Total parathyroidectomy without autotransplantation in the management of "refractory" renal hyperparathyroidism

The optimal surgical treatment in patients with refractory renal hyperparathyroidism (RHP) on hemodialysis for end stage renal disease is still a point of controversy. The high percentage of recurrences after standard surgical procedures i.e. subtotal parathyroidectomy (SPTx) and total parathyroidectomy with autotransplantation (TPTx + At) reactualised the practice of total parathyroidectomy (TPTx). Fortythree patients with RHP underwent surgery between 1994-2009. There were 24 SPTx and 6 TPTx + At, both procedures determining 20.7% (6 cases) recurrences so in the last five years TPTx was performed in a series of 13 cases (7 men and 6 women, with median age 43, 6 years; range 22 - 65 years and median dialysis time before PTx 8,2 years; range 3 -12 years. Parameters studies included demographics, preoperative and follow-up laboratory tests, surgical techniques, pathology results and postoperative immediate and medium term results. Main indications for PTx were severe bone disease, soft tissue calciphycations, neuro muscular phenomena, grossly elevated iPTH and sometimes hypercalcemia. TPTx was done in 12 patients, the 13th one suffering a completion PTx one year after outward exeresis of only two glands. Postoperatively the majority of symptoms markedly improved and the values of calcaemia, phosphatemia and alkaline phosphatasis normalised together with low or no measurable level of iPTH. One patient required a re-exploration for a cervical hematoma but no one presented permanent hypocalcemia or recurrent hyperparathyroidism. Pathology revealed nodular hyperplasia in all the cases, a parathyroid carcinoma but also an incidental thyroid papillary microcarcinoma in a complementary thyroidectomy. TPTx alone proves to be an equally safe and successful as another techniques currently used in management of RHP eliminating the hyperparathyroid status but being superior with regard to aparition of recurrences. The procedure is indicated especially in cases with aggressive, refractory forms of RHP without the prospect of renal transplantation.