ventriculoperitoneal ( vp ) shunting for hydrocephalus is a common neurosurgical procedure in our daily practice .
migration of distal part of vp shunt into the adjacent organs including bowel tract , thoracic cavity , heart , scrotum , umbilicus , abdominal wall , and urinary bladder is reported . a case of repeated shunt migration in different organs
this is the first case of bowel perforation with transanal extrusion continued with bladder migration and urethral extrusion of peritoneal shunt .
we report our case of a child with these unusual complications ; treatment was done by a team involving neurosurgeons and urologists .
a 4-year - old boy was admitted to the hospital because of abdominal discomfort . on further examination
the first operation was undertaken when he was 2 months old because of his congenital hydrocephalus .
the patient went back to the hospital when he was 1 year old because of severe headache . computed tomography ( ct ) scan confirmed a large right porencephaly .
his abdominal x - ray revealed that the extruded shunt was the right peritoneal catheter [ figure 2 ] .
the result was showing 200 cells found with protein 100 mg / dl , glucose 13 mg / dl , and the culture showed micrococcus sp .
urological procedure was performed endoscopically through the urethra to explore the site of migration and potential of leakage .
it was found that the shunt was penetrated through the bladder wall just above the trigonal area [ figure 3 ] .
we decided to treat conservatively by inserting an urethral catheter to keep the bladder decompressed for optimal healing process .
extruded shunt was exposed through the external urethral orificium abdominal x - ray shows the extruded ventriculoperitoneal shunt cathether through the urethral orificium during endoscopic urological surgery , migration site just above the triogonal area of the urinary bladder was identified ( blue arrow ) thereafter , intraventricular antibiotic was administered according to the culture results .
one month later , culture of csf was performed and it showed a sterile result .
bowel perforation was present in 0.1%0.7% of cases in which colon was the most involved organ , and the most common site of extrusion is anus ( 68.9% ) , followed by scrotum ( 22% ) , umbilicus ( 6.9% ) , and vagina ( 3.2% ) .
a case of urinary bladder migration as well as urethral extrusion of vp shunt is extremely rare .
there have been various theories proposed such as bioreactivity , local inflammation , infection , and surgical error .
the location of the bladder makes it highly unlikely site of perforation , as the catheter must pass through the peritoneum into the extraperitoneal space and subsequently perforate the bladder . in this present case ,
the first migration of the catheter was into the anus , and this is considered as a frequent event of migration . the second migration into the bladder is a rare case .
symptom was only abdominal discomfort and it became obvious after the expose through the urethral orifice .
repeated case of shunt migration is an interesting case regarding the pathophysiology and management of this patient . with the history of prior bowel perforation by shunt catheter , and cultures of specimens indicating an infection
fixation of the tip catheter at the specific site of the peritoneum is facilitated and then , continuous erosion and perforation of the peritoneum into the bladder was done .
the trigonal area , which comprises less muscle layer , was the site of migration in this case .
there are three main procedures of shunt removal : gentle pulling , endoscopic surgery , and major open surgery . as per earlier reports ,
catheter removal is mostly done by open abdominal surgery , but in author 's opinion , removal of the catheter could be done with a less invasive method . in our case presenting per - urethtraly , the catheter was gently pulled out through the urethral orifice .
the surgery was then followed by urological endoscopic exploration through the urethra to view the size and location of the perforation .
it is believed that the perforation site seals off due to the presence of a chronic fibrous sheath around the shunt tract and requires no aggressive surgical intervention .
we found the pitfall of this case to be the lack of detailed history of the previous operation because the patient underwent the surgery in another hospital .
the repeated migrations also give us some thought of another option of shunting , for example , ventriculo - atrial shunt .
bladder migration and transurethral extrusion is an extremely rare complication of vp shunt . to our knowledge , this is the ninth case reported .
the presence of previous abdominal complication and repeated organ perforation indicates predisposition factors which must be sought and handled before any further treatment .
 bladder migration and transurethral extrusion is an extremely rare complication of ventriculoperitoneal ( vp ) shunt . 
 only eight cases have been reported in the english literature since 1995 . 
 we report a case of a 4-year - old boy with cerebral palsy , hydrocephalus , and vp shunted on both sides who presented with a protruded distal vp shunt from his urethral orifice . 
 the patient was reported for having previous shunt extrusion through the anus . 
 the patient was treated on by a multidisciplinary approach , involving a neurosurgeon and urologist . 
 shunt removal with simple procedure was smoothly achieved without morbidities . 
 he was discharged home in satisfactory condition . 
I
C
D
C
Financial support and sponsorship
Conflicts of interest