Factors Associated with Ventriculoperitoneal Shunt Placement Following Posterior Fossa Tumor Resection in Children: A Systematic Review and Meta-Analysis.
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Background and Objectives: Posterior fossa tumors (PFTs) are common pediatric brain tumors and frequently present with obstructive hydrocephalus. Although tumor resection restores cerebrospinal fluid (CSF) circulation in many patients, a subset subsequently requires ventriculoperitoneal shunt (VPS) placement. This systematic review and meta-analysis aimed to identify factors associated with postoperative VP shunt placement following PFT resection in children. Materials and Methods: This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was prospectively registered with PROSPERO (CRD420261455396). A comprehensive search of major electronic databases was conducted from inception to April 2025. Observational studies evaluating factors associated with postoperative VP Shunt placement in children undergoing PFT resection were included. Risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and certainty of evidence was evaluated using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework for prognostic factor research. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects meta-analysis. Results: Nine retrospective cohort studies comprising 922 children were included. Higher odds of postoperative VP shunt placement were observed with preoperative hydrocephalus (OR = 7.62, 95% CI 2.19-26.47), midline tumor location (OR = 4.75, 95% CI 1.21-18.69), ependymoma (OR = 2.56, 95% CI 1.38-4.76), subtotal resection (OR = 3.04, 95% CI 1.92-4.79), postoperative intraventricular hemorrhage (OR = 4.36, 95% CI 1.16-16.44), postoperative infection (OR = 4.96, 95% CI 1.77-13.91), and pseudomeningocele (OR = 6.17, 95% CI 3.12-12.19). Astrocytoma was associated with lower odds of VP shunt placement (OR = 0.47, 95% CI 0.27-0.85), whereas sex, medulloblastoma, and postoperative CSF leakage were not significantly associated. EVD exposure was associated with higher odds of subsequent VP shunt placement (OR = 4.79, 95% CI 2.11-10.87), although this association is susceptible to confounding by indication. Certainty of evidence ranged from very low to low, with most pooled estimates derived from unadjusted data. Conclusions: Several clinical and perioperative characteristics may help identify children requiring closer surveillance for persistent hydrocephalus after posterior fossa tumor resection. The observed relationship with EVD likely reflects underlying hydrocephalus severity rather than an independent prognostic effect. Given the limited certainty and predominantly unadjusted evidence, these findings should support risk-informed surveillance rather than decisions for permanent CSF diversion. Future prospective studies with standardized definitions and multivariable adjustment are needed to develop reliable prediction models.