Cases with Fewer than Four Parathyroid Glands in Patients withRenal Hyperparathyroidism at Initial Parathyroidectomy

In the surgical treatment of secondaryhyperparathyroidism (2HPT) due to uremia, it is considered necessary toremove all parathyroid glands from the neck to prevent persistent andrecurrent parathyroid hyperfunction. However, in some cases fewer thanfour parathyroid glands can be recognized at initial operation; in thepresent study, we evaluated the long-term prognosis and estimatedsurgical strategy in such cases. Between March 1981 and January 1999,822 patients underwent total parathyroidectomy (PTx) with forearmautograft for advanced 2HPT at the Department of Transplant Surgery of Nagoya Second Red Cross Hospital. In 21 cases (2.6%) fewer than fourparathyroid glands were macroscopically found at the initial operation.These cases were followed up and their parathyroid function wasevaluated by measurement of intact parathyroid hormone (PTH). In 20 ofthe 21 cases three glands were found, in 1 patient only two glands. In5 of these cases the fourth gland was identified first afterpostoperative histopathologic evaluation. In all these cases the intactPTH level was normalized. In 8 of the remaining 16 cases high PTHlevels persisted after the initial operation, including 3 patients who underwent neck reexploration. However, in the other 7 patients PTHlevels dropped within normal range immediately after PTx and a fourthgland has never been recognized. One patient was lost to follow-up. Thus, using our operative strategy, 12 of 822 cases (0.85%) did notdevelop persistent or recurrent HPT even though only three glands wereidentified at the operation. To avoid postoperative hypoparathyroidism,autotransplantation should be performed when fewer than four parathyroid glands are found at the initial operation.