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Distal shunt obstruction in children with myelomeningocele after bladder perforation
G M Barker1, G Läckgren, A Stenberg
1Sections of Paediatric Urology and Paediatric Neurosurgery, University Childrens Hospital, S 75185 Uppsala, Sweden.
Insights
Bladder perforation in myelomeningocele patients with shunts can cause shunt dysfunction due to urine irritating the abdomen. Early recognition of increased intracranial pressure is crucial for timely intervention.
Area of Science:
- Urology
- Pediatric Surgery
- Neurosurgery
Background:
- Myelomeningocele often requires bladder augmentation and ventriculoperitoneal shunts.
- Shunt dysfunction is a serious complication in these patients.
- Bladder perforation is a known complication of augmentation surgery.
Purpose of the Study:
- To investigate short-term complications of augmented bladder perforation.
- To identify signs of shunt dysfunction following bladder perforation in myelomeningocele patients.
Main Methods:
- Retrospective review of 27 myelomeningocele patients with ventriculoperitoneal shunts undergoing bladder augmentation.
- Analysis of 4 patients who developed bladder perforation 2-5 years post-augmentation.
- Evaluation of shunt function and symptoms of increased intracranial pressure.
Main Results:
- No shunt dysfunction observed immediately after primary surgery.
- Four of five patients with bladder perforation experienced leakage of urine into the abdominal cavity.
- Severe shunt dysfunction symptoms (headache, high intracranial pressure) appeared 2-7 days post-perforation in affected patients.
- Shunts were externalized for 1-6 weeks without complications.
Conclusions:
- Urine in the abdominal cavity can cause peritoneal inflammation, potentially disrupting cerebrospinal fluid resorption.
- This can lead to shunt dysfunction and elevated intracranial pressure in myelomeningocele patients.
- Urologists must recognize and evaluate signs of increased intracranial pressure post-bladder perforation; early brain CT is recommended.
Purpose:
We studied short-term complications and particularly the signs of shunt dysfunction after augmented bladder perforation in patients with myelomeningocele and ventriculoperitoneal shunts.
Materials And Methods:
In our series of bladder augmentations in 27 patients with myelomeningocele and a ventriculoperitoneal shunt in the last 10 years (1994 to 2004) we noted 4 who were 8 to 16 years old at our institute with bladder perforation 2 to 5 years after augmentation. Three patients received a colonic augmentation and 1 received an ileal augmentation. One patient underwent surgery for small bowel obstruction 2 years after the primary operation, when a hole in the augmented bladder was identified and oversewn. The other 3 bladder perforations occurred spontaneously or after failure to catheterize. An additional patient with spontaneous perforation underwent auto-augmentation elsewhere.
Results:
After primary open abdominal surgery and enterocystoplasty there was no sign of shunt dysfunction in any patient. Bladder perforation and leakage of free urine into the abdominal cavity occurred in 4 of the 5 patients. In those patients severe symptoms of shunt dysfunction, including headache and high intracranial pressure, were noted 2 to 7 days after perforation. In patient 1 there was only urine leakage into a small cavity close to the bladder and no acute signs of post-perforation shunt dysfunction. In all cases the shunt was externalized for 1 to 6 weeks without further complications.
Conclusions:
In patients with myelodysplasia who have bladder perforation and free urine in the abdominal cavity the peritoneum is chemically inflamed by urine. Resorption of cerebral liquor may be disturbed, leading to shunt dysfunction and high intracranial pressure. Therefore, it is important for the urologist to recognize and evaluate postoperative signs and symptoms of increased intracerebral pressure in patients with bladder perforation. If found, early computerized tomography of the brain is recommended.
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