Comparative efficacy and safety of surgical interventions for communicating hydrocephalus: a systematic review and network meta-analysis of randomized controlled trials

Objectives Surgical intervention is the standard treatment for communicating hydrocephalus (CH), a condition involving cerebrospinal fluid (CSF) accumulation in the ventricles without a blockage. The optimal surgical approach for CH remains uncertain, with clinical decisions varying by patient characteristics and institutional practices. This study aims to compare the efficacy and safety of surgical interventions for CH. Methods In this systematic review and network meta-analysis (NMA), we searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, ClinicalTrials.gov , China National Knowledge Infrastructure (CNKI), Wanfang, Vip, China Biomedical Literature, and the Chinese Clinical Trial Registry (ChiCTR) from inception to September 24, 2024, for randomized controlled trials (RCTs). Primary outcomes were efficacy (favorable outcome) and safety (complications). Secondary outcomes included revision, infection, seizures, operation time (minutes), and duration of hospitalization (days). Bayesian NMAs synthesized the data, and the certainty of evidence was assessed using the confidence in NMA (CINeMA) framework. Surface under the Cumulative Ranking Curve (SUCRA) values were generated to rank the treatments. This study is registered with PROSPERO (CRD42024585931). Results Of 4,159 citations identified by our search, 34 trials (2,528 participants) met the inclusion criteria. For efficacy, lumboperitoneal shunt (LPS) risk ratio (RR) 1.18, 95% credible interval (CrI) 1.13–1.23; high certainty and LPS with laparoscope (LPS + LS) (RR 1.27, 95% CrI 1.18–1.39; high certainty) were more effective than ventriculoperitoneal shunt (VPS). Both LPS and LPS + LS outperformed endoscopic third ventriculostomy (ETV) and ETV with choroid plexus cauterization (ETV + CPC) (RR range 1.16–1.48; high to moderate certainty). For safety, LPS, LPS + LS, and ETV had fewer complications than VPS (RR range 0.20–0.40; high certainty). LPS + LS had fewer complications than LPS (RR 0.49, 95% CrI 0.29–0.79; moderate certainty). Compared with cranial approaches, lumbar surgeries improved favorable outcomes RR 1.23, 95% confidence interval (CI) 1.19–1.28; moderate certainty, and reduced complications (RR 0.33, 95% CI 0.26–0.43; moderate certainty). Conclusion LPS and LPS + LS appeared to be the most efficacious surgical interventions for treating CH, with fewer complications than VPS and ETV + CPC, indicating the potential advantages of lumbar approaches. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD42024585931 , CRD42024585931.