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.