Re-examining the classification of abdominal pseudocysts as surgical site infections through review of broad-range polymerase chain reaction results.

BACKGROUND: The Hydrocephalus Clinical Research Network-quality group (HCRNq) historically defined all abdominal pseudocysts associated with a ventriculoperitoneal shunt as a surgical site infection regardless of culture result. METHODS: We retrospectively reviewed broad-range polymerase chain reaction (BRPCR) results sent between January 2017 and July 2023 from abdominal pseudocyst fluid sent from hospitals around the country to a reference laboratory to help further characterize these collections. RESULTS: A total of 19 samples were tested via BRPCR between 1/2017 and 7/2023. Two (10.5 %) had organisms identified; one with Staphylococcus epidermidis and one with Candida parapsilosis. No fastidious organisms that would be expected to not grow with typical culture techniques were identified. CONCLUSIONS: Few abdominal pseudocysts had organisms identified by BRPCR, suggesting that not all pseudocysts are due to infectious causes. Consideration should be given to alternate causes of pseudocyst development when cultures are negative.

Ventriculoperitoneal shunt tube migration into the heart and pulmonary artery: successful tube removal. Illustrative case.

BACKGROUND: Ventriculoperitoneal (VP) shunt tube migration is recognized as an occasional complication; however, migration into the cardiac system is rare. The authors report a case of VP shunt tube migration into the heart and pulmonary artery and the safe removal of the tube. OBSERVATIONS: The patient had a VP shunt implanted for hydrocephalus after a subarachnoid hemorrhage. The screening chest radiograph taken a few months later showed the migration of the abdominal tube into the heart. Examinations revealed that the abdominal tube had migrated from the left subclavian vein, passed through the superior vena cava, right atrium and ventricle, and looped into the pulmonary artery. The patient had no symptoms; however, there were some risks, such as damage to the valves or fatal arrhythmia. The authors therefore decided to remove the tube. To avoid various intraoperative risks, in particular tube knot formation, the tube was removed under fluoroscopy with a guidewire inserted, which was 0.035 inches for the angiography catheter. The tube was successfully removed without any complications. LESSONS: Knot formation can be one of the fatal complications of shunt tube removal. The authors' technique is an effective method for safe removal. https://thejns.org/doi/10.3171/CASE24127.

Ventriculoperitoneal shunt extrusion in pediatric patients, clinical patterns and therapeutic strategies: A scoping review.

Background: Ventriculoperitoneal shunts (VPSs) are frequently employed in neurosurgery to treat hydrocephalus, with a particular focus on pediatric patients. Although VPSs are commonly utilized, they are not exempt from difficulties, such as shunt extrusion. The main aim of this study is to enhance comprehension regarding the occurrence, causes contributing to, and consequences of VPS extrusion in pediatric patients. Methods: A comprehensive search approach was implemented, including electronic databases, including PubMed, Google Scholar, and Scopus, to locate pertinent articles published between January 1950 and May 2023. The utilization of keywords such as "ventriculoperitoneal shunt" and "extrusion," "ventriculoperitoneal shunt" and "migration," and "ventriculoperitoneal shunt" and "perforation" was employed. Data on patient demographics, underlying diseases, origin of extrusion, presenting symptoms, treatment, and follow-up were gathered. Statistical studies were conducted to identify potential risk factors connected with the occurrence of shunt extrusion. Results: A study analyzed 80 studies on 120 individuals with extruded VPS catheters. The majority of patients (55.8%) had symptoms such as cerebrospinal fluid leakage and irritation. Hydrocephalus was categorized into congenital (40%), obstructive (36.7%), and communicating (11.7%) groups. Catheter extrusion sites varied, with most from the anal or rectal site. Preoperative meningitis or peritonitis was present in 20% of patients. Treatments ranged from shunt removal to endoscopic third ventriculostomy, resulting in a 90% recovery rate, 1.7% mortality, and 5% follow-up loss. Conclusion: Extrusion of the distal catheter in VPSs is a critical medical situation that necessitates urgent surgical intervention. The presence of an infection raises the likelihood of complications; hence, it is vital to promptly address the issue through the administration of antibiotics and the replacement of the shunt. Timely intervention enhances results.

Cauda equina syndrome due to posttraumatic syringomyelia in conus medullaris - A case report.

Background: Most posttraumatic syringomyelias occur in the cervical or thoracic spinal cord, where they contribute to myelopathic deficits. Here, a 40-year-old patient presented with the left leg monoparesis due to syringomyelia involving the conus medullaris 10 years after an L2 vertebral "crush" fracture. Case Description: Ten years following an L2 vertebral "crush" fracture, a 40-year-old male presented with the new onset of left lower leg paresis. The magnetic resonance imaging showed a T12-L1 syrinx associated with accompanying high-intensity areas above the syrinx located between the T11 and T12 levels. One month after placing a syringosubarachnoid (SS) shunt, both the syrinx and high-intensity area rapidly disappeared, and the left distal motor weakness resolved. Conclusion: Ten years following an L2 "crush" fracture, a 40-year-old male presented with the new onset of a cauda equina syndrome secondary to a posttraumatic T12-L1 syringomyelia causing expansion of the conus medullaris.

Communicating hydrocephalus after resection of a meningioma ventral to the foramen magnum.

Background: Tumors in or near the foramen magnum may cause communicating or non-communicating hydrocephalus (HC), depending on their size and location. Here, an 81-year-old female developed communicating HC following the resection of a meningioma ventral to the foramen magnum. Case Description: An 81-year-old female presented with numbness in the left neck and left hemiparesis. The magnetic resonance revealed an 18-mm tumor ventral to the foramen magnum that significantly enlarged over the past 6 months. She underwent total tumor resection but then presented with progressive HC both clinically (i.e., instability of gait with confusion) and radiographically (computed tomography). Following placement of a lumboperitoneal (LP) shunt, symptoms markedly improved. Further, the cerebrospinal fluid (CSF) analysis showed elevated cell counts and protein concentrations, indicating likely "leakage" of intratumoral contents postoperatively contributing to the progressive HC. Conclusion: Patients presenting with acute meningiomas ventral to the foramen magnum may develop postoperative communicating HC attributed to tumor-related CSF leakage of necrotic intratumoral components that can be successfully treated with a LP shunt.

Cerebrospinal Fluid Seeding Versus Inflammation in Setting of Ventriculoperitoneal Shunt as a Potential Cause for Distant Recurrence of Glioblastoma.

Glioblastoma multiforme (GBM) is the most common primary brain tumor in adults with a median survival of approximately 15 months, despite treatment, with most patients experiencing recurrence within 9 months of resection. The propensity of recurrence in GBM exemplifies the fatal course of the disease and remains an underlying area of study as novel instances of recurrence are encountered. The authors present a unique case of a 31-year-old male patient with a history of cerebellomedullary junction astrocytoma who later developed a supratentorial GBM followed by recurrence centered around a preexisting ventriculoperitoneal catheter and located in the hemisphere contralateral to his first GBM. Each of these lesions was initially thought to represent de novo glial neoplasms because of the absence of intervening T2 fluid-attenuated inversion recovery signal change between each lesion. However, next-generation sequencing using the GlioSeq™ platform revealed similar mutational profiles in both GBMs, suggesting an alternative method of migration of tumor cells to the shunt catheter site, and a local inflammatory environment likely triggering recurrence. This study concludes that in rare instances, in the presence of dormant glioma cells, intracranial foreign bodies may promote an inflammatory microenvironment that may activate tumorigenesis.

Shunt dysfunction and mortality after transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension.

OBJECTIVES: Transjugular intrahepatic portosystemic shunt (TIPS) is a catheter-based, minimally invasive procedure to reduce portal hypertension. The aim of the study was to investigate dysfunction and mortality after TIPS and to identify factors associated with these events. METHODS: A retrospective analysis of 834 patients undergoing TIPS implantation in a single center from 1993-2018 was performed. Cumulative incidence curves were estimated, and frailty models were used to assess associations between potentially influential variables and time to dysfunction or death. RESULTS: 1-, 2-, and 5-year mortality rates were 20.9% (confidence interval (CI) 17.7-24.1), 22.5% (CI 19.1-25.8), and 25.0% (CI: 21.1-28.8), 1-year, 2-year, and 5-year dysfunction rates were 28.4% (CI 24.6-32.3), 38.9% (CI 34.5-43.3), and 52.4% (CI 47.2-57.6). The use of covered stents is a protective factor regarding TIPS dysfunction (hazard ratio (HR) 0.47, CI 0.33-0.68) but does not play a major role in survival (HR 0.95, CI 0.58-1.56). Risk factors for mortality are rather TIPS in an emergency setting (HR 2.78, CI 1.19-6.50), a previous TIPS dysfunction (HR 2.43, CI 1.28-4.62), and an increased Freiburg score (HR 1.45, CI 0.93-2.28). CONCLUSION: The use of covered stents is an important protective factor regarding TIPS dysfunction. Whereas previous TIPS dysfunction, emergency TIPS implantation, and an elevated Freiburg score are associated with increased mortality. Awareness of risk factors could contribute to a better selection of patients who may benefit from a TIPS procedure and improve clinical follow-up with regard to early detection of thrombosis/stenosis. CRITICAL RELEVANCE STATEMENT: The use of covered stents reduces the risk of dysfunction after transjugular intrahepatic portosystemic shunt (TIPS). TIPS dysfunction, emergency TIPS placement, and a high Freiburg score are linked to higher mortality rates in TIPS patients. KEY POINTS: The risk of dysfunction is higher for uncovered stents compared to covered stents. Transjugular intrahepatic portosystemic shunt dysfunction increases the risk of instantaneous death after the intervention. A higher Freiburg score increases the rate of death after the intervention. Transjugular intrahepatic portosystemic shunt implantations in emergency settings reduce survival rates.

Evaluating the efficacy of the punch-out technique in systemic-to-pulmonary shunts: A computational fluid dynamics approach.

BACKGROUND: Systemic-to-pulmonary shunt is a palliative procedure used to decrease pulmonary blood flow in congenital heart diseases. Shunt stenosis or occlusion has been reported to be associated with mortality; therefore, the management of thrombotic complications remains a challenge for most congenital cardiovascular surgeons. Despite its importance, the optimal method for shunt anastomosis remains unclear. OBJECTIVE: The study investigates the clinical benefits of the punch-out technique over conventional methods in the anastomosis process of Systemic-to-pulmonary shunt, focusing on its potential to reduce shunt-related complications. METHODS: Anastomotic models were created by two different surgeons employing both traditional slit and innovative punch-out techniques. Computational tomography was performed to construct three-dimensional models for computational fluid dynamics (CFD) analysis. We assessed the flow pattern, helicity, magnitude of wall shear stress, and its gradient. RESULTS: The anastomotic flow area was larger in the model using the punch-out technique than in the slit model. In CFD simulation, we found that using the punch-out technique decreases the likelihood of establishing a high wall shear stress distribution around the anastomosis line in the model. CONCLUSION: The punch-out technique emerges as a promising method in SPS anastomosis, offering a reproducible and less skill-dependent alternative that potentially diminishes the risk of shunt occlusion, thereby enhancing patient outcomes.

Presentation, management, and outcomes of pediatric hydrocephalus in Africa: a systematic review and meta-analysis of 12,355 patients.

OBJECTIVE: The prevalence, management, and outcomes of hydrocephalus remain underexplored in Africa. This study aimed to analyze demographic and clinical features, evaluate treatment strategies, and assess neurological outcomes of pediatric hydrocephalus in Africa. METHODS: A systematic review of the literature using the PubMed, Google Scholar, and Web of Science electronic databases was completed according to the PRISMA guidelines to identify articles describing pediatric patients in Africa with hydrocephalus. RESULTS: Seventy-four retrospective and prospective studies and 33 case reports involving 12,355 patients were included. In 54 retrospective articles reporting patient demographics, 53.8% (3926/7297) were male with a mean age of 12.3 months. Nineteen studies reported macrocephaly (80.2%, 1639/2043) as the most common presentation. The etiology of hydrocephalus was reported as postinfectious (41.0%, 2303/5614) across 27 articles and congenital (48.6%, 1246/2563) in 10 articles. Eleven articles reported 46.7% (609/1305) of patients had communicating hydrocephalus while 53.3% (696/1305) had obstructive hydrocephalus. Diagnostic imaging included CT (76.1%, 2435/3202; n = 29 articles), ultrasonography (72.9%, 2043/2801; n = 15 articles), and MRI (44.8%, 549/1225; n = 11 articles). In 51 articles, 83.1% (7365/8865) of patients had ventriculoperitoneal shunting (VPS) while 33 articles described 54.1% (2795/5169) receiving endoscopic third ventriculostomy (ETV) for hydrocephalus surgical management. Postoperative complications included sepsis (6.9%, 29/421; n = 4 articles), surgical site infections (5.1%, 11/218; n = 4 articles), and CSF leaks (2.0%, 15/748; n = 8 articles). Shunt-related complications included infections (4.3%, 117/2717; n = 21 articles) and blockages (4.1%, 34/829; n = 6 studies). In 15 articles, 9.0% (301/3358) of patients with shunts had revisions. The mean follow-up duration was 18.9 ± 16.7 months with an overall mortality rate of 7.4% (397/5383; n = 29 articles). In the analysis of comparative studies, the 160 patients undergoing ETV demonstrated significantly higher odds of a successful operation (OR 1.54, 95% CI 0.51-4.69; p = 0.03) and neurological improvement at last follow-up (OR 3.36, 95% CI 0.46-24.79; p < 0.01) compared with the 158 who received VPS, but no significant differences were observed for complications and mortality between the two groups (p > 0.05). CONCLUSIONS: This review offers a comprehensive summary of pediatric hydrocephalus in Africa, highlighting shunting as the primary treatment. However, the observed variations across studies highlight the need to establish standardized guidelines for reporting patient characteristics, management strategies, and outcomes to ensure consistency and comparability in articles.

Comparing motor development in children with hydrocephalus after treatment with ventriculoperitoneal shunt and endoscopic third ventriculostomy: a cross-sectional study.

Introduction: Ventriculoperitoneal shunt insertion (VPSI) and endoscopic third ventriculostomy (ETV) are the major procedures for treating pediatric hydrocephalus. However, studies comparing motor development following the two treatments are limited. Objective: We aimed to determine motor development outcomes in children with hydrocephalus up to 2 years of age after undergoing VPSI or ETV, to identify which surgical approach yields better motor outcomes and may be more effective for Malawian children. Methods: This was a cross-sectional study where we recruited two groups of participants: one group consisted of children with hydrocephalus treated with VP shunt whilst the other group were treated with ETV, at least 6 months prior to this study. Participants were identified from the hospital records and were called to come for neurodevelopmental assessment using the Malawi Development Assessment Tool (MDAT). Results: A total 152 children treated for hydrocephalus within an 18-month period met the inclusion criteria. Upon follow up and tracing, we recruited 25 children who had been treated: 12 had VPSI and 13 had ETV. MDAT revealed delays in both assessed motor domains: 19 out of the 25 children had delayed gross motor whilst 16 of 25 had delayed fine motor development. There was no significant difference between the shunted and the ETV groups. Conclusion: Children with hydrocephalus demonstrate delays in motor development six to 18 months after treatment with either VPSI or ETV. This may necessitate early and prolonged intensive rehabilitation to restore motor function after surgery. Long-term follow-up studies with bigger sample sizes are required to detect the effect of the two treatment approaches.

Spleen volume is associated with overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with portal hypertension.

BACKGROUND: Portal shunt and immune status related to the spleen are related to the occurrence of hepatic encephalopathy (HE). It is unknown whether spleen volume before transjugular intrahepatic portosystemic shunt (TIPS) is related to postoperative HE. AIM: To investigate the relationship between spleen volume and the occurrence of HE. METHODS: This study included 135 patients with liver cirrhosis who underwent TIPS, and liver and spleen volumes were elevated upon computed tomography imaging. The Kaplan-Meier curve was used to compare the difference in the incidence rate of HE among patients with different spleen volumes. Univariate and multivariate Cox regression analyses were performed to identify the factors affecting overt HE (OHE). Restricted cubic spline was used to examine the shapes of the dose-response association between spleen volumes and OHE risk. RESULTS: The results showed that 37 (27.2%) of 135 patients experienced OHE during a 1-year follow-up period. Compared with preoperative spleen volume (901.30 ± 471.90 cm3), there was a significant decrease in spleen volume after TIPS (697.60 ± 281.0 cm3) in OHE patients. As the severity of OHE increased, the spleen volume significantly decreased (P < 0.05). Compared with patients with a spleen volume ≥ 782.4 cm3, those with a spleen volume < 782.4 cm3 had a higher incidence of HE (P < 0.05). Cox regression analysis showed that spleen volume was an independent risk factor for post-TIPS OHE (hazard ratio = 0.494, P < 0.05). Restricted cubic spline model showed that with an increasing spleen volume, OHE risk showed an initial increase and then decrease (P < 0.05). CONCLUSION: Spleen volume is related to the occurrence of OHE after TIPS. Preoperative spleen volume is an independent risk factor for post-TIPS OHE.

Referred Shoulder Pain Due to the Positioning of the Ventriculoperitoneal Shunt: A Case Report and Literature Review of an Unusual Complication.

We present the case of an 18-year-old male with a ventriculoperitoneal (VP) shunt for hydrocephalus who experienced right shoulder pain. The patient was thoroughly investigated for gastrointestinal disease, including abdominal ultrasound and upper endoscopy, which revealed no abnormalities that could explain his symptoms. X-ray imaging subsequently revealed that the shunt's distal peritoneal tubing was positioned in a supra-hepatic subdiaphragmatic location. Surgical shortening and repositioning of the peritoneal tubing successfully alleviated the patient's shoulder pain. A review of the literature uncovered four articles, comprising a total of six patients, who exhibited similar symptoms of shoulder pain linked to their VP shunts. Given the rarity of this complication, it can be easily overlooked or misdiagnosed. It is crucial for physicians to consider this possibility when evaluating patients with VP shunts who present with shoulder pain to ensure prompt and effective treatment.

Changes in callosal angle and Evans index after shunt surgery in patients with idiopathic normal pressure hydrocephalus.

BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) is a disease characterized by gait disturbance, cognitive impairment and urinary incontinence. For those patients who do not respond to shunt surgery, it lacks objective radiological findings for the diagnosis of shunt malfunction. Here we aimed to evaluate whether Evans index and callosal angle change during a prospective long-term follow-up of patients with iNPH submitted to shunt surgery. METHODS: Clinical (NPH Japanese Scale) and radiological (Evans index, callosal angle) data were collected pre- and postoperatively (3, 6, 12 months) in 19 patients with iNPH. Imaging tests were evaluated by the same neuroradiologist during the follow-up. RESULTS: Patients had lower scores on NPH Japanese Scale over time (p< 0.001). There was no significant difference among Evans index values during the follow-up (p= 0.24). Preoperative average callosal angle was 72 ± 15, which increased to 91 ± 18 in 6 months (p= 0.003). CONCLUSIONS: In this sample, patients with iNPH submitted to a programmable valve shunt had an increase in callosal angle concomitant to neurological improvement. Evans index did not change during follow-up.

Management of cephalic arch stenosis in hemodialysis access: Updated systematic review and meta-analysis.

INTRODUCTION: Cephalic arch stenosis (CAS) is often recurrent, resistant to treatment and the intervention outcome is not well validated so far. We purposed to assess the clinical outcomes of CAS treatment in patients with hemodialysis access. METHODS: Electronic bibliographic sources were searched up to December 4 2023 to identify studies reported outcome after treating CAS. Direct and indirect evidence was combined to compare odds ratios (OR) and surfaces under the cumulative ranking curves across the different treatment modalities through meta-analysis and network meta-analyses (NMA). This systematic review was conducted in accordance with the PRISMA-P. The review is registered in PROSPERO (CRD42022296513). RESULTS: Four randomized controlled trials (RCTs) and 15 non-RCTs were included in the analysis. The study population differed in fistula type, restenosis or thrombosis, and significant heterogeneity was observed among the publications. The risk of bias was low to serious. Meta-analysis found no significant difference between DCB and PTA in primary patency at 6 and 12 months (OR 1.16 and 0.60, respectively; low certainty of evidence). Favorable result with STG compared to stent or PTA at 3, 6, and 12 month was observed (OR 4.28, 5.13, and 13.12, and 4.28, 5.13, 13.12, respectively; low certainty of evidence). Regarding primary patency, the treatment rankings, from highest to lowest, were STG (92.7%), transposition (76.0%), stent (67.5%), DCB (46.3%), and PTA (64.5%) at 12 months. CONCLUSION: Despite data limitations, the low-quality evidence suggests that STG may merit consideration as a primary treatment option when all alternatives are applicable, given their potential for better primary patency and higher treatment ranking.

The functional impact on donor vessel following transcatheter closure of coronary artery fistulas-a retrospective study using QFR analysis.

Background: The impact of transcatheter closure of coronary artery fistula (CAF) and residual shunt after occlusion on improving blood flow in the donor vessel remains uncertain. Objectives: To evaluate the functional impact on the donor vessel following CAFs closure using QFR (Quantitative Flow Ratio) analysis. Methods: A total of 46 patients with 48 CAFs who underwent transcatheter closure at Shanghai Chest Hospital and Shuguang Hospital between March 2015 and August 2023 were included in the review. The clinical, angiographic details, and QFR data were subjected to analysis. The size of the fistulae was defined according to the ratio between the diameters of the fistulae and the largest diameter of the coronary vessel not feeding the coronary fistula. Results: Among 48 CAFs, the average diameter of the fistulae ostium was 3.19 ± 1.04 mm, while the mean diameter of the donor vessel segment following fistulae was 3.45 ± 1.01 mm. The mean QFR value of the donor vessels with medium CAFs was found to be significantly lower than those with small CAFs (0.93 ± 0.10 vs. 0.98 ± 0.03; p < 0.05). Furthermore, the mean QFR value of donor vessels with medium CAFs was observed to be significantly improved after occlusion (0.99 ± 0.01 vs. 0.93 ± 0.10; p = 0.01). However, there was no statistical difference in the mean QFR value of donor vessels with small CAFs before and after occlusion (0.98 ± 0.03 vs. 0.98 ± 0.02; p > 0.05). Moreover, the changes in QFR were more pronounced in donor vessels with medium CAFs compared to those with small CAFs after occlusion (0.06 ± 0.10 vs. 0.005 ± 0.012; p = 0.01). There is no statistical difference in the mean QFR variation and QFR variation rate between donor vessels with CAFs that occurred residual shunt and those without residual shunt after occlusion (p > 0.05). Conclusions: The presence of medium CAFs has a significant impact on the blood flow of the donor vessel, as compared to small CAFs, and may benefit from occlusion. A small residual shunt has no significant impact on the effectiveness of CAFs occlusion in enhancing donor blood flow.

Autoimmune hepatitis presenting as severe anemia.

Autoimmune hepatitis (AIH) is relatively rare in children. Herein, our case demonstrates a unique presentation of AIH in a previously healthy 18-year-old female presenting with a mild cough, fatigue, and severe anemia (hemoglobin 2.9 g/dL). Initial evaluation revealed jaundice and scleral icterus, prompting transfer of care and further testing, which demonstrated severe microcytic anemia, pancytopenia, elevated liver enzymes, direct hyperbilirubinemia, and marked splenomegaly. Concern for autoimmune hemolytic anemia resulted in a delayed diagnosis. The combination of triple antibody positivity (anti-nuclear antibodies, anti-actin, and anti-liver-kidney microsomal-1) and liver histology findings confirmed the diagnosis of AIH. Intravenous methylprednisolone was initiated to induce remission. Due to pancytopenia and persistently elevated international normalized ratio, tacrolimus was chosen as the maintenance immunosuppression instead of azathioprine. This case highlights several significant considerations for clinicians, including the importance of a timely clinicopathologic diagnosis, the severe anemia presentation secondary to hypersplenism, and the rare finding of triple autoantibody-positive AIH.

Surgically Correctable Central Cyanosis: Congenital Extrahepatic Portosystemic Shunt in a Child.

Congenital extrahepatic portosystemic shunts (CEPS) are rare anomalies connecting the portal system to the inferior vena cava. This report discusses a 10-year-old boy with Type II c CEPS, presenting cyanosis and dyspnea. Surgical ligation resulted in significant improvement in symptoms. Early identification and intervention are crucial, necessitating a protocolized approach.

Contemporary management of ischemic priapism: A 12-year population-based analysis from a large US database.

BACKGROUND: Priapism is a urological condition characterized by a persistent erection. The management varies based on its subclassifications. Despite established clinical guidelines for ischemic priapism, there is a lack of large-scale research focused on patient characteristics and management strategies. OBJECTIVES: To analyze the contemporary management of ischemic priapism in the US, exploring patient demographics and clinical characteristics, as well as predictors of erectile dysfunction (ED) and penile prosthesis implantation (PPI). MATERIALS AND METHODS: We performed a retrospective analysis of the PearlDiver Mariner database, reviewing records from 2010-2021. Adult males diagnosed with ischemic priapism were included. Data analysis covered demographic, clinical variables, and management strategies. Predictors of de novo ED and PPI were evaluated using multivariable logistic regression analysis. RESULTS: Of 36,120 patients, most (93%) received only medical management, and a minority underwent surgical interventions (penile shunt surgery [PSS], PPI or both). Medical management was typically effective, as 67.08% of the patients in this group experienced only one episode of priapism. However, de novo ED occurred in 16.57% of these patients. The majority of patients undergoing PPI had an inflatable prosthesis (81%). Older age (odds ratio, OR 1.02), the presence of metabolic diseases (OR 1.39), neurogenic disorders (OR 1.72), solid pelvic malignancies (OR 1.09), and multiple episodes of priapism were identified as significant predictors of de novo ED (all p < 0.05). Similarly, age (OR 1.03), the presence of metabolic diseases (OR 1.23), solid pelvic malignancies (OR 1.99), and multiple episodes of priapism were associated with higher likelihood of PPI (all p < 0.05). CONCLUSION: Most cases of ischemic priapism are managed with the medical therapy. Less than 3% of patients with ischemic priapism receive PPI, and when this occurs an inflatable prosthesis is favored. Age, specific comorbidities, and multiple episodes of priapism appear to be significant predictors of ED and PPI.

Ventriculoatrial shunt remains a safe surgical alternative for hydrocephalus: a systematic review and meta-analysis.

Hydrocephalus is a commonly encountered pathology in the neurosurgical practice. Since the first permanent ventriculo-subarachnoid-subgaleal shunt described by Mikulicz in 1893, there were multiple attempts to find solutions for draining the excess production/less reabsorption of the cerebrospinal fluid (CSF) from the brain. Nowadays, the most common technique is the ventriculoperitoneal shunt (VPS), whereas the ventriculoatrial shunt (VAS) is applied only in some rare conditions. To date there are still no specific guidelines or strong evidence in literature that guide the surgeon in the choice between the two methods, and the decision usually relies on the confidence and expertise of the surgeon. Considering the lack of established recommendations, this systematic review and meta-analysis aims to evaluate the effectiveness and safety of these two shunting techniques. This systematic review was conducted following the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). No chronological limits of study publications were included. Prospective and retrospective clinical studies, and reports of case series with at least five patients per group and reporting data on comparison between VAS and VPS techniques were eligible for inclusion. Nine studies reporting 3197 patients meeting the inclusion and exclusion criteria were identified and included in the quantitative synthesis. The risk of shunt dysfunction/obstruction was significantly lower in the VAS group [odds ratio (OR) 0.49, 95%-CI 0.34-0.70, I2 0%]. The risk of infection was not significantly different between the two groups (OR 1.02, 95%-CI 0.59-1.74, I2 0%). The risk of revision was not significantly different between the two groups; however, the heterogeneity between the studies was significant (OR 0.73, 95%-CI 0.36-1.49, I2 91%). Additionally, the risk of death was not significantly different between the two groups; however, the heterogeneity between the studies was high (OR 1.93, 95%-CI 0.81-4.62, I2 64%). VAS remains a safe surgical alternative for hydrocephalus. The results of this study highlight a lower risk of shunt dysfunction/obstruction variable in the VAS group, with no significant statistical differences regarding the occurrence of at least one infection-related complication. In consequence, the choice between these two techniques must be tailored to the specific characteristics of the patient.Protocol Registration: The review protocol was registered and published in Prospective Register of Systematic Reviews (PROSPERO) ( www.crd.york.ac.uk/PROSPERO ) website with registration number: CRD42023479365.