腦室腹腔分流術導管位移致膀胱穿孔–個案報告及處置

 顏維晨、蒙恩、吳勝堂

 國防醫學院三軍總醫院外科部泌尿外科

 Migration of a Ventriculo-Peritoneal Shunt into the Urinary Bladder- A Rare Case Report and Management

Wei-Chen Yen , En Meng , Hisao-Hsien Wang

Division of Urology, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

Ventriculoperitoneal (VP) shunt surgery is the most common technique used in the treatment of hydrocephalus. The distal V-P shunt migration is a rare but documented complication. Anatomically, the urinary bladder poses a difficult target for the shunt catheter, as the tip must either pass through the peritoneum and into the extra-peritoneal space then reaching the bladder, or penetrate the peritoneal lining directly adjacent to the bladder dome and entering the urinary bladder.

We present the case of a 23-year-old male with a history of congenital hydrocephalus suspecting Crouzon syndrome related status post V-P shunt with anti-siphon device (Codman, Programmable) since 2018. The patient presented with headache and fever suspecting CNS infection. After evaluation, MRI showed the distal end of VP shunt catheter migrate and penetrate into the urinary bladder. The VP shunt had been last revised over 4 years prior to admission. Cystoscopy demonstrated the VP shunt distal tip over the posterior wall about 1cm in length.

Dysfunction VP shunt catheter removal was accomplished through a multidisciplinary approach, involving both neurosurgery and urology teams. Mini exploratory laparotomy wound was made below xiphoid process about 4cm. VP shunt catheter and anti-siphon device as identified 2 cm below. Simultaneously, Cystoscopy was performed, and the distal VP shunt tip was identified and grasped. VP shunt catheter was cut over the laparotomy wound. Catheter tip culture was collected. Cut off catheter was removed from bladder vis biopsy forceps. Meanwhile, diluted gentamicin was injected into the tract of previous catheter. Also, VP shunt with distal externalization was performed. About the tiny hole over posterior wall of urinary bladder, transurethral electrocautery ablation with electrosurgical knife through the hole tract and electrosurgical bottom probe for nearby bladder wall. 16Fr foley catheter was placed for 6 weeks. Further cystoscopy and OPD follow up showed no persistent urinary leakage occurred.