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|LETTER TO EDITOR
|Year : 2013 | Volume
| Issue : 4 | Page : 448-450
Ventriculo-ureteric shunt surgery: Thou shalt not be forgotten of me!
Hrishikesh Sarkar1, A Karthikeyan2
1 Department of Neurosurgery, Sri Narayani Hospital and Research Centre, Thirumalaikodi, Vellore, Tamil Nadu, India
2 Department of Urology, Sri Narayani Hospital and Research Centre, Thirumalaikodi, Vellore, Tamil Nadu, India
|Date of Submission||17-Jul-2013|
|Date of Decision||20-Jul-2013|
|Date of Acceptance||21-Jul-2013|
|Date of Web Publication||4-Sep-2013|
Department of Neurosurgery, Sri Narayani Hospital and Research Centre, Thirumalaikodi, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sarkar H, Karthikeyan A. Ventriculo-ureteric shunt surgery: Thou shalt not be forgotten of me!. Neurol India 2013;61:448-50
We describe an extremely rare case of refractory multiple shunt failure, in which we had to resort to ventriculo-ureteric shunt (VUS) and at the end of 1 year follow-up the patient remains asymptomatic.
A 60-year-old male patient was diagnosed to have shunt dependent tuberculous meningitis and hydrocephalus since 5 years. He presented with the multiple times, with failed ventriculo-peritoneal/atrial/pleural shunt and twice attempted endoscopic third ventriculostomy, all these procedures were carried out at other facilities [Figure 1].
|Figure 1: Computed tomography scan of the brain (plain) taken at the time of admission showed gross hydrocephalus with periventricular lucencies suggestive of failure of existing left ventriculopleural shunt|
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| » Technique|| |
Right lateral ventricle was tapped. The shunt tube (ST) was tunneled into the neck, chest and the anterior abdominal wall. The wounds were closed and then the patient was turned left lateral position. Rolls were placed under the chest and the table was angled midway to facilitate renal exposure [Figure 2]a and b. The kidney was mobilized to reveal the renal pelvis and the ureter [Figure 2]c. Next, the ST lying in the anterior abdominal wall was brought into the perinephric space. A small stab incision was made in the renal pelvis through which 7-8 cm of the distal end of the ST was inserted. Since the existing commercial medium pressure ST (Chabra) does not have a flange its distal end for anchoring, we improvised and used silicone suction catheter for the purpose [Figure 2]d. This step is very important as we noticed that there was a tendency of the ST to come out of the ureter frequently.
|Figure 2: (a) Table was bent at the flank level to facilitate renal exposure. (b) Right kidney (outline demonstrated with dashed line) the renal pelvis and ureter (white arrow) exposed. (c) Distal end of the tube inserted into the ureter and anchored. (d) Technique to anchor the shunt catheter. Inset: A bit of suction catheter 14F size (t) is taken and one of its walls is cut longitudinally with scissors (s). Shunt tube is inserted within the lumen of T. Sutures can be taken through the wall of the T (black arrow) and then onto the soft‑tissue|
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Post-operatively, after initial high wound drain output for 3 days, it reduced considerably and was removed once the ultrasound can of the abdomen and pelvis did not show any perirenal collection. However, he developed depletional hyponatremia during this period that was corrected with hypertonic saline. Computed tomography scan of the brain following the VUS showed adequately decompressed ventricles [Figure 3]. Kidney, ureter and bladder (KUB) X-ray showed correctly placed distal end of the ST [Figure 4]. Sensorium remained normal. He has been disease free for the past 1 year, which is the longest period of illness free duration in the past 5 years.
|Figure 3: Post ventriculoureteric shunt – 10 days post‑operative: Complete resolution of hydrocephalus with multiple shunt tubes within the ventricular system. This was consistent with improved sensorium|
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|Figure 4: Post‑operative kidney, ureter and bladder X‑ray shows the wound drain (black arrow) and the distal end of the shunt catheter (white arrow) within the ureter|
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VUS has been sparsely reported in the literature. ,,, Of late, this surgery has become obsolete in standard neurosurgical practice owing to much better techniques that are available to modern day neurosurgeon.  This case report brings back the importance of this "forgotten" procedure that indeed saved a life. Lessons learnt from managing this patient were as follows: (1) Technically demanding - exposure of the renal pelvis and ureter is technically demanding for neurosurgeon. Involvement of an Urologist is crucial as they are more familiar with the anatomy and the surgical technique; (2) anchor the distal tube well - commercially available STs do not come with a flange at the distal end for anchoring and there is a good possibility of it slipping out of the ureter; (3) nephrectomy and reimplantation of the ureter, as it was thought to be a necessity earlier, is not required; (4) hyponatremia is a known metabolic complication immediately following the VUS  It has been described by Irby et al. and it is hypothesized to be due to the volume depletion; (5) initial high drainage from the wound and further cessation - we assume that there must have been some urine (along with cerebrospinal fluid) leakage from the ureter at the insertion site, which gradually sealed off. Possibly we should have applied fibrin glue and fat around the insertion site to prevent leakage; and (6) urine routine analysis, urine culture, ultrasound of the KUB may be performed in the pre-operative state to assess the renal system. This may alter the decision making.
| » References|| |
|1.||Aschoff A, Kremer P, Hashemi B, Kunze S. The scientific history of hydrocephalus and its treatment. Neurosurg Rev 1999;22:67-93. |
|2.||Pittman T, Steinhardt G, Weber T. Ventriculo-ureteral shunt without nephrectomy. Br J Neurosurg 1992;6:261-3. |
|3.||Irby PB 3 rd , Wolf JS Jr, Schaeffer CS, Stoller ML. Long-term follow-up of ventriculoureteral shunts for treatment of hydrocephalus. Urology 1993;42:193-7. |
|4.||Ohaegbulam C, Peters C, Goumnerova L. Multiple successful revisions of a ventriculoureteral shunt without nephrectomy for the treatment of hydrocephalus: Case report. Neurosurgery 2004;55:988. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]