gms | German Medical Science

Background: Reoperations for persistent or recurrent renal hyperparathyroidism are often extremely difficult and require exact preoperative imaging. Even in experienced centers, failure and complication rates are relatively high.

Materials and methods: We performed a retrospective analysis of 547 patients operated for renal hyperparathyroidism between January 1998 and December 2014 in our institution with regard to reoperations. Preoperative imaging, operative findings, results and complications were recorded.

Results: 56 patients (30 males, 26 females, mean age 51 years) were operated for symptomatic persistent or recurrent disease refractory to conservative treatment. 45 patients suffered from renal failure at the time of operation, 11 had a functioning kidney graft. Mean time between primary and reoperation was 6.4 years (3 days to 25 years). In 18 of the 56 patients primary surgery was performed in our institution, the remaining were referred only for recurrent surgery.

Selective venous sampling had the best positive predictive value (17/19 cases), followed by Mibi/SPECT (11/17 cases) and sonography (10/13 cases). Mean operating time was 129.7 ± 77 minutes. In 20 patients (36%), a concomitant thyroid resection was performed due to intracapsular parathyroid tissue (n=12), intrathyroidal parathyroid glands (n=3) and thyroid disease (n=5). The mean preoperative PTH was 868 ± 627ng/l. Reoperation was successful in 48 patients (86%). Underlying causes of persistent or recurrent disease were missed parathyroid glands in normal anatomic position (n=27; 56%), supranumeric and/or ectopic parathyroid glands (n=9), hypertrophy of cervical remnant glands/autotransplants (n=9) and cervical parathyreomatosis (n=3). None of the patients with missed parathyroids in normal anatomic position had the primary surgery at our center. 51 cervical reexplorations, three removals of autotransplanted tissue in the forearm and two thoracoscopic resections of mediastinal parathyroids were performed. 14% of patients developed transient and 5% persistent recurrent nerve palsy, 4% wound infection and 2% hematoma requiring reoperation. Mean length of hospital stay was 12 days (2-36 days).

Conclusion: The main reason for persistent or recurrent renal hyperparathyroidism was a missed parathyroid gland in normal position. Therefore, the primary operation should be performed in an experienced center. Exact preoperative imaging and information about the primary operation are essential for the success of the reoperation. Thyroid resections are often necessary to remove all parathyroid tissue. Temporary recurrent nerve palsies frequently occur despite intraoperative neuromonitoring.