVERTON, M. D., III, and SNODGRASS, S. R.: Ventriculovenous shunts for infantile hydrocephalus, ibid. 23: 517 (1965). 4. LITTLE, J. R., RHOTON, A. L., and MELLINGER, J. F.: Comparison of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus in children, Mayo Clin. Proc. 47: 396 (1972). 5. PUDENZ, R. H.: Experimental and clinical observations on the shunting of cerebra-spinal fluid into the circulating system, Clin. Neurosurg. 5: 98 (1957). 6. RAIMONDI,A. J., and MATSUMOTO,S.: A simplified technique for performing the ventriculo-peritoneal shunt, J. Neurosurg. 26: 357 (1967). 7. AMES, R. H.: Ventriculo-peritoneal shunts in the mangement of hydrocephalus, ibid. 27: 525 (1967). 8. MURTAGH, F., and LEHMON, R.: Peritoneal shunts in the management of hydrocephalus, J.A.M.A. 202: 1010(1967). 9. WILSON, C. B., and BERTAN, V.: Perforation of the bowel complicating peritoneal shunts for hydrocephalus, Am. Surg 32: 691 (1966). 10. SAKADA,T. H., MAXWELL, J. A., and BRACKETT,C. E., JR.: Intestinal volvulus secondary to a ventriculo-peritoneal shunt, J. Neurosurg. 35: 95 (1971). 11. ROMANI, P. S.: Extrusion of abdominal catheter of ventriculo-peritoneal shunt into the scrotum, ibid. 40: 772 (1974). 12. GROSFELD, J. L., et al.: Intra-abdominal complications following ventriculo-peritoneal shunt procedures, Pediatrics 54: 791 (1974). 13. ADELAYE, A. : Spontaneous extrusion of the abdominal tube through the umbilicus complicating peritoneal shunts for hydrocephalus, case report, J. Neurosurg. 38: 758 (1973). 14. PATEL, C. D., and MATLAUB, H.: Vaginal perforation as a complication of ventriculo-peritoneal shunts, case report, ibid. 38: 761 (1973). 15. RUBIN, R.: Personal communication, 1975. 16. GROSFELD, J. L., et al. : Op. cit.12 17. ROWE, M. I., et al. : The patent processus vaginalis and the inguinal hernia, J. Pediatr. Surg. 4: 102 (1969). 18. GROSFELD, J. L., and COONEY, D. R.: Inguinal hernia after ventriculo-peritoneal shunt for hydrocephalus, ibid. 9: 311 (1974). 19. IGNELZI, R. J., and KIRSH, W. M. : Follow-up analysis of ventriculo-peritoneal ventriculoatrial shunts for hydrocephalus, J. Neurosurg. 42: 679 (1975).
UROLOGY /
FEBRUARY 1977 / VOLUME IX, NUMBER 2