Medical Journal of Dr. D.Y. Patil Vidyapeeth

REVIEW ARTICLE
Year
: 2022  |  Volume : 15  |  Issue : 6  |  Page : 840--853

Systematic review of migration of distal ventriculoperitoneal shunt catheter into the urinary bladder with or without per-urethral extrusion


Rajendra K Ghritlaharey 
 Department of Pediatric Surgery, Gandhi Medical College and Associated, Kamla Nehru and Hamidia Hospitals, Bhopal, Madhya Pradesh, India

Correspondence Address:
Dr. Rajendra K Ghritlaharey
Department of Pediatric Surgery, Gandhi Medical College and Associated, Kamla Nehru and Hamidia Hospitals, Bhopal - 462 001, Madhya Pradesh
India

Abstract

Ventriculoperitoneal shunt (VPS) insertion is the most widely performed surgical procedure for the treatment of hydrocephalus across all age groups but is associated with several complications. The objectives of the present review were to review the demographics, clinical characteristics, operative procedures executed, postoperative major complications, and outcome of the cases published on the management of migration of the distal VPS catheter into the urinary bladder with or without per-urethral extrusion. PubMed, Medline, PubMed Central, Embase, ResearchGate, and Google Scholar database online search was performed to retrieve the published/available literature relating to the above-mentioned complication. Literature/Case reports were retrieved from the year 1974 to June 30, 2020, and those were available in the English language. Thirty-seven cases were included for review, and included n = 20 (54.05%) male, n = 15 (40.54%) female and gender details were not available for n = 2 (5.4%) of the cases. The mean age of the cases at the time of diagnosis of the above complication was 15.27 years. The mean interval from the VPS insertion to the diagnosis of the complication for the entire case was 4.7 years and ranged from 1 day to 26 years. Surgical procedures were performed for the management and were in order of frequency as; (a) removal of entire VPS catheter n = 20, (b) removal of distal VPS catheter n = 10, (c) removal/relocation of distal VPS catheter n = 6, and (d) details not available n = 1. Migration of the distal VPS catheter into the urinary bladder with or without per-urethral extrusion occurred across all the age groups. Seventy percent of the cases were children below the age of 15 years. In 50% of the cases, the complication was documented within 24 months after the VPS insertion. In two-third of the cases, repair of the urinary bladder perforation was not done and that healed spontaneously after the removal of the intra-vesical migrated VPS catheter.



How to cite this article:
Ghritlaharey RK. Systematic review of migration of distal ventriculoperitoneal shunt catheter into the urinary bladder with or without per-urethral extrusion.Med J DY Patil Vidyapeeth 2022;15:840-853


How to cite this URL:
Ghritlaharey RK. Systematic review of migration of distal ventriculoperitoneal shunt catheter into the urinary bladder with or without per-urethral extrusion. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2023 Jan 30 ];15:840-853
Available from: https://www.mjdrdypv.org/text.asp?2022/15/6/840/336313


Full Text



 Introduction



Ventriculoperitoneal shunt (VPS) implantation is relatively simple, well-accepted and one of the most commonly performed neurosurgical procedures for the treatment of hydrocephalus.[1],[2],[3],[4] Perforation of the hollow viscera by the VPS catheter and extrusion of the distal VPS catheter through the natural orifices is a known complication of the VPS insertion.[3],[5],[6],[7] Perforation of the colon, followed by the trans-anal extrusion of the distal VPS catheter is more frequent.[3],[8] Perforation of the stomach/jejunum, followed by the trans-oral extrusion of the distal VPS catheter has been reported in approximately n = 27 isolated cases to date.[5],[8],[9] Uterine perforation and extrusion of the distal VPS catheter through the vagina has also been reported as a rare occurrence.[7],[10] Migration of the distal VPS catheter into the urinary bladder with per-urethral extrusion is a rare complication and has been reported in n = 24 cases, and reported as isolated case reports.[6],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33] Migration of the distal VPS catheter into the urinary bladder without per-urethral extrusion is rarer than above and reported only in n = 13 cases.[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45] Present manuscript is a systematic review of the literature to highlight the demographics, clinical characteristics, surgical procedures executed, postoperative complications, and the outcome of the cases managed/operated for the migration of the distal VPS catheter into the urinary bladder with or without per-urethral extrusion.</1 TX text>

 Materials and Methods



This is a systematic review of the cases published on the management of the migration of the distal VPS catheter into the urinary bladder with or without trans-urethral extrusion. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines are followed for this systematic review. PubMed, Medline, PubMed Central, Embase, Google Scholar, and ResearchGate database online search was performed to retrieve the published/available literature relating to the above complication. The keywords employed during the online search were; “urethral extrusion of ventriculoperitoneal shunt catheter,” “trans-urethral (per-urethral) extrusion of ventriculoperitoneal shunt catheter,” “migration of ventriculoperitoneal shunt catheter into the urinary bladder,” “perforation of the urinary bladder by ventriculoperitoneal shunt catheter,” “visceral perforation by ventriculoperitoneal shunt catheter,” “distal migration of ventriculoperitoneal shunt catheter,” and “rare complication of ventriculoperitoneal shunt catheter.” Manuscripts relating to the above-described complication were retrieved from 1974 to June 30, 2020, and those were available in the English language. Case reports published in languages other than English, conference proceedings, cases with incomplete details, and the unpublished data retrieved during the online search were excluded from the review.

The process of manuscript selection was done by assessing the titles, abstracts, and full texts of the manuscripts. Manuscript selection and extraction of the desired information from the manuscripts were done independently by the author alone. Published literature/case reports were reviewed for patient's age, sex, and indication for the VPS insertion, interval from VPS insertion to the diagnosis of the complication, clinical characteristics, diagnostic modalities used, surgical procedures executed, postoperative major complications, and the outcome. Cases are categorized into two groups; (A) migration of the distal VPS catheter into the urinary bladder with per-urethral extrusion and (B) migration of the distal VPS catheter into the urinary bladder without per-urethral extrusion. The purpose of this categorization is for easy identification of the cases, and the comparative interpretation of the results. Institutional ethical committee approval is not required due to the review of the already published manuscripts.

 Results



The result of the online database search for the manuscripts on the management of migration of the distal VPS catheter into the urinary bladder with or without per-urethral extrusion is provided as PRISMA flow chart in [Figure 1]. A total of n = 41 cases were retrieved on the management of the above complication.[6],[8],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48] Thirty-seven cases are selected for the review and were retrieved from the 36 manuscripts.[6],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45] Two case reports, published in a language other than English, and both of the cases were excluded from this review.[46],[47] Two more cases are also excluded due to the incomplete details.[8],[48] This review included male n = 20 (54.05%), female n = 15 (40.54%), and gender detail was not available for n = 2 (5.4%) of the cases.{Figure 1}

Demographics details for Group-A cases are provided in [Table 1] and it consists of n = 24 cases.[6],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33] Demographics details for Group-B cases are provided in [Table 2] and it consists of n = 13 cases.[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45] In both the tables, cases are listed in descending order, i.e., in the order of their publication. In n = 35 of the cases, normal urinary bladders were perforated by the distal VPS catheter and presented with or without per-urethral extrusion of the distal VPS catheter.[6],[11],[13],[14],[15],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45] In n = 2 of the children, augmented urinary bladders were perforated by the distal VPS catheter, and both the cases presented with the per-urethral extrusion of the distal VPS catheter. In both of the children augmentation, cystoenteroplasty was earlier done for the treatment of neurogenic urinary bladder secondary to the myelodysplasia.[12],[16]{Table 1}{Table 2}

For the entire case, the distribution of the age at the time of VPS insertion is detailed in [Figure 2]. For the entire case, indications for the VPS insertion are provided in [Figure 3]. For the entire case, the distribution of the age at the time of diagnosis of the complication is detailed in [Figure 4]. The mean age of the entire case at the time of diagnosis of complication was 15.27 years and ranged from 7-days to 82-years. The interval from VPS insertion to the diagnosis of complication is provided in [Figure 5]. The mean interval from VPS insertion to the diagnosis of complication for the entire case was 4.7 years and ranged from 1-day to 26-years.{Figure 2}{Figure 3}{Figure 4}{Figure 5}

The main complaint (Group-A) was extrusion of the distal VPS catheter through the urethra.[6],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33] Additional symptoms (Group-A cases) were relating to the (i) central nervous system (headache, neck pain, irritability, and altered sensorium) n = 8, (ii) lower urogenital tract (straining, retention of urine, incontinence, and urinary tract infection) n = 5, and (iii) gastrointestinal tract (abdominal discomfort) n = 1. Group-B cases were presented with vague lower urinary tract symptoms.[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45] Additional symptoms (Group-B cases) were abdominal pain (n = 3), headache (n = 1), and fever (n = 1). During the clinical examination, extrusion of the distal VPS catheter through the urethra was evident in the entire Group-A cases, except for one. During the clinical examination, migration of the distal VPS catheter into the urinary bladder was not suspected in any of the Group-B cases. Among 37 cases from both the groups; features of meningitis were evident in 3, shunt tract infection in 2, but none of the cases had features suggesting peritonitis.

Radiological investigations were ordered for the entire case and were in the order of frequency as; (a) skiagram of the abdomen and chest including head n = 37, (b) ultrasonography of the abdomen n = 35, (c) computed tomography (CT) scan of the head n = 14[6],[11],[13],[16],[17],[18],[19],[20],[22],[29],[32],[35],[41],[44] and (d) CT scan of the abdomen n = 10.[17],[18],[20],[24],[32],[40],[41],[43],[44],[45] Cystoscopic evaluation of the urinary bladder was also done in n = 12 cases, 4 in Group-A and 8 in Group-B cases.[13],[17],[19],[28],[36],[37],[39],[40],[41],[43],[44],[45] Radiological investigations and cystoscopic evaluation of the urinary bladder also detected vesical calculus/calculi in n = 8 of the Group-B cases.[36],[38],[39],[40],[42],[43],[44],[45]

Clinical diagnosis of migration of the distal VPS catheter into the urinary bladder with trans-urethral extrusion was obvious due to the characteristic history and presence of the distal VPS catheter protruding out through the urethral meatus. The diagnosis of migration of the distal VPS catheter into the urinary bladder without trans-urethral extrusion was established on the radiological findings and cystoscopic evaluation of the cases.

Surgical procedures were executed for the management of migration of the distal VPS catheter into the urinary bladder with or without trans-urethral extrusion are provided in [Figure 6]. For the entire case; the surgical approach opted for the management in the order of frequency were; (a) operative procedures done through urinary bladder/cystostomy with or without percutaneous (PC) cranial incision n = 10, (b) cystoscopic procedures with or without other procedures n = 9, (c) operative procedures done through PC cranial incision n = 7, (d) operative procedures done through PC cranial and PC abdominal incisions n = 4, (e) operative procedures done through PC abdominal incision n = 3, (f) laparoscopic procedures n = 2, (g) operative procedure performed through exploratory laparotomy n = 1, and (h) operative procedure not done/details not available n = 1.{Figure 6}

Postoperative complications were also documented in n = 5 (13.5%) of the cases and that was meningitis (n = 1), shunt malfunction/shunt infection (n = 1), pelvic abscess (n = 1), pleural effusion due to migration of the distal VPS catheter into the pleural cavity (n = 1), and chronic pyelonephritis/renal tubular acidosis leading to renal failure (n = 1).[16],[17],[33],[40],[41] Case with meningitis was treated with antibiotics, a patient complicated with pelvic abscess required exploratory laparotomy, and a patient complicated with the distal shunt catheter migration to the chest required VPS revision. This review also documented n = 1 (2.7%) death.[16] A 12-year old girl developed chronic pyelonephritis and renal tubular acidosis secondary to the neurogenic urinary bladder and she died suddenly on the 11th postoperative day due to the electrolyte imbalance, secondary to the renal tubular acidosis.[16]

 Discussion



Grosfeld et al. first time in the year 1974 published their experience with the migration of the VPS catheter into the urinary bladder without per-urethral extrusion of the distal VPS catheter in two of the infants aged 3 months and 12 months, respectively.[34] Burnette in the year 1982 published a case of migration of the VPS catheter into the urinary bladder with per-urethral extrusion of the distal VPS catheter.[11]

Summary of evidence

Migration of the distal VPS catheter into the urinary bladder with or without trans-urethral extrusion was more in males and also documented more frequently in children than adults. Sixty percent (n = 22) of the cases were children under the age of 10 years. It was less frequently (n = 3) documented after the age of 40 years.[14],[40],[45]

This review revealed that in half (n = 19) of the cases, it was diagnosed within 24-months after the VPS insertion. In one-third (n = 13) of the cases, it was diagnosed within 12-months after the VPS insertion. In another one-third (n = 12) of the cases, it was diagnosed between 3 and 10 years after the VPS insertion. It was less frequently documented (n = 5) 10 years after the VPS implantation.[29],[31],[35],[41],[43]

This review also revealed that the distal VPS catheter migration into the urinary bladder without per-urethral extrusion was a late complication as compared to the cases presented with per-urethral extrusion of the distal VPS catheter. The exact cause is not known for the late presentation of the cases that had migration of distal VPS into the urinary bladder but without trans-urethral extrusion. The following factors probably prevent trans-urethral extrusion of the distal VPS catheter and are (a) fibrous tissues around the intra-peritoneal part of the VPS catheter and its anchoring effect, and (b) formation of vesical calculi/calculus around the tip of the VPS catheter. The exact cause is also not known why some of the cases of migration of VPS catheter into the urinary bladder presented early with trans-urethral extrusion of the distal VPS catheter.

The following factors probably help in early trans-urethral extrusion of the distal VPS catheter and are redundant, the extra length of the peritoneal part of the VPS catheter inside the peritoneal cavity especially in children, and the urinary bladder musculature contraction during urination. Once the tip of the distal VPS catheter is propelled towards the bladder neck/urethra, most often it would present as trans-urethral extrusion of the distal VPS catheter, unless the short length of the VPS catheter prevents it.

The mean interval from the VPS insertion to the diagnosis of the complication for group-A cases was 2.9 years and ranged from 1-day to 12-years. The mean interval from the VPS insertion to the diagnosis of the complication for group-B cases was 7.73 years and ranged from 2-month to 26-years. Migration of the distal VPS catheter into the urinary bladder with or without per-urethral extrusion is also a late complication as compared to the per-rectal or per-oral extrusion of the distal VPS catheter.[3],[5],[8] Present review revealed that only one-third (n = 13) of cases presented within 12 months after the VPS insertion. Ghritlaharey et al. in a retrospective review of the management of per-rectal extrusion of the distal VPS catheter in 10 children documented that 90% of the cases presented within 12-months after the VPS insertion.[3] Ezzat et al. reported their experience of the management of VPS complication in n = 15 cases, including n = 6 cases of per-rectal extrusion of the distal VPS catheter. They documented that all of the n = 6 cases presented within 6 months after the VPS insertion.[8] Ghritlaharey in a systematic review of n = 22 cases of per-oral extrusion of the distal VPS catheter revealed that 40% of the cases were diagnosed within 6-months. Two-third of the cases of per-oral extrusion of the distal VPS catheter were detected within 12-months of the VPS insertion.[5]

Extrusion of the distal VPS catheter through the urethra was the main complaint about group-A cases.[6],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33] One-third of the cases also had symptoms relating to the central nervous system and one-fifth of the cases had symptoms relating to the lower urogenital tract. Group-B cases presented with vague symptoms relating to the lower urinary tract.[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45] Clinical diagnosis of the cases of migration of the distal VPS catheter into the urinary bladder with per-urethral extrusion was obvious (Group-A). The diagnosis of migration of the distal VPS catheter into the urinary bladder without per-urethral extrusion (Group-B) was made based on the radiological investigations and cystoscopic evaluation of the urinary bladder.

Various radiological investigations were ordered to confirm or exclude the continuity of the VPS catheter, to document the course of the VPS catheter, and to document the presence or absence of peritoneal fluid collections. Cranial CT scan was obtained for more than one-third of the cases for the assessment of brain parenchyma, presence or absence of hydrocephalus, and to document the position of the ventricular catheter.[6],[11],[13],[16],[17],[18],[19],[20],[22],[29],[32],[35],[41],[44] CT scan of the abdomen was also available for review and it was done in one-fourth of the cases for the documentation of the course of the distal VPS catheter, presence or absence of peritoneal fluid collection, and to document the site of urinary bladder perforation by the VPS catheter.[17],[18],[20],[24],[32],[40],[41],[43],[44],[45] Presence of distal VPS catheter inside the urinary bladder also acted as a nidus for the formation of vesical calculus in n = 8 of the cases.[36],[38],[39],[40],[42],[43],[44],[45] Literature review also revealed that vesical calculus was also formed at the intravesical distal part of the “ventriculo-vesical shunt” insertion done for the treatment of hydrocephalus.[49],[50]

The objectives of managing the cases of migration of the distal VPS catheter into the urinary bladder with or without per-urethral extrusion were three-fold (i) removal of the entire or distal VPS catheter, with or without external ventricular drainage (EVD), (ii) repair or not to repair the urinary bladder perforation and (iii) VPS revision or re-VPS insertion.[6],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45]

Group-A included n = 24 cases and they were managed in the order of frequency by (a) removal of entire VPS catheter with or without EVD n = 15, (b) removal of distal VPS catheter n = 6, (c) relocation/repositioning of distal VPS catheter n = 2, and (d) surgical procedure not done n = 1. Thirteen of the cases were managed by PC cranial with or abdominal incision, 5 were managed by doing suprapubic cystostomy, 2 were managed by cystoscopic procedures, another 2 were managed by laparotomy, 1 was managed by laparoscopic procedure, and surgical procedure was not done in 1 of the case. Urinary bladder perforation was repaired only in 7 of the cases. Seven of the cases required re-VPS insertion; delayed re-VPS insertions were done in 4 and immediate re-VPS insertions were done in 3 of the cases. In another 3 of the cases, the distal VPS catheters were revised. Five of the cases did not require re-VPS insertion.

Group B included 13 cases and were managed in order of frequency by (a) removal of the distal VPS catheter n = 6, (b) removal of the entire VPS catheter, with or without EVD n = 5, and (c) relocation/repositioning of the distal VPS catheter n = 2. Six of the cases were managed by cystoscopic procedures, 5 were managed by doing suprapubic cystostomy, one was managed by doing laparotomy and another one of the cases was managed by the laparoscopic procedure. Eight of the cases also had urinary bladder calculi/calculus; 5 of them were managed by cystoscopic procedures and the remaining 3 were managed by the suprapubic cystolithotomy.[36],[38],[39],[40],[42],[43],[44],[45] Urinary bladder perforation was repaired only in 6 of the cases.[34],[37],[38],[42],[45] In three of the cases, the distal VPS catheters were relocated into the peritoneal cavity and in another 2 cases delayed re-VPS insertions were done.

Drainage of the urinary bladder through a per-urethral catheter for 5–10 days was a standard protocol and was done for the entire case, whether the urinary bladder was repaired or not.

Urinary bladder perforation was repaid only in one-third (n = 13) of the cases; 7 of the Group-A cases and 6 of the Group-B cases.[6],[18],[20],[24],[28],[29],[33],[34],[37],[38],[42],[45] In two-third (n = 24) of the cases the urinary bladder perforation was not repaired, and perforation of the urinary bladder by the distal VPS catheter healed spontaneously within few days after the removal of the intra-vesical migrated VPS catheter.

Re-VPS insertions were done in 9 of the cases; delayed re-VPS insertions in 6, and immediate re-VPS insertions in 3 of the cases. Distal VPS revisions were performed in 3 of the cases and in another 3 of the cases the distal VPS catheters were relocated into the peritoneal cavity. Five of the cases did not require re-VPS insertions.

The exact cause and mechanism for the perforation of the urinary bladder by the distal VPS catheter and migration into the urinary bladder with or without trans-urethral extrusion of the distal VPS catheter are not known. Probably the mechanism similar to the perforation of the bowel/colon by the distal VPS catheter with or without trans-anal extrusion employs for the occurrence of the migration of the distal VPS catheter into the urinary bladder with or without trans-urethral extrusion. The urinary bladder is extraperitoneal when empty and it becomes intraperitoneal when filled with urine. The urinary bladder musculature is very tough therefore perforation of the urinary bladder by the VPS catheter is rare, but it occurs. Several authors have tried to explain the mechanism for the occurrence of the above complication.[6],[13],[17],[19],[20],[22],[23],[40],[42],[43],[44] The occurrence of the above complication is a cumulative effect of various factors and requires various steps and are;

Migration of the distal VPS catheter adjacent to the urinary bladder: The distal VPS catheter descends adjacent to the urinary bladder with the effect of gravity and bowel movementAdhesion/fixation of the tip of distal VPS catheter to the urinary bladder wall: This may be the result of various factors and are foreign-body reactions for VPS catheter, tissue reaction towards cerebrospinal fluid, and inflammatory reaction and changesPerforation and penetration of the urinary bladder wall by the VPS catheter: Urinary bladder wall perforation may be the result of recurrent friction by the tip of the distal VPS catheter to the urinary bladder wall, pressure necrosis, and inflammatory reaction leading to the weakening of the bladder musculature, and resulting in the perforation of the urinary bladder wall and the bladder mucosaIntra vesicle migration of the distal VPS catheter: The migration of the distal VPS catheter inside the urinary bladder lumen is probably due to the bladder musculature contractions during the urinationTrans-urethral migration and extrusion of the distal VPS catheter: Once the distal VPS catheter is inside the urinary bladder, due to the recurrent bladder contractions the tip of the distal VPS catheter is propelled towards the bladder neck/urethra. Once the tip of the distal VPS catheter is within the urethra it is bound to extrude out through the urethral meatus.

Why some of the cases failed to clinically present as per-urethral extrusion of the distal VPS catheter is not known. This is probably because in some of the cases the tip of the distal VPS catheter failed to propel to the bladder neck/urethra or maybe the tip of the VPS catheter turned upwards again within the bladder cavity. The presence of a VPS catheter inside the urinary bladder also acts as a nidus for the calculus formation that further prevents the trans-urethral extrusion of the VPS catheter.

Limitations

The limitation of the present review is that the number of cases is limited. Four of the cases were also excluded from the review due to various reasons.[8],[46],[47],[48] A standard guideline for the management of such cases is lacking and authors have used different modalities/techniques for managing their cases. Based on the findings of the present review, management plans are proposed for the migration of the distal VPS catheter into the urinary bladder with per-urethral extrusion or without per-urethral extrusion of the distal VPS catheter as [Figure 7] and [Figure 8], respectively.{Figure 7}{Figure 8}

 Conclusions



Migration of the distal VPS catheter into the urinary bladder with or without per-urethral extrusion is a rare complication and occurs across all age groups. It was documented more in males and also documented more frequently in children than adults. Seventy percent of the cases were children <15 years of age. In 50% of the cases, it occurred within 24 months after the VPS insertion. Repair of the urinary bladder perforations was not done in two-third of the cases and that healed spontaneously after the removal of the intra-vesical migrated distal VPS catheter. Standard guidelines for the management of such cases are not available due to the paucity of the published data.

Informed consent

Review manuscript, Informed consent not required for this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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