Post on 14-Apr-2017
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.
THANK YOU