Scrotal Migration of Two Ventriculoperitoneal Shunts Presenting as Hydrocele.

Sir,

Ventriculoperitoneal (VP) shunt is a common procedure performed for treating hydrocephalus.[1] There is a higher rate of inguinal hernia and hydrocele in pediatric patients who undergo VP shunt procedure.[23] Migration of peritoneal end of the VP shunt into the scrotum is uncommon.[45] Herein, we present an extremely rare case of the right-sided hydrocele with migration of peritoneal ends of two VP shunts (both right and left) into ipsilateral (right side) hemiscrotum through patent processus vaginalis. To the best of our knowledge, there is only a single case of scrotal migration of two VP shunts presenting as hydrocele reported in the literature.[45]

An 11-month-old male infant presented to the pediatric surgery department with swelling in the right inguino-scrotal region for the past 2 months. He had undergone medium pressure VP shunt procedures (Chhabra shunt) twice for congenital hydrocephalus at the age of 1 month and then at 8 months (nonfunctioning/blocked) evident by bilateral subcostal scars [Figure 1]. He was doing apparently well after the second surgery. The swelling was not associated with redness, pain, or fever or features of intestinal obstruction. On examination, a swelling was noted in the right scrotal region, especially on straining and crying; shunt tubing could be rolled between the fingers on palpation [Figure 1]. Cough impulse was present; transillumination test was also present [Figure 1]. There were no features of shunt malfunction. An X-ray of the abdomen and pelvis showed that the peritoneal end of the VP shunt was extending into the right hemiscrotum [Figure 1]. Laboratory investigations were normal. The patient was operated, and a reduction in the hernial sac containing peritoneal ends of both the right and left VP shunts was done by means of a right inguinal herniotomy [Figure 2]. The patient is currently asymptomatic and doing well at follow-up.

Figure 1

Clinical photograph (left image) showing right-sided hydrocele with transillumination test confirming the presence of shunt tubing in the scrotum (arrow); inset image showing bilateral subcostal scars (yellow and red arrows). Abdominal X.ray (right image) showing both the right (yellow arrow) and left (red arrow) ventriculoperitoneal shuntin situ; peritoneal end of ventriculoperitoneal shunt extending into the right inguino-scrotal region is evident

Figure 2

Intraoperative images of the right inguinal herniotomy (after opening the hernial sac) showing peritoneal ends of both the right and left ventriculoperitoneal shunts as contents of the sac and entering into the scrotum (left image); catheters being repositioned into the peritoneal cavity (right image)

Introduced in 1908, VP shunt is one of the most common neurosurgical procedures performed for patients with hydrocephalus.[1] VP shunt complications include shunt infection, over drainage, and shunt malfunction. Peritoneal complications involve pseudocyst formation, intestinal obstruction or volvulus, perforations of a hollow viscus, and protrusion outside the body; other shunt complications are disconnection and migration.[1] There is a higher rate of inguinal hernia and hydrocele in pediatric patients who undergo a VP shunt procedure.[23] The reported incidence of inguinoscrotal complications may be as high as 10%–20%.[23] Most of them being unilateral, developing within a few weeks to months.[23]

Migration of peritoneal end of the VP shunt into the scrotum is uncommon.[45] Migration of the shunt into the scrotum tends to occur in younger children due to higher incidence of an unobliterated processus vaginalis and smaller volume of the peritoneal cavity in these patients.[6] The processus vaginalis normally remains patent in 50%–60% of infants at age 1 year.[2] Development of scrotal swelling or hydrocele in a pediatric patient with a VP shunt should raise the possibility of a shunt complication.[6]

It was proposed that with continuous cerebrospinal fluid (CSF) drainage into the peritoneal cavity, a point is reached when CSF inflow exceeds absorption. The raised fluid in the peritoneal cavity and increased intra-abdominal pressure may prevent obliteration or forces open the patent processus vaginalis, producing a clinical hydrocele or hernia.[4] Furthermore, chronic catheter irritation and fluid flow from the tubing may result in hydrocele.[6]

Scrotal migration of VP shunt catheter was hypothesized to be due to (i) trough effect of CSF into the patent processes vaginalis which tends to draw mobile objects (shunts) into the center of the trough,[4](ii) the inguinal canal contributes to the “guttering and funnelling” mechanism.[4] In our infant, migration of two peritoneal catheters (both right and left) into the right side hemiscrotum through the ipsilateral conduit produced this unusual complication.

Early surgical repair of the inguinal hernia and repositioning of the peritoneal end of the shunt tubing is suggested due to the increased risk of incarceration in children.[6] Contralateral inguinal exploration or diagnostic laparoscopy has been proposed in infants with VP shunt because of the likelihood of patent processus vaginalis in infancy and high bilaterality rate (75%–80%).[26] The lower rate of presentation with bilateral manifestation may be due to a pop-off mechanism.[2]

In conclusion, the development of hydrocele or any scrotal swelling in a pediatric patient with a VP shunt should be recognized as a possible shunt complication in the early postoperative period.

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Conflicts of interest

There are no conflicts of interest.