PRIMARY HIPERPARATHYROID & KIDNEY STONE

Write By : Eko Indra

INTRODUCTION

• Primary hyperparathyroidism (PHPT) refers to the inappropriate or unregulated overproduction of the parathyroid hormone (PTH) leading to abnormal calcium homeostasis

• Renal manifestations of PHPT : hypercalciuria, nephrolithiasis, nephrocalcinosis, chronic renal insufficiency, and renal tubular dysfunction.

• A recent study has reported that 19 (7.0%) of the 271 patients with mild PHPT had renal stones

ANATOMY

ANATOMY

ETIOLOGY

David Rosen JS, Edmund A. Pribitkin. Minimally-Invasive Parathyroid Surgery. Thyroid and Parathyroid Diseases. 2012;31309.

Single Adenoma 81-90%

Multi gland hyperplasia 4-14%

Double Adenoma 2-11%

Carcinoma <1%

PATHOPHYSIOLOGY

Urinary tract stone

Age Sex Profession Nutrition Climate Race Inheritance

Abnormal renal morphologyDisturbed urin flow UTIMetabolic abnormalGenetic factors

Increaseexcretion of : 1. Stone forming constituents2. Crystallization promoters

Decrease :1. Urinary volume2. Excretion of

crystallization inhibitors

SUPER SATURATIONSTONE

Ca2+

Clinical Manifestation• Symptomatic and asymptomatic• “classic” pentad of symptoms :

1. kidney stones2. Painful bones, 3. Abdominal groans, 4. Psychic moans, and 5. Fatigue overtones

• Most patients present with weakness, fatigue, polydipsia, polyuria, nocturia, bone and joint pain, constipation, decreased appetite, nausea, heartburn, pruritus, depression, and memory loss.

• Truly “asymptomatic” <5% of patients

DIAGNOSTIC

Biochemical Investigations

• Elevated serum calcium and PTH, without hypocalciuria

• Decreased serum phosphate ( 50%) and ∼elevated 24-hour urinary calcium concentrations ( 60%). ∼

• PTH assays use immunoradiometric or immunochemiluminescent techniques

IMAGING

IMAGING

Nuclear Imaging :- Single radioisotope scintigraphy using

technetium-99m (99mTc) sestamibi - Sensitivity 85-95%- sensitivity is much lower for

hyperplastic glands as compared to primary adenomas as well as for glands under 300 mg in weight

USGEffective, noninvasive and

inexpensiveLimitation are operator dependent

Sensitivity 42-82%, Spec 90%Often combined with sestamibi

Tomography

Higher sensitivity than USG, but involves radiation

Effective for identifying inferior ectopic adenoma

Sensitifity 92%

MRI MRI provides a

higher sensitivity at identifying ectopic parathyroid adenomas than does CT scan

TREATMENT

• Most authorities agree that patients who have developed complications and have “classic” symptoms of PHPT should undergo parathyroidectomy.

• The treatment of patients with asymptomatic PHPT has been the subject of controversy

OPERATION INDICATION

Bilezikian JP et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. The Journal

of Clinical Endocrinology & Metabolism. 2014;99(10):3561-9.

GUIDELINES FOR SURGERY IN ASIMPTOMATIC PHPT

Bilezikian JP et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. The Journal of Clinical Endocrinology & Metabolism. 2014;99(10):3561-9.

GUIDELINES FOR MONITORING PATIENTS WITH ASIMPTOMATIC PHPT WHO DO NOT UNDERGO SURGERY

Bilezikian JP et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. The Journal of Clinical Endocrinology & Metabolism. 2014;99(10):3561-9.

SURGERY APPROACHMENT

A. CONVENSIONAL PARATHYROIDECTOMY

B. MINIMAL INVASIVE :

- Focused parathyroidectomy

- Radio guided surgery

- Endoscopic parathyroidectomy

-Minimally invasive video-assisted parathyroidectomy (MIVAP)

CONVENSIONAL PARATHYROIDECTOMY

4 glans exploration, removal of enlarged parathyroid

Complication rate 1-3% Cure rate 95-99%

MINIMAL INVASIVE PARATHYROIDECTOMY

Focused Parathyroidectomy :• Focused o/t one parathyroid gland• Dissection depends on preoperative imaging• Monitoring intraoperative PTH • Do not need Vit D and Calsium supplement• Cure Rate 95-99%

MINIMAL INVASIVE PARATHYROIDECTOMY

Radio-guided Surgery :• Using 99mTc-sestamibi radioactive

which can be detected with gamma probe localized

• Short Incision 2-4 cm• Sensitivity Gamma Probe 93-94%

MINIMAL INVASIVE PARATHYROIDECTOMY

Endoscopic Parathyroidectomy :• First reported by Gagner (1996)• Very small Incision (5 mm) as

endoscope access• Satisffying cosmetic• Using 5 mm trochar o/t sternal

notch and 3 additional port• Complication : Subcutaneous

Emphysema, respiratory acidosis, tacicardia, and air emboly

MINIMAL INVASIVE PARATHYROIDECTOMY

Minimally invasive video-assisted parathyroidectomy

(MIVAP)

Minimally invasive video-assisted parathyroidectomy (MIVAP) :• First reported Miccoli 1998• Not the choice for multiple glands

disease, parathyroid Ca, preoperative localized fail

• Incision size 15-20 mm o/t midline• Endoscope size 5mm 30o,

endoscope 2 mm for dissection• Do not need CO2

• Cure Rate 96-100%

MINIMAL INVASIVE PARATHYROIDECTOMY

Comparison between Convensional Method and Minimal Invasive

Del Rio P, Vicente D, Maestroni U, et al. A comparison of minimally invasive video-assisted parathyroidectomy and traditional parathyroidectomy for parathyroid adenoma. Journal of Cancer. 2013;4(6):458.

MEDICAL OPTIONS DURING EXPECTANT MANAGEMENT OF NEPHROLITHIASIS

• Pain control• AB prophylaxis• Alpha blockers• Ca channel blockers• steroids

INDICATIONS FOR ACTIVE STONE REMOVAL

• The stone diameter is > 7 mm (because of a low rate of spontaneous passage)

• Pain relief cannot be achieved• Stone obstruction associated with infection• Pyonephrosis or urosepsis• In single kidneys with obstruction• Bilateral obstruction

SURGERY FOR NEPHROLITHIASIS

• ESWL• Ureteroscopy• Percutaneous nephrolithotomy (PNL)• Laparascopy• Open surgery

MANAGEMENT OF UROLITHIASIS

Türk C, Petřík A, Sarica K, et al. EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis. European urology. 2015.

REFERENCE1. Lila AR, Sarathi V, Jagtap V, et al. Renal manifestations of primary hyperparathyroidism. Indian journal of endocrinology and

metabolism. 2012;16(2):258.2. Wang C-a. Surgical management of primary hyperparathyroidism. Current problems in surgery. 1985;22(11):4-50.3. Suh JM, Cronan JJ, Monchik JM. Primary hyperparathyroidism: is there an increased prevalence of renal stone disease? American

Journal of Roentgenology. 2008;191(3):908-11.4. Rejnmark L, Vestergaard P, Mosekilde L. Nephrolithiasis and renal calcifications in primary hyperparathyroidism. The Journal of

Clinical Endocrinology & Metabolism. 2011;96(8):2377-85.5. Sorensen MD, Duh Q-Y, Grogan RH, et al. Urinary parameters as predictors of primary hyperparathyroidism in patients with

nephrolithiasis. The Journal of urology. 2012;187(2):516-21.6. Oertli D, Udelsman R. Surgery of the thyroid and parathyroid glands: Springer; 2007.7. Elkoushy MA, Alice XY, Tabah R, et al. Determinants of urolithiasis before and after parathyroidectomy in patients with primary

hyperparathyroidism. Urology. 2014;84(1):22-6.8. Pallan S, Rahman MO, Khan AA. Diagnosis and management of primary hyperparathyroidism. Bmj. 2012;344.9. Bilezikian JP, Brandi ML, Eastell R, et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary

statement from the Fourth International Workshop. The Journal of Clinical Endocrinology & Metabolism. 2014;99(10):3561-9.10. Worcester EM, Coe FL. Nephrolithiasis. Primary Care: Clinics in Office Practice. 2008;35(2):369-91.11. Cusano NE, Silverberg SJ, Bilezikian JP. Normocalcemic primary hyperparathyroidism. Journal of Clinical Densitometry. 2013;16(1):33-

9.12. Türk C, Petřík A, Sarica K, et al. EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis. European urology. 2015.13. Gopalakrishna Iyer N, Shaha AR. Current concepts in the management of primary hyperparathyroidism. Indian journal of surgical

oncology. 2010;1(2):112-9.14. David Rosen JS, Edmund A. Pribitkin. Minimally-Invasive Parathyroid Surgery. Thyroid and Parathyroid Diseases. 2012;31309.15. Del Rio P, Vicente D, Maestroni U, et al. A comparison of minimally invasive video-assisted parathyroidectomy and traditional

parathyroidectomy for parathyroid adenoma. Journal of Cancer. 2013;4(6):458.

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