Total parathyroidectomy with autotransplantation in renal hyperparathyroidism: low recurrence after intra‐operative tissue selection

Background. Total parathyroidectomy with simultaneous autotransplantation (AT) is a well‐established surgical modality in the treatment of severe drug‐resistant renal hyperparathyroidism. In literature, the high rate of graft‐dependent recurrence seems a serious disadvantage. This complication can possibly be avoided by parathyroid tissue selection prior to AT. Methods. Total parathyroidectomy with simultaneous AT was performed in 37 patients on intermittent haemodialysis treatment. Parathyroid tissue with a low proliferative potential (‘A‐regions’) was selected for AT intra‐operatively with a stereomagnifier. The mean post‐operative follow‐up was 37±24 months. Results. Plasma levels of intact parathyroid hormone decreased from 1211±541 to 69±32 pg/ml, calcium from 2.49±0.27 to 2.17±0.30 mmol/l, phosphorus from 2.28±0.63 to 2.11±0.69 mmol/l, and total alkaline phosphatases from 272±210 to 117±70 U/l. Graft‐dependent recurrent hyperparathyroidism occurred in one patient after 32 months and was cured by the selective removal of five enlarged autografts. Conclusions. Simply discriminating between diffuse and nodular hyperplastic parathyroid tissue appears to be inadequate. Intra‐operative tissue selection with a stereomagnifier may facilitate the identification and AT of tissue with optimal functional characteristics and a low proliferative potential, thus minimizing the rate of recurrent hyperparathyroidism.