Ventriculoperitoneal (VP) shunt migration causing an acute scrotum: a case report of Doppler evaluation

Scrotal Migration of the Ventriculoperitoneal Shunt: A Case Report and Review of the Literature

Ventriculoperitoneal (VP) shunt placement is the most frequently used treatment for hydrocephalus. This procedure is not always free of complications, and patients may need additional surgeries to overcome these complications. We are presenting the case of a seven-month-old baby who underwent myelomeningocele repair and VP shunt placement 13 days ago and now presents with inguinal swelling extending into the scrotum. The radiological workup revealed that the peritoneal end of the VP shunt had migrated to the scrotum, causing hydrocele. The shunt was relocated to the abdomen after a right herniotomy and sac reduction. He was discharged on the second postoperative day without any complications, and the further recovery was good at three months. Scrotal migration of a VP shunt is a rare complication and can be avoided by careful early assessment of inguinal hernia or patent processus vaginalis and its surgical repair.

Treatment Options for Scrotal Migration of Ventriculoperitoneal Shunts: Case Illustration and Systematic Review of 48 Cases

BACKGROUND

Scrotal migration of intact or disconnected tubing is a rare complication of ventriculoperitoneal shunts. While some illustrative case reports can be found in the literature, a systematic review on treatment options is lacking.

OBJECTIVE

To propose the first literature-based treatment algorithm on scrotal shunt migration.

METHODS

We conducted a literature search using the keywords: "VP," "ventriculoperitoneal," "shunt," and "scrotum." We identified 36 publications with 48 cases reported including our index case.

RESULTS

Median age at presentation was 13.5 mo (3 d to 65 yr) which was 4 mo (3 d to 72 mo) after last shunt-related surgery. All patients had scrotal swelling, 39 (81%) patients presented without other symptoms, 4 (8%) had additionally local pain, and 4 (8%) patients presented with symptoms of shunt dysfunction. Treatment was surgically in all but one case where spontaneous resolution without repeat migration occurred. In 3 of 4 patients who had either subcutaneous shortening or abdominal repositioning of the shunt without hernia repair, scrotal shunt migration recurred within the following month. Whereas the surgical treatment with reposition of the migrated catheter back into the peritoneal cavity via a groin incision plus hernia repair yielded a definite treatment in all 26 performed cases, the revision rate was significantly higher in the shunt revision without hernia repair cohort (P = .0009).

CONCLUSION

Scrotal shunt migration is a rare shunt complication with good recovery when treated surgically. We recommend hernia repair in addition to either manual or surgical repositioning of migrated tubing.

Case report of migration of 2 ventriculoperitoneal shunt catheters to the scrotum: Use of an inguinal incision for retrieval, diagnostic laparoscopy and hernia repair

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A ventriculoperitoneal shunt catheter migrated through an inguinal hernia into the scrotum.

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A single incision was used to for diagnostic laparoscopy, catheter removal and hernia repair.

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Prompt surgical removal of fractured shunt catheters is recommended to prevent organ injury.

Backgroud

Ventriculoperitoneal shunts are commonly used in the treatment of hydrocephalus, and catheter migration to various body sites has been reported. Pediatric and general surgeons are asked on occasion to assist with intraabdominal access for these shunts, particularly when there may be extensive adhesions or other complicating factors.

Methods

We describe a case in which an old shunt catheter was never removed from the abdomen, and it migrated through an inguinal hernia into the scrotum. The catheter became entangled and fibrosed to the testicle. A second and more recent shunt catheter was also in the scrotum. A single incision in the inguinal region was used to remove both shunt catheters, repair the inguinal hernia and perform diagnostic laparoscopy to assist in placing a new ventriculoperitoneal shunt.

Results

Prompt surgical removal is recommended for catheters remaining in the abdomen after ventriculoperitoneal shunt malfunction. These catheters may cause injury to the testicle, or possibly other intraabdominal organs. General or pediatric surgical consultation should be obtained for lost catheters or inguinal hernias.

Conclusion

In the case of an inguinal hernia containing a fractured shunt catheter, the hernia sac can be used to remove the catheter, repair the hernia and gain laparoscopic access to the abdomen to assist with shunt placement.

Rare complication of ventriculoperitoneal shunt. Early onset of distal catheter migration into scrotum in an adult male: Case report and literature review

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Cases of scrotal migration of distal catheter in adults are rare.

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There have been no reports for scrotal migration in adults at an early onset.

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Early detection of migration of distal catheter prevents shunt malfunction.

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Prompt surgical management of catheter repositioning is recommended.

Introduction

The role of shunt placement is to divert cerebrospinal fluid from within the ventricles to an alternative location in the setting of hydrocephalus. One of the rare shunt complications is distal catheter migration, and various body sites have been reported, including the scrotum. Although cases of scrotal migration of distal catheter have been reported in pediatric patients, cases in adult patients are rare due to obliterated processus vaginalis. Furthermore, there has not been a case reported for scrotal migration in an adult at an early onset.

Presentation of case

65-year-old male underwent shunt placement for normal-pressure hydrocephalus-like symptoms. On post-operative day seven patient developed right testicular edema, for which ultrasound was performed, revealing hydrocele along with the presence of distal catheter in the scrotum. On post-operative day nine patient underwent distal catheter trimming via laparoscopic approach with general surgery, with post-operative imaging showing satisfactory location of distal catheter in the peritoneal cavity.

Discussion/Conclusion

Early onset of distal catheter migration into scrotum in an adult male is a unique case, as most cases are reported in pediatric patients, and it is the first case reported in the English literature to have occurrence at an early onset during the peri-operative period. As our case demonstrates, early occurrence and detection of scrotal migration of the distal catheter prevent shunt malfunction. Prompt surgical management of catheter repositioning is therefore recommended to avoid the risk of further complications.

Shunt in scrotum: unusual complication in operated cases of hydrocephalus

Shunt surgeries in patients with hydrocephalus are associated with morbidity and mortality. The most common problems are shunt obstruction and malfunction. We described a case of shunt migration into the scrotal sac masquerading as scrotal swelling. Shunt repositioning along with posterior wall repair and herniotomy was performed.

Unusual complication of ventriculoperitoneal shunt surgery

Ventricular shunts are commonly employed in the management of hydrocephalus, and numerous complications such as dissection or migration have been reported in the literature besides shunt malfunction. We present a case of the migration of the peritoneal catheter into the scrotum who attended at our institute. He was managed successfully, but subsequently developed intraabdominal cystic swelling for which he was reoperated.

Scrotal migration of the peritoneal catheter of a ventriculoperitoneal shunt in a 5-year-old male. Case report

A 5-year-old male presented with scrotal migration of the catheter from a ventriculoperitoneal shunt manifesting as left scrotal swelling 4 months after implantation. Surgical obliteration of the patent peritoneal processus vaginalis that forms a corridor from the peritoneum to the scrotum was performed to avoid shunt malfunction. Review of the 26 reported cases including the present case revealed that most patients were up to 18 months old. Our patient was the oldest. Migration tended to occur within 6 months after implantation (mean 3.8 months, median 1.0 month). Involvement of the right side of the scrotum was prevalent (23 of 26 cases). Patent processus vaginalis and small peritoneal cavity probably contribute to scrotal catheter migration.

Rectal extrusion of the catheter and air ventriculography following bowel perforation in ventriculo-peritoneal shunt

Ventriculo-peritoneal shunt is frequently carried out in infantile hydrocephalus. The peritoneal shunt has a lower morbidity than ventriculo-atrial shunts and severe complications are uncommon. Abdominal complications include intestinal perforation, shunt migration, inguinal hernia, cerebrospinal fluid pseudocysts and hollow viscus perforation. A few cases of catheter extrusion from the rectum, vagina, umbilicus and urethra have been described. We report a new case of intestinal perforation with rectal extrusion of the catheter associated with a ventriculogram.

Migration of a dissected peritoneal shunt catheter into the scrotum

Migration of a dissected peritoneal piece of the shunting material into the scrotum was encountered in a 1-year-old boy who had received a V-P shunt. Removal of the migrated shunt tube by inguinal exploration and herniorrhaphy were performed, and another V-P shunt was installed simultaneously. This case was considered worthy of reporting as a rare complication of a V-P shunt, and the causal mechanism is discussed with a review of the literature.