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Combined Percutaneous Nephrolithotomy/Parathyroidectomy Under One Anesthetic in Patients with Primary Hyperparathyroidism and Stones
Jessica A. Mandeville, MD1, Naeem Bhojani, MD1, Richard Graffis, MD2, James E. Lingeman, MD1.
1Indiana University Health / IU Health Physicians, Indianapolis, IN, USA, 2Tower Surgical, Indianapolis, IN, USA.

BACKGROUND:
Up to 20% of patients with primary hyperparathyroidism (HPT) develop stones. Treatment for HPT is resection of the offending adenoma(s). We present our results for combined percutaneous nephrolithotomy (PNL) and parathyroidectomy for patients with HPT and stones.
METHODS:

Between December 2003 and October 2010, 8 patients underwent PNL /parathyroidectomy. All PNLs were performed by one surgeon (JEL) as were all parathyroidectomies (RG). PNL was performed first, followed by parathyroidectomy.
RESULTS:

Table 1 reviews pre-operative characteristics. All patients had serum-based evidence of HPT. In 6 (75%), adenomas were identified on sestamibi scan. In 2 (25%) the scan was indeterminate. Table 2 reviews intra-operative findings. Mean total OR time was 254.8 min (mean PNL 174 min, mean parathyroidectomy 80.9 min) and mean blood loss was 128.2cc (mean PNL 117.4cc, mean parathyroidectomy 9.4cc). In 1 (12.5%) patient, pus was found behind impacted stones and the PNL procedure was terminated prematurely. Table 3 reviews post-operative results. Mean hospital stay was 2.5 days. Six (75%) patients required secondary PNL. No patient required transfusion. Serum calcium normalized in all. Two post-operative PNL complications occurred (1 UTI, 1 pleural effusion requiring drainage). To date, 1 (12.5%) patient required additional surgery for stones (basket extraction of ureteral stone).
CONCLUSIONS:

Combined PNL /parathyroidectomy can be safely performed in patients with HPT and renal stones.
Table 1: Pre-operative Characteristics
Male1 (12.5%)
Female7 (87.5%)
Mean Age (years)53 (28-79)
Mean Years with Stone Disease7.8 (0.16-25)
Number w/ Prior Stone Surgery5 (62.5%)
Mean Serum Calcium (mg/dL)11.01 (10.1-11.9)
Mean Serum Phosphorus (mg/dL)2.67 (1.7-3.2)
Mean Serum Parathyroid Hormone (PTH; pg/mL)138.3 (101-172)
Mean Urine Calcium / Creatinine (mg/g)258.8 (80-310)
Mean Serum Creatinine (mg/dL)
Mean Hemoglobin (g/dL)
1.04 (0.5-1.5)
11.7 (9.3 - 15.3)


Table 2: Intra-Operative Results
Number undergoing unilateral PNL4 (50%)
Number undergoing bilateral PNL4 (50%)
Mean total OR time (minutes)254.8 (210-303)
Mean OR Time PNL (minutes)174 (120-210)
Mean # accesses / kidney1.08 (1-2)
Mean OR Time Parathyroidectomy (minutes)80.9 (44-140)
Mean Intra-Op PTH (pg/mL)37.8 (14.3-70)
Mean Total EBL (cc)
Mean EBL PNL
Mean EBL parathyroidectomy (CC)
128.2 (25-260)
117.4 (20-250)
9.4 (5-30)
Intra-Op Complication PNL1 (12.5%) pus behind impacted stones, early termination
Intra-Op Complications Parathyroidectomy0 (0%)


Table 3: Post-Operative Results
Mean Hospital Stay (Days)2.5 (1.5-3.5)
Mean Post-Op day 1 Hb (g/dL)10.4 (6.8-15.1)
Number Requiring Transfusion0 (0%)
Mean Post-Op day 1 Serum Creatinine (mg/dL)1.3 (0.9-1.8)
Mean Post-Op day 1 Serum Calcium (mg/dL)8.6 (8.2-9.5)
Number Requiring Secondary PNL6 (75%)
Post-Op Parathyroidectomy Complications0 (0%)
Post-Op PNL Complications
-UTI
-Pleural Effusion
2 (25%)
-1 (12.5%)
-1 (12.5%)
Final Pathology Parathyroid Specimen
-Hypercellular Adenoma
8 (100%)
Mean 1 Month Follow Up Serum Caclium (mg/dL)
Mean Follow Up Urine Ca/Creatinine (mg/g)
9.2 (8.8-9.7)
106.8 (75.8-144.4)


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