Cases with fewer than four parathyroid glands in patients with renal hyperparathyroidism at initial parathyroidectomy

In the surgical treatment of secondary hyperparathyroidism (2HPT) due to uremia, it is considered necessary to remove all parathyroid glands from the neck to prevent persistent and recurrent parathyroid hyperfunction. However, in some cases fewer than four parathyroid glands can be recognized at initial operation; in the present study, we evaluated the long-term prognosis and estimated surgical strategy in such cases. Between March 1981 and January. 1999, 822 patients underwent total parathyroidectomy (PTx) with forearm autograft for advanced 2HPT at the Department of Transplant Surgery of Nagoya Second Red Cross Hospital. In 21 cases (2.6%) fewer than four parathyroid glands were macroscopically found at the initial operation. These cases were followed up and their parathyroid function was evaluated by measurement of intact parathyroid hormone (PTH). In 20 of the 21 cases three glands were found, in 1 patient only two glands. In 5 of these cases the fourth gland was identified first after postoperative histopathologic evaluation. In all these cases the intact PTH level was normalized. In 8 of the remaining 16 cases high PTH levels persisted after the initial operation, including 3 patients who underwent neck reexploration. However, in the other 7 patients PTH levels dropped within normal range immediately after PTx and a fourth gland has never been recognized. One patient was lost to follow-up. Thus, using our operative strategy, 12 of 822 cases (0.85%) did not develop persistent or recurrent HPT even though only three glands were identified at the operation. To avoid postoperative hypoparathyroidism, autotransplantation should be performed when fewer than four parathyroid glands are found at the initial operation.