Abstract
PurposeTotal parathyroidectomy (tPTX) in patients with renal hyperparathyroidism (RHPT) aims at the complete removal of all hyperfunctioning parathyroid tissue. Whenever parathyroidectomy is termed “total,” undetectable postoperative parathyroid hormone (PTH) levels within the first postoperative week are expected. The aim of this study was to evaluate if tPTX is technically possible using a radical surgical procedure.MethodsIn 109 consecutive patients with RHPT (on hemodialysis: n = 50; after kidney grafting n = 59), removal of all visible parathyroid tissue, bilateral thymectomy, bilateral central neck dissection (level VI), and immediate autotransplantation (AT) was performed. Intact PTH (iPTH) levels were measured in the first postoperative week. PTX was classified “total” when iPTH dropped below 10 pg/ml, “subtotal” between 10 and 65 pg/ml, and “insufficient” where levels stayed above 65 pg/ml.ResultsAccording to the postoperative PTH value, tPTX was achieved in 80 of 109 (73.4%) patients (hemodialysis n = 27, normal kidney function: n = 43, restricted: n = 10). PTX was “subtotal” in 25 patients (22.9%), 19 on hemodialysis, 2 had normal, and 4 had restricted kidney graft function. PTX turned out to be insufficient in four patients (3.7%); all of them were on hemodialysis. Insufficient PTX was not observed in kidney-grafted patients. Postoperative temporary laryngeal nerve morbidity was 1.8% (no permanent paresis).ConclusionsAlthough applying a very radical concept in patients with RHPT, PTX was “total” in only 73.4%. Persistence of disease was avoided in 91.7%, and low morbidity was documented. In conclusion, it seems difficult to remove all parathyroid tissue from the neck which has to be considered when choosing the surgical procedure.
Highlights
The current treatment of renal hyperparathyroidism (RHPT) is mainly medically using oral calcimimetic drugs which influence parathyroid hormone (PTH), calcium, and phosphorus metabolism
Ten patients were not eligible for analysis, as nine received a functioning kidney graft within less than 6 months after surgery, a time frame, which was set to be the minimum for interpretation, and 1 patient with recurrence of disease died before we could localize the site of excess PTH production
Total PTX aims at the complete removal of all parathyroid tissue
Summary
The current treatment of RHPT is mainly medically using oral calcimimetic drugs which influence PTH, calcium, and phosphorus metabolism. Some patients develop resistance to cinacalcet or develop high PTH values after initial sufficient medical suppression, or suffer from side effects of cinacalcet treatment. Besides subtotal (3 1/2) parathyroidectomy, total parathyroidectomy (total PTX) with immediate autotransplantation (AT) is a widely performed treatment of renal hyperparathyroidism (RHPT) [3,4,5,6,7,8]. After total PTX and immediate AT, the persistence and recurrence of RHPT are 4.4% and 9.3%, respectively, even in the era of calcimimetic drugs [9, 10]. The cause of persistence is most likely unintended Bincomplete^ initial PTX and reoperation may be required with unpredictable success [9, 10]
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