The patterns of persistence and recurrence following parathyroidectomy for renal hyperparathyroidism: A 10-year review

Background: Renal hyperparathyroidism can be effectively treated with parathyroidectomy. However, managing persistence or recurrence after the initial surgery is still challenging. Understanding the anatomical patterns observed in reoperative parathyroidectomies can help localize the disease during initial and subsequent surgeries. Aim: This study aimed to identify the patterns of persistence and recurrence following parathyroidectomy for renal hyperparathyroidism and assess the performance of various localization studies. Methods: A retrospective cohort study was conducted on dialysis patients who underwent reoperative parathyroidectomy at a single center. Patient demographics, laboratory test results, localization study findings, surgical details, and postoperative outcomes were obtained through the chart reviews. Persistence was defined as an intact parathyroid hormone level >300 pg/mL within 6 months after the primary surgery; otherwise, recurrence was defined as > 6 months. Results: Among 377 patients who underwent parathyroidectomies, 20 (5.3%) required reoperations. Supernumerary glands were the primary cause of persistence (70%) and recurrence (50%), predominantly located posteriorly within the tracheoesophageal groove. Besides, overgrowth of the forearm graft accounted for 30% of recurrences. Neck ultrasound (US) showed 6 out of 19 false negatives (68% sensitivity and 100% specificity), whereas 99mTc-sestamibi scintigraphy with single-photon emission computed tomography (SPECT)/computed tomography (CT) had one false negative (95% sensitivity and 100% specificity). CT scans accurately localized the disease in cases where US and sestamibi scintigraphy yielded discordant results. Conclusion: Supernumerary glands frequently contribute to the persistence and recurrence of renal hyperparathyroidism after parathyroidectomy. In the reoperative context, sestamibi SPECT/CT and CT scans detect affected parathyroid tissue in the neck and mediastinum more effectively than neck USs.