Some patients with hydrocephalus cannot be adequately treated with either ventriculo-peritoneal or ventriculo-atrial shunts. Ventriculo-ureteral (VU) shunts are seldom considered in this group of patients because of the belief that nephrectomy is an essential part of the procedure. We report a case in which a VU shunt was performed with direct ureteral re-implantation and we suggest that a VU shunt is a reasonable alternative for the treatment of a patient with difficult-to-manage hydrocephalus.