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Current trends in surgery for renal hyperparathyroidism (RHPT)—an international survey

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Abstract

Purpose

The indications and results of preoperative localization, surgical strategy, indication for thymectomy, the application of intraoperative parathyroid hormone (PTH) monitoring, cryopreservation, and replantation of cryopreserved parathyroid tissue are not well documented in renal hyperparathyroidism (RHPT). The current trends in surgery for RHPT are to be evaluated in an international online survey.

Methods

Thirty-three questions regarding preoperative localization, surgical management of RHPT, intraoperative PTH monitoring, immediate/delayed autotransplantation (AT), and parathyroid cryopreservation were sent to members of various societies of endocrine surgeons.

Results

The data from 86 responses were analyzed, 61.6 % reported more than 50 parathyroid surgeries per year, and 62.7 % operated on less than 16 patients with RHPT per year. Subtotal or total parathyroidectomy (with/without AT) was the standard procedure in 98.8 % of the cases. Immediate AT was performed in 40.7 % (72.7 % in the forearm). In most patients, the onset of graft function was documented later than 1 week after AT. Cryopreservation was routinely performed in 27.4 %. In 10.7 %, replantation was performed in more than five patients (hypo- or aparathyroidism: n = 41; fresh graft failure: n = 13; reoperations: n = 9). Intraoperative PTH monitoring (in RHPT) was routinely used in 46.2 %. Its influence on surgical strategy was confirmed in 40 %.

Conclusions

The survey reflects the divergent strategies applied for AT, cryopreservation, and PTH monitoring in RHPT.

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Acknowledgments

The authors are particularly grateful to Alexander Klockhaus who, with his advanced programming skills, made this online survey feasible.

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Section of Endocrine Surgery, Division of General Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria

    Philipp Riss, Reza Asari, Christian Scheuba & Bruno Niederle

Authors
  1. Philipp Riss
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  2. Reza Asari
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  3. Christian Scheuba
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  4. Bruno Niederle
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Corresponding author

Correspondence to Philipp Riss.

Additional information

This paper was partly presented as an oral presentation at the 5th Biennial Congress of the “European Society of Endocrine Surgeons (ESES),” Gothenburg, Sweden, May 24–26, 2012.

Appendix: Questions in details

Appendix: Questions in details

General questions

1

Country of your hospital

TEXT (optional)

2

Region

 • Africa

 • Asia

 • Australia

 • Europe

 • North America

 • South America

3

City

TEXT (optional)

4

Institution

TEXT (optional)

5

How many parathyroid surgeries are performed in your hospital (average per year)?

 • <10

 • 10–30

 • 30–50

 • 50–100

 • >100

6

How many surgeries for RENAL hyperparathyroidism are performed in your hospital (average per year)?

 • <10

 • 10–30

 • 30–50

 • 50–100

 • >100

Preoperative localization

7

Which preoperative localization studies are routinely performed?

 • Ultrasound

 • 99mTc-Sestamibi

 • CT

 • MRT

 • Other (TEXT)

Surgical strategy

8

Which operation do you perform?

 • Subtotal (3 ½) parathyroidectomy

 • Total parathyroidectomy with autograft

 • Total parathyroidectomy without autograft

 • Excision only of the Sestamibi-positive gland(s)

 • Other (TEXT)

9

If “Subtotal parathyroidectomy”—how many glands are left in situ?

 • ½

 • 1

 • 1½

 • 2

 • Other

10

Immediate autotransplantation: location of graft

 • Forearm

 • Sternocleidomastoid muscle

 • Other

11

Immediate autotransplantation: amount of tissue transplanted

 • ___mg (TEXT)

 • ___pieces (TEXT)

12

Is transcervical thymectomy routinely performed?

 • Yes

 • No

13

Is sternotomy performed in first operation?

 • Yes (routinely)

 • Only with positive localization

 • Never

 • Other (TEXT)

Immediate autotransplantation during surgery for renal hyperparathyroidism

14

Is parathyroid autotransplantation performed?

 • Routinely

 • Depends on PTH monitoring

 • Only in patients before renal transplantation

 • Only in patients after renal transplantation

 • Other (TEXT)

15

Location of implantation?

 • Forearm

 • Sternocleidomastoid muscle

 • Other (TEXT)

16

Preparation of graft?

TEXT

17

Control of graft function?

 • Casanova test routinely

 • Blood samples from graft-arm

 • Serum PTH

 • Other (TEXT)

18

Startup of graft function in most cases (from experience)?

 • 0–24 h

 • 24–48 h

 • 48 h–4 days

 • 4–7 days

 • 7–14 days

 • 14–30 days

 • >30 days

Cryopreservation

19

Cryopreservation performed?

 • Routinely

 • Depends on PTH monitoring

 • Only in patients before renal transplantation

 • Only in patients after renal transplantation

 • Other (TEXT)

20

Technique of cryopreservation?

TEXT

21

Storage time

 • 6 months

 • 1 year

 • 2–4 years

 • 5 years

 • >5 years

Delayed autotransplantation of cryopreserved tissue

22

Indication for autotransplantation

 • Reoperation

 • Fresh graft failure

 • Hypoparathyroidism following total

 • Parathyroidectomy

 • Other (TEXT)

23

How often was replantation necessary?

 • No replantation yet

 • 1 patient

 • 2–5 patients

 • 5–10 patients

 • 10–20 patients

 • >20 patients

24

Location of replantation?

 • Forearm

 • Sternocleidomastoid muscle

 • Anterior tibial muscle

 • Presternal

 • Other (TEXT)

25

Amount of tissue transplanted

 • ___mg (TEXT)

 • ___pieces (TEXT)

26

Evaluation of graft before implantation?

TEXT

27

Postimplantation function control?

 • Basal serum PTH

 • Casanova test routinely

 • Blood samples from graft-arm vs.

 • Non-grafted arm

 • Other (TEXT)

28

Results

 • No substitution necessary

 • Mild substitution

 • Recurrent disease in graft

Intraoperative PTH- monitoring

29

IOPTH used?

 • Routinely

 • Only for scientifically reasons

 • Only for reoperations

 • Never

30

Type of assay?

 • Quick-intraoperative iPTH assay (Nichols Institute Diagnostics, San Juan Capistrano, CA, USA)

 • Immulite Turbo intact PTH assay (Diagnostic Products Corporation, Los Angeles, CA, USA)

 • Assay using Roche Elecsys analyzers (Roche Diagnostics, Indianapolis, IN, USA)

 • Future Diagnostics BV, Wijchen, the Netherlands

31

Time points

 • Before skin incision

 • Visualization of adenoma

 • Excision of a gland

 • 5 min after excision

 • 10 min after excision

 • 15 min after excision

 • 20 min after excision

 • 25 min after excision

 • 30 min after excision

 • Other (TEXT)

32

Criterion used

 • ≥50 % from highest value within 10 min

 • ≥50 % from preincision value within 10 min

 • ≥50 % from highest value within 15 min

 • ≥50 % from highest value within 15 min and normal range

 • Other (TEXT)

33

Influence on surgical strategy

 • Yes

 • No

 • IOPTH only gives “recommendations”

 • Other (TEXT)

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Riss, P., Asari, R., Scheuba, C. et al. Current trends in surgery for renal hyperparathyroidism (RHPT)—an international survey. Langenbecks Arch Surg 398, 121–130 (2013). https://doi.org/10.1007/s00423-012-1025-6

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  • DOI: https://doi.org/10.1007/s00423-012-1025-6

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