Unilateral Surgery for Hyperparathyroidism: Indications, Limits, and Late Results—New Philosophy or Expensive Selection without Improvement of Surgical Results?

Abstract

We assessed the "late" results after unilateral parathyroidectomy (PTX) performed for selected indications. From October 1998 throughout March 2001 we operated on 454 patients for hyperparathyroidism (HPT). A positive unifocal (99m)tc-MIBI scan was required for the unilateral approach to be used. Intact parathormone (PTH) measurements were done intraoperatively. Postoperative calcium and PTH serum levels of unilaterally operated patients were checked. Follow-up has been 16.2 months (range 6-40 months). Of the 454 patients, 336 (74.0%) were not eligible for the unilateral approach; and 125 (27.5%) of the 454 patients had renal HPT. Among the 329 patients with primary HPT, 125 (38.0%) were excluded for well established reasons, and in 77 other cases (23.5%) preoperative imaging results did not allow the unilateral approach. Altogether, 126 patients (38.3%) with primary HPT were selected for the unilateral approach. Of the 126 unilateral operations, 8 (6.3%) had to be converted to a bilateral procedure. Among the 118 patients with a unilateral approach, 3 patients have been reoperated for overlooked contralateral disease, and 13 dropped out of the study. A total of 102 postoperative calcium and PTH serum late levels are known: 90 (88.2%) patients had normal levels; 10 (9.8%) had a high PTH level, and 2 (1.9%) had high ionized calcium levels. The failure rate in selected cases was 4.2% (5/118) (three were reoperated, and two had a supranormal postoperative ionized Ca level). Even with stringent indications, the late results of unilateral surgery (95.8% cure rate) barely matched those of conventional bilateral surgery (97.6% cure rate). The economic impact of such a surgical strategy should be clarified.

Surgical strategy for sporadic primary hyperparathyroidism an evidence-based approach to surgical strategy, patient selection, surgical access, and reoperations

“…A much lower incidence was found in a randomized trial in which two of 46 patients randomized to BNE had an unsuspected additional enlarged parathyroid on the contralateral side [6]. In contrast, multigland disease was observed in 16.5% of 395 patients undergoing routine BNE and in 11.1% of patients treated in an institution where SP is the preferred strategy [24]. One possible explanation of such contrasting figures is that some of the small glands considered to be asymmetric hyperplasia were "overinterpretations" of the operative or histological diagnoses.…”

“…Many authors have provided retrospective case series demonstrating the feasibility and high success rate of UNE or SP [8][9][10][11][12][13][14][15][16] (Table 1).…”

Preoperative evaluation of hyperparathyroidism: the role of dual-phase parathyroid scintigraphy and ultrasound imaging

“…Mortier et al [29] reported their US sensitivity as 50% and attributed this result to the fact that cervical echography is not always performed by endocrine sonographers but rather by general radiologists in local or private centers. These two studies show that experience in neck sonography regardless of the specialty makes a major difference.…”

Outcomes of Parathyroidectomy in Patients with Primary Hyperparathyroidism: A Systematic Review and Meta‐analysis

“…Our literature search (Fig. 1) identified 3,141 abstracts, of which 82 observational studies and 6 RCTs, published between 1973 and 2014, were included (Table 1) [17–104]. Most of them were conducted in adults who underwent surgery for PHPT using MIP (70 studies, 9643 patients) or BNE (38 studies, 2471 patients).…”