Scrotal migration of ventriculoperitoneal shunts

Spontaneous regression of migrated ventriculoperitoneal shunt catheter from scrotum to peritoneum: a case-based review

OBJECTIVE

The incidence of scrotal migration of a ventriculoperitoneal shunt (VPS) catheter is rare and may lead to life-threatening visceral complications. Management requires prompt removal of the migrated portion of the shunt and closure of the scrotal sac. We report an interesting case of a young child who presented with asymptomatic unilateral swelling of his scrotum secondary to a migrated VPS catheter. A repeat X-ray prior to his surgery to remove the migrated catheter showed that the entire length of the distal VPS catheter was back in the peritoneal cavity. In view of this unusual phenomenon, the case is discussed in corroboration with published literature.

METHODS AND RESULTS

A systematic search of publications in the English language is performed in PubMed and Google Scholar. Our findings show that there are 49 reported cases (including our patient) of scrotal migration of shunt catheters in patients less than 18 years old. There is only 1 other case of spontaneous resolution of shunt catheter from the scrotum. Favoured management of choice is repositioning the distal shunt catheter back into the peritoneal cavity and herniotomy in the same setting, if possible. Overall, the literature suggests this is a shunt-related complication that has a good prognosis if intervention is timely.

CONCLUSION

Scrotal migration of a VPS catheter is a rare but potentially life-threatening complication in children. Our case report highlights the role of updated preoperative imaging and the need for consistent long-term shunt surveillance in children.

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.

Sepsis Caused by Bacterial Colonization of Migrated Distal Ventriculoperitoneal Shunt Catheter into the Pulmonary Artery: A First Case Report and Literature Review

BACKGROUND

Migration of distal ventriculoperitoneal (VP) shunt catheter into another body part has been described as a potentially serious surgical complication. We present the first case of sepsis caused by transcardial and pulmonary migration of a distal catheter into the heart and pulmonary artery, which was subsequently colonized by Klebsiella pneumoniae.

CASE REPORT

A 56-year-old man underwent VP shunt insertion for hydrocephalus that developed after the surgery for intracranial meningioma. Three years later, he was admitted to department for infectious diseases because of persistent fever. Klebsiella pneumoniae was isolated from the blood cultures. Computed tomography (CT) of the thorax showed migration of the distal catheter into the heart and pulmonary artery. The migrated shunt catheter was retrieved without any complication with the assistance of a cardiovascular surgeon; microbiologic analysis confirmed that the catheter was colonized with K. pneumoniae. We decided to delay new VP shunt placement because of the positive blood cultures, and 3 weeks after the surgery, the patient was without signs of increased intracranial pressure and without any heart problems.

CONCLUSION

Migration of a distal VP shunt catheter into the heart should be considered in patients with a previously placed VP shunt presenting with cardiopulmonary problems, arrhythmia, and/or fever. Neurosurgeons should be involved as soon as possible, and a multidisciplinary approach is warranted.

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.

Vulvar migration of the peritoneal end through the inguinal canal in a female infant: An unusual complication of the ventriculo-peritoneal shunt: A case report and review of literature

Migration of the peritoneal end of the ventriculo-peritoneal shunt through the patent processus vaginalis has been described in preterm male infants with 26 such cases in the literature. The occurrence of this rare complication in the female preterm infants has not yet been reported. We report a 3-month-old premature female infant who presented with a gradual increase in head size since birth. Computed tomography revealed obstructive hydrocephalous secondary to the aqueductal stenosis and ventriculo-peritoneal shunt was performed. Ten days following the procedure she presented with swelling and other signs of inflammation over the right vulvar region. X-ray abdomen confirmed the migration of the peritoneal end into the vulva. Surgical obliteration of the patent processus vaginalis and replacement of the peritoneal end was performed. The patient had no recurrence at 6 months of follow-up. This report presents the unusual complication of a common procedure in a female infant with a review of the current literature.

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.

Cardiac tamponade and heart failure secondary to ventriculo-pleural shunt malfunction: a rare presentation

We report an unusual case of a patient with a ventriculo-pleural shunt presenting with signs and symptoms of heart failure due to massive pericardial effusion. Imaging revealed the distal shunt catheter end within the middle mediastinum to have migrated from the pleural space. The patient underwent a shunt revision procedure resulting in complete resolution of the presenting pathology. We intend to draw the reader's attention to this rare presentation of ventriculo-pleural shunt malfunction.

A ventriculoperitoneal shunt masquerading as a paratesticular tumor

A 3-year-old boy with hydrocephalus was observed to have a painless 2.0-cm right scrotal mass. Abdominal radiograph showed ventriculoperitoneal shunt tubing in the right scrotal sac. Removal of a detached shunt catheter and inguinal hernia repair resolved the problem.

Scrotal pneumatocele: a rare phenomenon

In contrast to what would be expected in newborns with pneumoperitoneum, pneumoscrotum is a rare phenomenon. A newborn who presented with a pneumoscrotum as first, overt, sign of pneumoperitoneum is described. A perforated Meckel's diverticulum was responsible for the airleak.

Duplicated peritoneal catheter as a cause of shunt malfunction. Case report

A rare example of ventriculo-peritoneal shunt malfunction is presented. Radiological and operative findings demonstrated a self-duplication with upward migration of the peritoneal catheter.

CSF hydrocele--unusual complication of V-P shunt

CSF hydrocele as a complication of migration or extrusion of the peritoneal end of the V-P shunt has rarely been reported. Here the case of a 6 month old infant, born at 28 weeks gestational age, is reported. The baby was noted to have scrotal swelling, exacerbated by crying, two months after insertion of ventriculoperitoneal shunt. The hydrocele resolved following revision of the shunt. Possible pathophysiological causes are discussed.

Emergency department management of ventriculoperitoneal cerebrospinal fluid shunts

Emergency physicians must be familiar with VP shunts in order to recognize critical complications associated with these devices. Knowledge of the major types of shunt devices commonly used and the mechanics of those devices allows emergency physicians to evaluate patients with shunts in an orderly manner.