Parathyroidectomy in the Treatment of Childhood Hyperparathyroidism: A Single-Institution Experience

Parathyroidectomy in the Treatment of Childhood Hyperparathyroidism: A Single-Institution Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Parathyroidectomy in the Treatment of Childhood Hyperparathyroidism: A Single-Institution Experience Seyithan Ozaydin, Serkan Sari, Emel Hatun Aytac Kaplan, Zumrut Kocabey Sutcu, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6489091/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Hyperparathyroidism (HPT) is a condition marked by excessive secretion of parathyroid hormone (PTH), leading to disturbances in calcium, phosphate, and vitamin D metabolism. HPT is classified into primary (pHPT), secondary (sHPT), and tertiary (tHPT) types, which can cause systemic complications. Parathyroidectomy (PTX) remains the cornerstone treatment for pHPT and refractory cases of sHPT and tHPT. Methods A retrospective review was conducted on 10 pediatric patients who underwent PTX for HPT at our clinic between 2016 and 2024. Demographic data, preoperative imaging, laboratory findings, surgical details, pathology reports, and postoperative outcomes were analyzed. Patients were categorized as having either pHPT (n = 6) or renal HPT (r-HPT; n = 4), which included one case of sHPT and three cases of tHPT. Results The mean age of pHPT and r-HPT patients was 15 and 13 years, respectively. While 50% of pHPT patients were female, all r-HPT patients were female. Preoperative imaging localized parathyroid lesions using ultrasonography in all cases, but Sestamibi scintigraphy had a lower detection rate (66.7%). Minimally invasive parathyroidectomy was performed in single-gland pHPT cases, while bilateral neck exploration was used for multiglandular pHPT and all r-HPT cases. No intraoperative complications were observed. Postoperatively, all patients demonstrated normalized calcium, phosphate, and PTH levels with significant symptomatic improvement. Hungry bone syndrome developed in one r-HPT patient and was managed successfully. No recurrences were noted during an average follow-up of 39 months. Conclusion PTX is a safe and effective treatment for pediatric HPT, providing excellent biochemical and clinical outcomes. Multidisciplinary collaboration is crucial in managing pediatric cases, particularly those with complex renal HPT. Hyperparathyroidism Parathyroidectomy Primary Hyperparathyroidism Renal Hyperparathyroidism Pediatric Surgery Figures Figure 1 Figure 2 Figure 3 1. Introduction Hyperparathyroidism (HPT) is characterized by the excessive secretion of parathyroid hormone (PTH) and is classified as a cause-and-effect disorder of calcium (Ca), phosphorus (P), and vitamin D metabolism. Based on its underlying mechanism, HPT is classified into three types: primary hyperparathyroidism (pHPT), secondary hyperparathyroidism (sHPT), and tertiary hyperparathyroidism (tHPT). pHPT is mainly caused by single and rarely by multiple parathyroid adenomas [ 1 ]. The sHPT results from excessive PTH secretion due to abnormal vitamin D and calcium metabolism, primarily caused by CRF but also by gastrointestinal malabsorption, liver disease, and pseudohypoparathyroidism. Persistent stimulation of the parathyroid glands in dialysis-dependent CRF patients can lead to hyperplasia and, eventually, adenoma formation, termed tHPT [ 2 , 3 ]. The imbalance in PTH, Ca, P, and vitamin D causes significant complications affecting various systems, including the skeletal, renal, gastrointestinal, neuropsychiatric, soft tissue, and cardiovascular systems. The primary treatment for pHPT involves the surgical excision of the pathological parathyroid gland through parathyroidectomy (PTX) [ 4 ]. In contrast, sHPT and tHPT are typically managed through medical interventions, with surgery being reserved for cases that fail to respond adequately to medical therapy [ 5 ]. This study aims to evaluate and present the clinical outcomes of patients who underwent PTX for pHPT, sHPT, and tHPT in our clinic, contextualized within findings from the current literature. 2. Methods The medical records of patients who underwent PTX for HPT between 2016 and 2024 were retrospectively reviewed following ethical approval (Approval No: 2023.10.145) granted by the XXX Ethics Committee. Data collected included demographic and clinical characteristics, preoperative localization studies, laboratory findings, surgical notes, postoperative follow-up data, and pathology reports. In addition to cases of isolated single or multiple parathyroid adenomas (pHPT), cases of sHPT and tHPT occurring due to chronic renal failure (CRF) were evaluated under the title of renal hyperparathyroidism (r-HPT). For cases of pHPT involving a single gland, minimally invasive parathyroidectomy (MIP) was performed, while subtotal PTX with bilateral neck exploration (BNE) was employed for cases of pHPT involving multiple glands and all r-HPT cases. This approach involved the excision of three and a half pathological glands. A comprehensive data set, inclusive of preoperative and postoperative Ca, P, and PTH values, preoperative ultrasonography (US), Tc 99 sestamibi scintigraphy/single-photon emission computed tomography (S-mibi/S-CT) reports, washout/fine needle aspiration biopsy (W/FNA) results, preoperative preparations, potential intraoperative additional interventions, complications, and postoperative follow-up were meticulously documented. A thorough review of the pathology reports was also conducted. The results were then analyzed in conjunction with postoperative follow-up examinations at 6 and 12 months. 2A. Statistical analysis Given the limited sample size, statistical comparisons were not performed. Instead, descriptive statistics were used to summarize data, with continuous variables presented as means, standard deviations, medians, minimums, and maximums. Categorical data were expressed as frequencies and percentages. Analyses were conducted using MedCalc® Statistical Software version 22.009 (MedCalc Software Ltd, Ostend, Belgium; https://www.medcalc.org ; 2023). 3. Results The study included ten patients, of whom six (60%) were diagnosed with pHPT, one (10%) with sHPT, and three (30%) with tHPT; the latter four cases (40%) were categorized as r-HPT. The mean age of patients with pHPT was 15 years, while the mean age for r-HPT cases was 13 years. Among the pHPT patients, half were female, whereas all r-HPT cases involved female patients. Patients with pHPT most commonly presented with gastrointestinal, neuropsychiatric, and musculoskeletal complaints, whereas r-HPT cases primarily exhibited symptoms associated with renal osteodystrophy, including issues related to the urinary and musculoskeletal systems. Table 1 presents the details of demographic data, clinical features, and diagnostic and therapeutic management of the ten cases in our pediatric HPT/PTX series. Table 2 summarizes the demographics and the system-related symptoms of the pHPT and r-HPT groups. In the pHPT group, no significant findings were noted in all six patients' medical histories. However, in the r-HPT group, one patient had bilateral dysplastic multicystic kidneys, whereas another had a history of apert hydrocephalus, ventriculoperitoneal shunt placement, meningomyelocele repair, spina bifida, and associated neurogenic bladder, and bilateral vesicoureteral reflux. The causes in the remaining two r-HPT cases with CRF were unknown. Table 1 Case Details Case 1 2 3 4 5 6 7 8 9 10 HPT Type pHPT pHPT pHPT pHPT pHPT pHPT sHPT tHPT tHPT tHPT Age (years) 17 14 16 9 17 17 15 8 11 18 Sex Male Female Female Female Male Male Female Female Female Female Symptom Duration (months) 24 2 6 12 9 12 36 84 132 132 Medical History None None None None None None Bilateral multicystic CKD Hydrocephalus surgery, VP shunt, meningomyelocele, bilateral VUR, CKD CKD CKD Family History None None Father: kidney stones Brother: growth hormone deficiency None None Sibling: CKD None None None Genetic/Molecular Abnormality None detected None detected None detected None detected None detected None detected None detected None detected None detected None detected Preoperative Ca (mg/dL) 13.4 11.5 13.4 13.9 11.9 13.5 10.4 8.3 9.3 8.8 Preoperative P (mg/dL) 2.4 2.3 1.8 2.9 2.9 2.6 7.7 5.2 7.3 4.7 Preoperative PTH (pg/mL) 184 144 821 127 104 177 3019 5000 5000 2427 Ultrasound (mm) Right 12×7×5 Left 10×8×2 Right lower 15×12×25 Left lower 6×6×4 Left lower 6.7×4.6×3 Right lower 9×6×4 Normal 4 glands: Right 30×6×1, right lower 6×3×2, left lower 7×4×3 and 7×5×4 Right lower 11×6.5×5, left lower 7.5×4×3 Right lower 20×10×10, left lower 13×5×5 Sestamibi/SPECT-CT Right Left lower Right lower Not detected Not detected Right lower Left lower Not detected Right lower, left upper Right lower, left lower Washout (pg/mL) > 5000 > 5000 > 5000 > 5000 > 5000 > 5000 > 5000 No data > 5000 > 5000 Gland Involvement Single gland Single gland Two glands Single gland Single gland Single gland 4 glands 4 glands 4 glands 4 glands Surgical Technique MIP MIP BNE MIP MIP MIP BNE BNE BNE BNE Additional Surgery None Partial thymectomy None None Partial thymectomy None None Right partial, left subtotal thymectomy Right thyroidectomy-left partial thymectomy Right partial thymectomy Intraoperative PTH No No Yes No No No No No No No Frozen Biopsy No No Yes No No No No Yes No No Nerve Monitoring Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Drain No Yes Yes No Yes Yes Yes Yes Yes Yes Pathology Result Adenoma Adenoma Adenoma Adenoma Adenoma Adenoma Hyperplasia Hypercellular adenomatous nodule Hypercellular adenomatous nodule Hypercellular adenomatous nodule Specimen Weight (mg) 660 580 620 and 320 340 330 510 420 (largest) 380 (largest) 390 (largest) 2230 (largest) Specimen Size (mm) 14×11×5 10×10×3 13×10×5; 8×7×4 8×8×3 8×7×4 10×8×4 Largest: 25×10×4 Largest: 17×7×2 Largest: 16×7×5 Largest: 20×10×10 Complications None None None None None None None Transient hyperthyroidism (Povidone-iodine suspected) Hungry bone syndrome None Early Postop Ca (mg/dL) 8.7 8.8 8.8 9.1 8.8 9.2 9.1 8.0 7.9 8.2 Early Postop P (mg/dL) 2.2 2.8 2.6 3.3 3.7 2.3 6.2 4.2 3.4 3.3 Early Postop PTH (pg/mL) 48 24 51 34 22 40 121 39 51 17 Hospital Stay (days) 2 2 2 2 2 2 7 12 13 12 6-Month Postop Ca (mg/dL) 9.6 9.2 9.5 8.6 9.9 8.6 8.8 8.5 8.2 9.8 6-Month Postop P (mg/dL) 3.5 3.2 3.5 3.3 4.8 3.4 5.6 4.4 2.5 4.5 6-Month Postop PTH (pg/mL) 40 45 64 44 49 55 81 23 20 28 12-Month Postop Ca (mg/dL) 8.9 8.6 8.8 8.5 8.7 8.9 8.2 8.2 9.9 9.6 12-Month Postop P (mg/dL) 3.4 3.5 3.6 3.4 3.8 3.5 5.8 3.8 3.8 5.6 12-Month Postop PTH (pg/mL) 42 41 55 40 46 45 66 17 17 22 Follow-up (months) 36 84 36 36 96 12 24 24 24 18 Table 2 Demographics and Presenting Symptoms pHPT (n = 6) r-HPT (n = 4) Age (years) ( Mean ± SD) 15 ± 3.1 13 ± 4.4 Gender, n (%) Male 3 (50%) 0 (0%) Female 3 (50%) 4 (100%) Symptom Duration (months) (Mean ± SD) 10.8 ± 7.5 96 ± 46 System-related Symptoms Neuropsychiatric Headache 3 0 Dizziness 1 0 Irritability 2 0 Forgetfulness 1 0 Fatigue 1 0 Seizures 0 1 Gastrointestinal Abdominal pain 4 0 Nausea/Vomiting 1 0 Gastroenteritis 1 0 Weight gain 1 0 Musculoskeletal Leg pain/Burning 4 1 Cramping/Spasms 2 0 Walking difficulty 0 2 Bone deformities (X-bone) 0 2 Fractures 0 2 Urinary Nephrolithiasis 1 0 Chronic kidney failure 0 4 Regarding family history, one pHPT patient had a father with urinary stone disease, and another had a sibling with growth hormone deficiency. In the r-HPT group, only one patient had a sibling with CRF. Genetic screening revealed no molecular or genetic abnormalities in any of the patients. The mean duration of symptoms was significantly longer in r-HPT cases (96 months) compared to pHPT cases (10.8 months). Preoperative laboratory findings revealed that, in the pHPT patients, the mean Ca, P, and PTH levels were 12.9 ± 1 mg/dL, 2.5 ± 0.4 mg/dL, and 259.5 ± 276.7 pg/mL, respectively. For r-HPT patients, these levels were 9.2 ± 0.9 mg/dL, 6.2 ± 1.5 mg/dL, and 3861.5 ± 1336.7 pg/mL, respectively. Regarding imaging studies, the preoperative US identified parathyroid adenomas in all pHPT cases, while hyperplastic/adenomatous findings were observed in all r-HPT cases except for one. W/FNAB was performed in all pHPT cases, confirming PTH levels exceeding 5000 pg/mL. Preoperative S-mibi/S-CT revealed no uptake in two pHPT cases (33.3%) and one r-HPT case (25%). Surgical approaches varied based on the clinical presentation. MIP was performed in five pHPT cases with single-gland involvement, while BNE was conducted in one pHPT case with multi-gland involvement and in all four r-HPT cases. An intubation tube-compatible neuromonitor (Dr Langer Avalanche, serial number: 789.09.2015, Germany) was used in all cases. During surgery, intraoperative PTH monitoring (io-PTH) was performed in only one pHPT case because of two-gland involvement. Moreover, a frozen section biopsy was conducted in one pHPT and one r-HPT case to confirm tissue pathology. Parathyroid adenoma was excised in all cases of pHPT, while partial thymectomy was additionally performed in two cases of lower lobe origin. All r-HPT cases underwent four-gland exploration and three-and-a-half-gland excision. Moreover, one underwent unilateral thyroidectomy, and three also underwent unilateral (partial/subtotal) thymectomy. The lower lobe was preferred for the half gland left as it is generally safer for the laryngeal nerve in a possible second exploration. However, in two cases in which the lower lobe glands were markedly hyperplasic, the upper lobe, which had a somewhat more normal appearance, was chosen. After excision, the remaining gland was marked with a metal clip. The three cases of pHPT originated in the left lower lobe, whereas one originated from the right lower lobe, one from the right upper lobe, and one from the right lower and upper lobes. In all but two cases of pHPT, a minivac drain was placed in the lounge and subsequently withdrawn on postoperative day 1 on average. No intraoperative complications or postoperative complications, such as bleeding, nerve injury, hematoma, or infection, were encountered. Postoperatively, one tHPT case developed hungry bone syndrome (HBS), which was successfully treated with medical intervention. Another tHPT case experienced transient hyperthyroidism, likely associated with the use of povidone-iodine antiseptic; this condition was resolved with appropriate medical management. In the early postoperative period, the mean Ca value was 8.9 ± 0.2 mg/dL, the mean P value was 2.5 ± 0.4 mg/dL, and the mean PTH value was 36.5 ± 12 in pHPT cases. Conversely, in r-HPT cases, the mean Ca value was 8.3 ± 0.5 mg/dL, the mean P value was 4.3 ± 1.3 mg/dL, and the PTH value was 57 ± 44.9 pg/mL. A subsequent examination of the pathology reports revealed that the lesions were evaluated as parathyroid adenoma in all cases of pHPT (n = 6) (Fig. 1 ). In r-HPT cases, all glands removed were evaluated as hyperplasia, particularly in sPHT cases (Fig. 2 ). In three cases of tHPT, all glands were evaluated as hypercellular adenomatous nodules. The weight of the pathology specimen in pHPT cases was found to be mean ± SD: 480 ± 147.5 mg (n = 7), while in r-HPT cases, it was mean ± SD: 453.1 ± 549.4 mg (n = 16). The volume (mm3) in pHPT cases was mean ± SD: 417.5 + 234.9 (n = 8); in r-HPT cases, whereas it was mean ± SD: 512.1 + 464.3 (n = 16). The average hospital stay was 2 ± 0 days for pHPT patients and 11 ± 2.7 days for r-HPT patients. The mean follow-up period after PTX was 50 ± 32.6 months in pHPT cases and 22.5 ± 3 months in r-HPT cases. Regarding all cases, no problem requiring reoperation was encountered. At the sixth postoperative month, the mean Ca value in pHPT cases was 9.2 ± 0.5 mg/dL, the mean P value was 3.6 ± 0.6 mg/dL, and the mean PTH value was 49.5 ± 8. 7 pg/mL, while the mean values of r-HPT cases were 8.8 ± 0.7 mg/dL for Ca, 4.3 ± 1.3 mg/dL for P, and 38 ± 28.9 pg/mL for PTH. At the 12th postoperative month, the mean Ca value of pHPT cases was 8.7 ± 0.2 mg/dL, the P value was 3.5 ± 0.2 mg/dL, and the PTH value was 44.8 ± 5.5 pg/mL, while in r-HPT cases, the mean values of Ca was 9 ± 0.9 mg/dL, P 4.8 ± 1.1 mg/dL, and PTH 30.5 ± 23.8 pg/mL (Table 3 ). Table 3 Laboratory Features Variable (Mean ± SD) pHPT (n = 6) r-HPT (n = 4) Calcium (Ca, mg/dL) Preoperative 12.9 ± 1 9.2 ± 0.9 Postoperative (Early) 8.9 ± 0.2 8.3 ± 0.5 Postoperative (6 months) 9.2 ± 0.5 8.8 ± 0.7 Postoperative (12 months) 8.7 ± 0.2 9 ± 0.9 Phosphorus (P, mg/dL) Preoperative 2.5 ± 0.4 6.2 ± 1.5 Postoperative (Early) 2.8 ± 0.6 4.3 ± 1.3 Postoperative (6 months) 3.6 ± 0.6 4.3 ± 1.3 Postoperative (12 months) 3.5 ± 0.2 4.8 ± 1.1 PTH (pg/mL) Preoperative 259.5 ± 276.7 3861.5 ± 1336.7 Postoperative (Early) 36.5 ± 12.1 57 ± 44.9 Postoperative (6 months) 49.5 ± 8.7 38 ± 28.9 Postoperative (12 months) 44.8 ± 5.5 30.5 ± 23.8 Specimen Weight (mg), n 480 ± 147.5, 7 453.1 ± 549.4, 16 Specimen Volume (mm³) 417.5 ± 234.9 512.1 ± 464.3 Hospital Stay (days) 2 ± 0 11 ± 2.7 Follow-up Period (months) 50 ± 32.6 22.5 ± 3 The preoperative and postoperative trends of Ca, P, and PTH levels are displayed in Fig. 3 . At the final follow-up visits, all patients reported that they had no longer experienced any complaints as those in the preoperative period and reported a significant improvement in their overall well-being. Furthermore, no new bone fracture findings were observed, particularly in r-HPT cases. 4. Discussion This study evaluated ten pediatric HPT patients, including six with pHPT and four with r-HPT. The mean age at diagnosis was 15 years for pHPT and 13 years for r-HPT. pHPT had an equal gender distribution, while all r-HPT cases were female. pHPT patients commonly presented with gastrointestinal, neuropsychiatric, and musculoskeletal symptoms, whereas r-HPT patients exhibited renal osteodystrophy. The diagnosis time was shorter for pHPT (10.8 months) than for r-HPT (96 months). Biochemical findings showed higher PTH and P levels in r-HPT. The US successfully localized all lesions, but S-mibi/S-CT had limited uptake in some cases. Surgical management included MIP for most pHPT cases and BNE for multiglandular pHPT and all r-HPT cases. No significant complications occurred except for one case of postoperative HBS. Long-term follow-up showed biochemical normalization and symptom improvement. 4A. Demographics, Etiology, Clinical Presentation and Diagnosis pHPT is rare in pediatric populations, with an incidence of 0.5–5 per 100,000, compared to 20–100 per 100,000 in adults [ 6 – 9 ]. Most reports indicate a female predominance, likely due to hormonal factors influencing parathyroid growth and function [ 6 , 10 ]. However, this study identified an equal male-to-female ratio, differing from such reports. This variation may be due to a small sample size, regional genetic factors, or differences in healthcare-seeking behavior among male and female pediatric patients. The etiology of pHPT has been extensively discussed in the literature. It has been reported that 68–81.5% of cases are sporadic, while 8.5–12.8% are familial, and 5.8–11.5% are associated with genetic or molecular abnormalities. These abnormalities are often linked to syndromes such as Multiple Endocrine Neoplasia (MEN-1, MEN-2A, MEN-4) or mutations in genes such as CASR, CDKN1A, CDKN1B, CDKN2C, and RET [ 11 – 13 ]. Consistent with prior studies emphasizing the sporadic nature of pediatric pHPT, this study found no familial or syndromic cases, and genetic screening did not reveal any molecular abnormalities. This further underscores that genetic testing remains valuable in pediatric pHPT workups, but its diagnostic yield may be low in sporadic cases. The literature indicates that about 80% of pHPT cases arise from single-gland involvement [ 14 ]. Multiglandular involvement is more commonly associated with syndromic or familial cases [ 11 , 13 ]. In our cohort, 83.3% of cases involved a single gland, while 16.7% exhibited multiglandular involvement, similar to the literature. Clinical presentation in pHPT is primarily symptomatic, with 64–96% of cases showing significant clinical findings. These symptoms commonly involve the musculoskeletal, gastrointestinal, neuropsychiatric, and urinary systems. Patients often present with muscle cramps, difficulty walking, bone deformities, bone fractures, nausea, vomiting, abdominal pain, gastroenteritis, headaches, fatigue, depression, or nephrolithiasis [ 4 , 6 , 10 , 15 ]. In agreement with previous findings, all pHPT cases in this study were symptomatic, with musculoskeletal, neuropsychiatric, and gastrointestinal complaints being the most frequent. Notably, nephrolithiasis and nephrocalcinosis, reported in about 40% of pediatric cases, were absent in this cohort, possibly due to earlier diagnosis or genetic predisposition differences [ 17 ]. Regarding r-HPT, CRF prevalence in adults is estimated at 40–70 per million, but it is much rarer in children (0.5–5 per million). Nevertheless, a significant proportion of pediatric CRF patients develop r-HPT (sHPT or tHPT), which, if untreated, can cause severe bone deformities and growth retardation [ 18 ]. Our study confirms this trend, with pediatric r-HPT patients presenting with bone deformities and leg pain as major clinical concerns. 4C. Preoperative Imaging and Intraoperative Localization/Monitoring Accurate localization of parathyroid adenomas is critical for surgical planning in cases with pHPT. Preoperative imaging using a combination of US and S-mibi/S-CT has been reported to have a sensitivity of 82–91.4% in localizing parathyroid lesions [ 6 , 10 , 15 , 19 ]. The sensitivity is exceptionally high in cases of single-gland involvement, where detection rates range from 89–94%, but it decreases in cases involving multiple glands or tiny lesions [ 20 ]. In one study, the US alone achieved 100% positive localization in their cohort. However, concordance with S-mibi was observed in only 93.8% of cases, and the authors concluded that S-mibi mainly improves specificity in suspected multiglandular disease and should be carefully evaluated in pediatric cases to minimize radiation exposure [ 21 ]. Multiglandular involvement in pHPT is reported in 7–33% of cases, varying rates depending on imaging methods. Multiglandular disease rates were 5.7%, 11%, and 21% for positive findings on both, one, or neither imaging modality, respectively [ 22 ]. Careful attention is needed when operating on small or multiple affected glands. Surgical outcomes were comparable, even in imaging-negative cases. The US successfully localized all parathyroid lesions in this study, reinforcing its reliability. At the same time, S-mibi/S-CT failed to detect uptake in 33.3% of pHPT cases, supporting prior reports that the necessity of S-mibi/S-CT in single-gland involvement remains debatable. Li et al. reported that, despite advancements in diagnostic tools, the average time to diagnose pHPT cases remains 41 months [ 23 ]. In contrast, our cohort's mean duration from symptom onset to diagnosis was 10.8 months. Preoperative imaging is also essential in r-PHT to identify ectopic glands and minimize unnecessary dissections [ 24 , 25 ]. Preoperative imaging effectively guided surgical planning in all of our cases except for one with multiglandular involvement. Despite advances, 10–20% of pHPT lesions were reported to remain unlocalized preoperatively, similar to our study, leading to intraoperative techniques like gamma-probe-guided localization and io-PTH [ 15 , 24 , 26 , 27 ]. Regarding io-PTH, both the American Association of Endocrine Surgeons (AAES) and the European Society of Endocrine Surgeons (ESES) endorse io-PTH, particularly in discordant imaging cases or reoperative PTX [ 26 ]. However, its routine use remains debated due to cost and logistical challenges. While intraoperative PTH testing can be conducted rapidly using immunochemical devices installed in the operating theater, this approach is more expensive than central laboratory testing. The major drawback of central laboratory PTH testing is the delay in obtaining results, typically requiring 25–30 minutes (19). For the case with multiglandular involvement, io-PTH and frozen section biopsy were performed to guide surgical decisions. Our approach reflects this controversy, as we opted against routine io-PTH use in all cases, prioritizing its application where necessary. Gamma-probe-guided localization techniques have proven safe and effective in reoperative PTX and sHPT [ 27 , 28 ]. Aygün et al. noted no consensus regarding their routine use [ 19 ]. Consistent with this, gamma probes were not routinely employed in our cohort. 4.D Management, Complications, and Outcomes of PTX in Pediatric HPT A multidisciplinary approach is essential in managing HPT, particularly in pediatric cases where surgical experience may be limited. Collaboration with endocrinology, radiology, nuclear medicine, and pathology departments is critical, and surgeries should be performed with the involvement of an experienced endocrine surgeon [ 4 ]. Our series evaluated all cases collaboratively with pediatric endocrinology, radiology, nuclear medicine, and pathology teams. Surgeries were conducted with the participation of an experienced endocrine surgeon. Although the small sample size is a limitation of our series, the outcomes align well with those reported in the literature. Intraoperative neuromonitoring (NIM 3.0, Medtronic, Minneapolis, MN, USA) is widely used in PTX procedures to prevent nerve injury. Despite transient vocal cord paralysis in two cases in a previous study, no permanent paralysis was observed [ 24 ]. Similarly, intraoperative neuromonitoring was employed in all our surgeries, and no cases of transient or permanent laryngeal nerve injury were recorded. PTX remains the gold standard for treating pHPT. Traditionally, BNE involved a large incision to explore all parathyroid glands. However, advancements in preoperative imaging, intraoperative gamma-probe technology, and io-PTH have facilitated a shift toward MIP for single-gland disease, allowing for a more targeted approach with a smaller incision [ 24 ]. MIP is particularly effective for solitary parathyroid adenomas, though multiglandular disease or ectopic gland locations—present in approximately 12% of cases—may necessitate a broader surgical field [ 15 ]. Studies report MIP usage rates ranging from 40–78%, with io-PTH playing a critical role, especially when ectopic glands are suspected [ 4 , 10 ]. In our cohort, the predominance of single-gland disease allowed for MIP in most cases, while multiglandular involvement required BNE, consistent with literature findings. Walsh et al. identified essential factors contributing to MIP success, including high-resolution US, S-mibi/S-CT, and io-PTH monitoring. More than a 50% reduction in PTH levels at 5–30 minutes post-excision or normalization to < 65 pg/mL is considered adequate for confirming surgical success [ 29 ]. Our findings align with these criteria, as io-PTH monitoring was selectively applied in a multiglandular PTH case, aiding surgical decision-making. A systematic review comparing MIP and BNE reported similar cure rates (97% vs. 98%) but found MIP to have a superior safety profile, with lower hypocalcemia (2.3% vs. 14%) and laryngeal nerve injury rates (0.3% vs. 0.9%) (1). Another study confirmed these benefits, highlighting MIP's association with shorter operative time (64 vs. 103 minutes), reduced pain, lower analgesic requirements, and improved cosmetic outcomes [ 19 ]. A 2021 systematic review emphasized MIP's increasing adoption due to its high success rates and reduced complications, concluding that MIP offers a success rate comparable to BNE but provides additional advantages, including fewer postoperative complications, shorter hospital stays, and superior cosmetic outcomes. The review also reported that both the American Association of Endocrine Surgeons (AAES) and the European Society of Endocrine Surgeons (ESES) guidelines for io-PTH recommend its use, especially in cases where preoperative localization by US-mibi/S-CT is not compatible or re-operative parathyroidectomy (PTX) is required; the true benefit of io-PTH monitoring remains a subject of debate among endocrine surgeons [ 26 ]. However, BNE remains the gold standard for multiglandular disease, MEN-1, or cases with negative preoperative imaging (19). Our findings support this distinction, as single-gland disease cases underwent MIP, while BNE was reserved for multiglandular involvement, ensuring optimal surgical outcomes. Histopathological findings in pHPT generally confirm parathyroid adenomas, with some cases of hyperplasia. Lesion weights reported in the literature range from 130 to 2440 mg [ 6 , 15 ]. Our findings align with these reports, with all excised lesions confirmed as adenomas and an average lesion weight of 480 ± 147.5 mg. Although outpatient PTX has been deemed safe for pediatric pHPT patients [ 30 ], we opted for a more cautious approach. All patients in our study were hospitalized for an average of two days, consistent with the need for careful postoperative monitoring. Following PTX, studies report postoperative improvements in insomnia, dyspepsia, quality of life, neuropsychiatric symptoms, cardiovascular health, reduced nephrolithiasis and fracture risks, and increased bone mineral density [ 19 , 31 ]. Similarly, our patients reported complete resolution of symptoms and improved overall well-being postoperatively. For r-HPT, first-line treatment involves vitamin D and cinacalcet therapy [ 32 , 33 ]. PTX is considered in 5–25% of cases unresponsive to medical management, as uncontrolled r-HPT can cause severe osteodystrophy and vascular calcifications [ 5 , 34 , 35 ]. Indications for PTX in sHPT include severe hypercalcemia, progressive bone disease, and pruritus, while in tHPT, persistent hypercalcemia and kidney dysfunction post-transplant warrant surgical intervention [ 18 ]. A study by Seong Hoon Kim et al. outlined PTX indications in sHPT as medical therapy resistance, symptomatic disease, and persistently elevated PTH, whereas in tHPT, indications include persistent hypercalcemia, nephrolithiasis and declining kidney graft function [ 24 ]. Our findings align, as all r-HPT patients in our cohort met surgical indications, including persistently elevated PTH and clinical symptoms. Surgical options for r-HPT include PTX with autotransplantation or subtotal PTX (removal of 3.5 glands). Total PTX without autotransplantation is not recommended in children due to high morbidity risks. Seong Hoon Kim et al.'s preferred surgical approach was subtotal PTX [ 24 ]. In our r-HPT cases, four glands were identified, and subtotal PTX with 3.5 gland excision was performed. Autotransplantation was not employed in any case. Unlike the reports advocating for autotransplantation in subtotal PTX, our findings indicate that avoiding it did not result in any postoperative complications or additional surgical interventions. Elijah Kakani et al. highlighted the critical role of PTX in managing inadequately controlled r-HPT cases but noted that evidence supporting its effect on reducing mortality is derived mainly from retrospective and observational data. They cautioned that PTX carries potential risks, including persistent or recurrent HPT and hypoparathyroidism, which necessitate careful long-term monitoring. Furthermore, they raised concerns that transitioning from a high-turnover to a low-turnover bone state post-PTX may predispose patients to vascular calcifications, complicating calcium homeostasis in CRF patients with mineral bone disease [ 36 ]. Our results support the efficacy of subtotal PTX in reducing PTH levels without leading to overt hypoparathyroidism, reinforcing the importance of preserving well-vascularized parathyroid tissue to mitigate post-PTX complications. None of our patients experienced new bone fractures, and significant clinical improvements in leg pain and mobility were observed. No significant complications occurred in our pHPT cohort. Long-term follow-up showed biochemical normalization and symptom improvement. On the other hand, one patient with tHPT developed postoperative HBS, a known complication due to high post-PTX osteoblastic activity. This condition was successfully managed with appropriate medical interventions, and the patient recovered without complications. Our results support prior findings that elevated PTH levels are a risk factor for HBS, emphasizing the importance of preoperative optimization. Curtis Hanba et al. reported that male patients, younger children, and those with pre-existing kidney disease had more prolonged and complex postoperative courses, including mental status changes, infections, and respiratory complications [ 37 ]. In contrast, all of our r-HPT patients were female, yet they still experienced extended hospital stays (11 ± 2.7 days), primarily due to the need for fluid and electrolyte management during dialysis rather than postoperative complications. A large-scale study comparing PTX outcomes in pHPT and r-HPT patients found no significant age differences between the two groups, although female predominance was noted in pHPT. It reported that r-HPT patients had longer operative times, higher estimated blood loss, and extended hospital stays compared to pHPT cases. The study also found that in pHPT, lesions were most frequently located in the right lower and left lower glands, whereas in r-HPT, the preserved gland was typically in the left upper position. Preoperative PTH levels were significantly higher in r-HPT patients (1242.1 ± 1075 pg/mL) than in pHPT patients (161.6 ± 95.4 pg/mL). Postoperative PTH levels at 6 and 12 months were comparable between both groups. Preoperative calcium levels were higher in pHPT cases (10.9 ± 0.9 mg/dL vs. 9.6 ± 1.7 mg/dL), while postoperative calcium levels normalized immediately in pHPT patients but took longer in r-HPT patients, with hypocalcemia persisting for up to six months postoperatively [ 24 ]. Consistent with these findings, our study also observed significantly higher preoperative PTH levels in r-HPT patients compared to pHPT patients. However, unlike the reported delayed calcium normalization in r-HPT cases, our cohort maintained stable postoperative calcium levels within normal ranges at the 6- and 12-month follow-ups. 5. Conclusions Pediatric HPT poses notable diagnostic and therapeutic complexities, compounded by its rarity and the broad spectrum of clinical presentations. In this series, pHPT manifested equally in males and females—diverging from the predominantly female trend reported elsewhere—while r-HPT affected only females. Despite these differences, all children in both groups presented with significant biochemical derangements, including markedly elevated PTH levels, underscoring the urgency of early recognition and intervention. Surgical management tailored to disease type and gland involvement proved highly effective: MIP was optimal for single-gland pHPT, while BNE with subtotal parathyroidectomy was preferred for multiglandular disease and r-HPT. Meticulous preoperative imaging—particularly ultrasound, which localized all lesions—minimized the need for additional imaging methods in straightforward single-gland pHPT. Complications were minimal, with only one postoperative HBS in an r-HPT patient successfully managed medically. No recurrences were observed during long-term follow-up, signaling robust and durable outcomes. These findings reinforce the efficacy of targeted surgical approaches and highlight the pivotal roles of multidisciplinary collaboration and vigilant postoperative monitoring. Refining diagnostic algorithms, optimizing intraoperative techniques, and honing perioperative care will be essential to improve further outcomes and quality of life for pediatric HPT patients. Abbreviations BNE Bilateral neck exploration CRF Chronic renal failure HBS Hungry bone syndrome HPT Hyperparathyroidism Io-PTH Intraoperative parathyroid hormone monitoring MIP Minimally invasive parathyroidectomy pHPT Primary hyperparathyroidism PTH Parathyroid hormone PTX Parathyroidectomy r-HPT Renal hyperparathyroidism S-CT Single-photon emission computed tomography sHPT Secondary hyperparathyroidism S-mibi Tc 99 sestamibi scintigraphy tHPT Tertiary hyperparathyroidism US Ultrasonography W/FNA Washout/Fine needle aspiration biopsy Declarations Conflicts of interest/Competing interests : The authors have no conflicts of interest to declare that are relevant to the content of this article. Funding: No funding was received to assist with the preparation of this manuscript. Ethics approval: The study was approved by Health Sciences University, Kanuni Sultan Suleyman Training and Education Hospital Ethics Committee (#2023.10.145) Consent to participate: Informed consent was obtained from all individual participants and parents included in the study. Data availability: The data that support the findings of this study are available from the corresponding author, upon reasonable request. Author's Contributions: Study conception and design: SO,SS,EHAK,ZKS,SY; data collection: EHAK,ZKS,SY,HYB,BEA; analysis and interpretation of results: SO,SS,SY,HYB,HK,BEA; draft manuscript preparation: SO,SS,HK; All authors reviewed the results and approved the final version of the article. Acknowledgements: We would like to present our thanks to our mentors Dr. Mehmet Halil Serdar Sander, Dr Oyhan Demirali ve Dr Cemile Besik for his invaluable contribution to the follow-up and surgeries of the patients. 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Med Bull Sisli Hosp 53:201–214 Soyer T, Karnak I, Tuncel M, Ekinci S, Andiran F, Ciftci AO, Akcoren Z, Orhan D, Alikasifoglu A, Ozon A, Tanyel FC (2016) Results of intraoperative gamma probe survey and frozen section in surgical treatment of parathyroid adenoma in children. J Pediatr Surg 51:1492–1495 He Y, Luo Y, Jin S, Wang O, Liao Q, Zhu Q, Liu H (2023) Can we skip technetium-99 m sestamibi scintigraphy in pediatric primary hyperparathyroidism patients with positive neck ultrasound results? Pediatr Radiol 53:2253–2259 Unlu MT, Kostek M, Caliskan O, Sekban TA, Aygun N, Uludag M (2023) The Relationship of Negative Imaging Result and Surgical Success Rate in Primary Hyperparathyroidism. Sisli Etfal Hastan Tip Bul 57:111–117 Li CC, Yang C, Wang S, Zhang J, Kong XR, Ouyang J (2012) A 10-year retrospective study of primary hyperparathyroidism in children. Exp Clin Endocrinol Diabetes 120:229–233 Kim SH, Lee SY, Min EA, Hwang YM, Choi YS, Yi JW (2022) Single-Center Experience of Parathyroidectomy Using Intraoperative Parathyroid Hormone Monitoring. Med (Kaunas). ;58 Oliva AR, Lobos PA, Moldes JM, Liberto DH (2021) Usefulness of combined ultrasonography and scintigraphy in the preoperative assessment of secondary or tertiary hyperparathyroidism. Cir Pediatr 34:63–66 Medas F, Cappellacci F, Canu GL, Noordzij JP, Erdas E, Calo PG (2021) The role of Rapid Intraoperative Parathyroid Hormone (ioPTH) assay in determining outcome of parathyroidectomy in primary hyperparathyroidism: A systematic review and meta-analysis. Int J Surg 92:106042 Caglar O, Otgun I, Yalcin Comert H, Gencoglu A, Baskin E (2020) Effectiveness of the Gamma Probe in Childhood Parathyroidectomy: Retrospective Study. Cureus 12:e6629 Sari S, Erbil Y, Ersoz F, Olmez A, Salmaslioglu A, Adalet I, Colak N, Ozarmagan S (2011) Radio-guided excision of parathyroid lesions in patients who had previous neck surgeries: a safe and easy technique for re-operative parathyroid surgery. Int J Surg 9:339–342 Walsh NJ, Sullivan BT, Duke WS, Terris DJ (2019) Routine bilateral neck exploration and four-gland dissection remains unnecessary in modern parathyroid surgery. Laryngoscope Investig Otolaryngol 4:188–192 Ramonell KM, Fazendin J, Lovell K, Iyer P, Chen H, Lindeman B, Dream S (2022) Outpatient parathyroidectomy in the pediatric population: An 18-year experience. J Pediatr Surg 57:410–413 Morimoto H, Nakajima H, Mori J, Fukuhara S, Shigehara K, Adachi S, Hosoi H (2018) Decrement in bone mineral density after parathyroidectomy in a pediatric patient with primary hyperparathyroidism. Clin Pediatr Endocrinol 27:81–86 Yuan Q, Liao Y, Zhou R, Liu J, Tang J, Wu G (2019) Subtotal parathyroidectomy versus total parathyroidectomy with autotransplantation for secondary hyperparathyroidism: an updated systematic review and meta-analysis. Langenbecks Arch Surg 404:669–679 Choi HR, Aboueisha MA, Attia AS, Omar M, Toraih AEL, Shama EA, Chung M, Jeong WY, Kandil JJ (2021) Outcomes of Subtotal Parathyroidectomy Versus Total Parathyroidectomy With Autotransplantation for Tertiary Hyperparathyroidism: Multi-institutional Study. Ann Surg 274:674–679 Higgins RM, Richardson AJ, Ratcliffe PJ, Woods CG, Oliver DO, Morris PJ (1991) Total parathyroidectomy alone or with autograft for renal hyperparathyroidism? Q J Med 79:323–332 Glassford DM, Remmers AR Jr., Sarles HE, Lindley JD, Scurry MT, Fish JC (1976) Hyperparathyroidism in the maintenance dialysis patient. Surg Gynecol Obstet 142:328–332 Kakani E, Sloan D, Sawaya BP, El-Husseini A, Malluche HH, Rao M (2019) Long-term outcomes and management considerations after parathyroidectomy in the dialysis patient. Semin Dial 32:541–552 Hanba C, Bobian M, Svider PF, Sheyn A, Siegel B, Lin HS, Raza SN (2016) Perioperative considerations and complications in pediatric parathyroidectomy. Int J Pediatr Otorhinolaryngol 91:94–99 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6489091","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":445330168,"identity":"724b20f8-ffd5-422b-a8cc-9d0941d1e598","order_by":0,"name":"Seyithan 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10:43:59","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1290223,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure21.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6489091/v1/0ad82deafa26bf2f718293e2.jpg"},{"id":81198006,"identity":"e87deab9-34d6-4431-bc68-4d5135195c14","added_by":"auto","created_at":"2025-04-23 10:43:59","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":305154,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure31.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6489091/v1/ff98a265399bc0d38f4ce1bf.jpg"},{"id":84298202,"identity":"76428d8c-985c-4f2e-9540-d5c54d84f974","added_by":"auto","created_at":"2025-06-10 09:54:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4171740,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6489091/v1/025707fa-855f-47a0-a842-9c7f174713f2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Parathyroidectomy in the Treatment of Childhood Hyperparathyroidism: A Single-Institution Experience","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eHyperparathyroidism (HPT) is characterized by the excessive secretion of parathyroid hormone (PTH) and is classified as a cause-and-effect disorder of calcium (Ca), phosphorus (P), and vitamin D metabolism. Based on its underlying mechanism, HPT is classified into three types: primary hyperparathyroidism (pHPT), secondary hyperparathyroidism (sHPT), and tertiary hyperparathyroidism (tHPT). pHPT is mainly caused by single and rarely by multiple parathyroid adenomas [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The sHPT results from excessive PTH secretion due to abnormal vitamin D and calcium metabolism, primarily caused by CRF but also by gastrointestinal malabsorption, liver disease, and pseudohypoparathyroidism. Persistent stimulation of the parathyroid glands in dialysis-dependent CRF patients can lead to hyperplasia and, eventually, adenoma formation, termed tHPT [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe imbalance in PTH, Ca, P, and vitamin D causes significant complications affecting various systems, including the skeletal, renal, gastrointestinal, neuropsychiatric, soft tissue, and cardiovascular systems. The primary treatment for pHPT involves the surgical excision of the pathological parathyroid gland through parathyroidectomy (PTX) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In contrast, sHPT and tHPT are typically managed through medical interventions, with surgery being reserved for cases that fail to respond adequately to medical therapy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aims to evaluate and present the clinical outcomes of patients who underwent PTX for pHPT, sHPT, and tHPT in our clinic, contextualized within findings from the current literature.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThe medical records of patients who underwent PTX for HPT between 2016 and 2024 were retrospectively reviewed following ethical approval (Approval No: 2023.10.145) granted by the XXX Ethics Committee. Data collected included demographic and clinical characteristics, preoperative localization studies, laboratory findings, surgical notes, postoperative follow-up data, and pathology reports.\u003c/p\u003e \u003cp\u003eIn addition to cases of isolated single or multiple parathyroid adenomas (pHPT), cases of sHPT and tHPT occurring due to chronic renal failure (CRF) were evaluated under the title of renal hyperparathyroidism (r-HPT). For cases of pHPT involving a single gland, minimally invasive parathyroidectomy (MIP) was performed, while subtotal PTX with bilateral neck exploration (BNE) was employed for cases of pHPT involving multiple glands and all r-HPT cases. This approach involved the excision of three and a half pathological glands. A comprehensive data set, inclusive of preoperative and postoperative Ca, P, and PTH values, preoperative ultrasonography (US), Tc 99 sestamibi scintigraphy/single-photon emission computed tomography (S-mibi/S-CT) reports, washout/fine needle aspiration biopsy (W/FNA) results, preoperative preparations, potential intraoperative additional interventions, complications, and postoperative follow-up were meticulously documented. A thorough review of the pathology reports was also conducted. The results were then analyzed in conjunction with postoperative follow-up examinations at 6 and 12 months.\u003c/p\u003e\n\u003ch3\u003e2A. Statistical analysis\u003c/h3\u003e\n\u003cp\u003eGiven the limited sample size, statistical comparisons were not performed. Instead, descriptive statistics were used to summarize data, with continuous variables presented as means, standard deviations, medians, minimums, and maximums. Categorical data were expressed as frequencies and percentages. Analyses were conducted using MedCalc\u0026reg; Statistical Software version 22.009 (MedCalc Software Ltd, Ostend, Belgium; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.medcalc.org\u003c/span\u003e\u003cspan address=\"https://www.medcalc.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e; 2023).\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe study included ten patients, of whom six (60%) were diagnosed with pHPT, one (10%) with sHPT, and three (30%) with tHPT; the latter four cases (40%) were categorized as r-HPT. The mean age of patients with pHPT was 15 years, while the mean age for r-HPT cases was 13 years. Among the pHPT patients, half were female, whereas all r-HPT cases involved female patients. Patients with pHPT most commonly presented with gastrointestinal, neuropsychiatric, and musculoskeletal complaints, whereas r-HPT cases primarily exhibited symptoms associated with renal osteodystrophy, including issues related to the urinary and musculoskeletal systems.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the details of demographic data, clinical features, and diagnostic and therapeutic management of the ten cases in our pediatric HPT/PTX series. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the demographics and the system-related symptoms of the pHPT and r-HPT groups. In the pHPT group, no significant findings were noted in all six patients' medical histories. However, in the r-HPT group, one patient had bilateral dysplastic multicystic kidneys, whereas another had a history of apert hydrocephalus, ventriculoperitoneal shunt placement, meningomyelocele repair, spina bifida, and associated neurogenic bladder, and bilateral vesicoureteral reflux. The causes in the remaining two r-HPT cases with CRF were unknown.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCase Details\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHPT Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epHPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003epHPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003epHPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003epHPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003epHPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003epHPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003esHPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003etHPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003etHPT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003etHPT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSymptom Duration (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedical History\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBilateral multicystic CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHydrocephalus surgery, VP shunt, meningomyelocele, bilateral VUR, CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCKD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily History\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFather: kidney stones\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBrother: growth hormone deficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSibling: CKD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGenetic/Molecular Abnormality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative Ca (mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative P (mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative PTH (pg/mL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e821\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2427\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUltrasound (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight 12\u0026times;7\u0026times;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft 10\u0026times;8\u0026times;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight lower 15\u0026times;12\u0026times;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLeft lower 6\u0026times;6\u0026times;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLeft lower 6.7\u0026times;4.6\u0026times;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRight lower 9\u0026times;6\u0026times;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4 glands: Right 30\u0026times;6\u0026times;1, right lower 6\u0026times;3\u0026times;2, left lower 7\u0026times;4\u0026times;3 and 7\u0026times;5\u0026times;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRight lower 11\u0026times;6.5\u0026times;5, left lower 7.5\u0026times;4\u0026times;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRight lower 20\u0026times;10\u0026times;10, left lower 13\u0026times;5\u0026times;5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSestamibi/SPECT-CT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft lower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight lower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRight lower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLeft lower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNot detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRight lower, left upper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRight lower, left lower\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWashout (pg/mL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNo data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGland Involvement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle gland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSingle gland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTwo glands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSingle gland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSingle gland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSingle gland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4 glands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4 glands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4 glands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4 glands\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgical Technique\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMIP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMIP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBNE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMIP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMIP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMIP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBNE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBNE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eBNE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eBNE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdditional Surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePartial thymectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePartial thymectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRight partial, left subtotal thymectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRight thyroidectomy-left partial thymectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRight partial thymectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntraoperative PTH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFrozen Biopsy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNerve Monitoring\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDrain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePathology Result\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHyperplasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHypercellular adenomatous nodule\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eHypercellular adenomatous nodule\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eHypercellular adenomatous nodule\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecimen Weight (mg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e660\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e580\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e620 and 320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e340\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e330\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e510\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e420 (largest)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e380 (largest)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e390 (largest)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2230 (largest)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecimen Size (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u0026times;11\u0026times;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u0026times;10\u0026times;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u0026times;10\u0026times;5; 8\u0026times;7\u0026times;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u0026times;8\u0026times;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u0026times;7\u0026times;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10\u0026times;8\u0026times;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLargest: 25\u0026times;10\u0026times;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLargest: 17\u0026times;7\u0026times;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eLargest: 16\u0026times;7\u0026times;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eLargest: 20\u0026times;10\u0026times;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTransient hyperthyroidism (Povidone-iodine suspected)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eHungry bone syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEarly Postop Ca (mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEarly Postop P (mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEarly Postop PTH (pg/mL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital Stay (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6-Month Postop Ca (mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6-Month Postop P (mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6-Month Postop PTH (pg/mL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e12-Month Postop Ca (mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e9.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e12-Month Postop P (mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e12-Month Postop PTH (pg/mL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFollow-up (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics and Presenting Symptoms\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003epHPT (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003er-HPT (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years) (\u003c/b\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSymptom Duration (months)\u003c/b\u003e (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96\u0026thinsp;\u0026plusmn;\u0026thinsp;46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSystem-related Symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeuropsychiatric\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDizziness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrritability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForgetfulness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeizures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGastrointestinal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNausea/Vomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastroenteritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight gain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMusculoskeletal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeg pain/Burning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCramping/Spasms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWalking difficulty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone deformities (X-bone)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFractures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUrinary\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNephrolithiasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic kidney failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding family history, one pHPT patient had a father with urinary stone disease, and another had a sibling with growth hormone deficiency. In the r-HPT group, only one patient had a sibling with CRF. Genetic screening revealed no molecular or genetic abnormalities in any of the patients.\u003c/p\u003e \u003cp\u003eThe mean duration of symptoms was significantly longer in r-HPT cases (96 months) compared to pHPT cases (10.8 months). Preoperative laboratory findings revealed that, in the pHPT patients, the mean Ca, P, and PTH levels were 12.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1 mg/dL, 2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4 mg/dL, and 259.5\u0026thinsp;\u0026plusmn;\u0026thinsp;276.7 pg/mL, respectively. For r-HPT patients, these levels were 9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9 mg/dL, 6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 mg/dL, and 3861.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1336.7 pg/mL, respectively.\u003c/p\u003e \u003cp\u003eRegarding imaging studies, the preoperative US identified parathyroid adenomas in all pHPT cases, while hyperplastic/adenomatous findings were observed in all r-HPT cases except for one. W/FNAB was performed in all pHPT cases, confirming PTH levels exceeding 5000 pg/mL. Preoperative S-mibi/S-CT revealed no uptake in two pHPT cases (33.3%) and one r-HPT case (25%).\u003c/p\u003e \u003cp\u003eSurgical approaches varied based on the clinical presentation. MIP was performed in five pHPT cases with single-gland involvement, while BNE was conducted in one pHPT case with multi-gland involvement and in all four r-HPT cases. An intubation tube-compatible neuromonitor (Dr Langer Avalanche, serial number: 789.09.2015, Germany) was used in all cases. During surgery, intraoperative PTH monitoring (io-PTH) was performed in only one pHPT case because of two-gland involvement. Moreover, a frozen section biopsy was conducted in one pHPT and one r-HPT case to confirm tissue pathology. Parathyroid adenoma was excised in all cases of pHPT, while partial thymectomy was additionally performed in two cases of lower lobe origin. All r-HPT cases underwent four-gland exploration and three-and-a-half-gland excision. Moreover, one underwent unilateral thyroidectomy, and three also underwent unilateral (partial/subtotal) thymectomy.\u003c/p\u003e \u003cp\u003eThe lower lobe was preferred for the half gland left as it is generally safer for the laryngeal nerve in a possible second exploration. However, in two cases in which the lower lobe glands were markedly hyperplasic, the upper lobe, which had a somewhat more normal appearance, was chosen. After excision, the remaining gland was marked with a metal clip. The three cases of pHPT originated in the left lower lobe, whereas one originated from the right lower lobe, one from the right upper lobe, and one from the right lower and upper lobes.\u003c/p\u003e \u003cp\u003eIn all but two cases of pHPT, a minivac drain was placed in the lounge and subsequently withdrawn on postoperative day 1 on average. No intraoperative complications or postoperative complications, such as bleeding, nerve injury, hematoma, or infection, were encountered. Postoperatively, one tHPT case developed hungry bone syndrome (HBS), which was successfully treated with medical intervention. Another tHPT case experienced transient hyperthyroidism, likely associated with the use of povidone-iodine antiseptic; this condition was resolved with appropriate medical management.\u003c/p\u003e \u003cp\u003eIn the early postoperative period, the mean Ca value was 8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2 mg/dL, the mean P value was 2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4 mg/dL, and the mean PTH value was 36.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12 in pHPT cases. Conversely, in r-HPT cases, the mean Ca value was 8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 mg/dL, the mean P value was 4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 mg/dL, and the PTH value was 57\u0026thinsp;\u0026plusmn;\u0026thinsp;44.9 pg/mL.\u003c/p\u003e \u003cp\u003eA subsequent examination of the pathology reports revealed that the lesions were evaluated as parathyroid adenoma in all cases of pHPT (n\u0026thinsp;=\u0026thinsp;6) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In r-HPT cases, all glands removed were evaluated as hyperplasia, particularly in sPHT cases (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In three cases of tHPT, all glands were evaluated as hypercellular adenomatous nodules. The weight of the pathology specimen in pHPT cases was found to be mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD: 480\u0026thinsp;\u0026plusmn;\u0026thinsp;147.5 mg (n\u0026thinsp;=\u0026thinsp;7), while in r-HPT cases, it was mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD: 453.1\u0026thinsp;\u0026plusmn;\u0026thinsp;549.4 mg (n\u0026thinsp;=\u0026thinsp;16). The volume (mm3) in pHPT cases was mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD: 417.5\u0026thinsp;+\u0026thinsp;234.9 (n\u0026thinsp;=\u0026thinsp;8); in r-HPT cases, whereas it was mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD: 512.1\u0026thinsp;+\u0026thinsp;464.3 (n\u0026thinsp;=\u0026thinsp;16).\u003c/p\u003e \u003cp\u003eThe average hospital stay was 2\u0026thinsp;\u0026plusmn;\u0026thinsp;0 days for pHPT patients and 11\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 days for r-HPT patients. The mean follow-up period after PTX was 50\u0026thinsp;\u0026plusmn;\u0026thinsp;32.6 months in pHPT cases and 22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3 months in r-HPT cases. Regarding all cases, no problem requiring reoperation was encountered. At the sixth postoperative month, the mean Ca value in pHPT cases was 9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 mg/dL, the mean P value was 3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 mg/dL, and the mean PTH value was 49.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8. 7 pg/mL, while the mean values of r-HPT cases were 8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 mg/dL for Ca, 4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 mg/dL for P, and 38\u0026thinsp;\u0026plusmn;\u0026thinsp;28.9 pg/mL for PTH. At the 12th postoperative month, the mean Ca value of pHPT cases was 8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2 mg/dL, the P value was 3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2 mg/dL, and the PTH value was 44.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5 pg/mL, while in r-HPT cases, the mean values of Ca was 9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9 mg/dL, P 4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 mg/dL, and PTH 30.5\u0026thinsp;\u0026plusmn;\u0026thinsp;23.8 pg/mL (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory Features\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003epHPT (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003er-HPT (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eCalcium (Ca, mg/dL)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative (Early)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative (6 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative (12 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhosphorus (P, mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative (Early)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative (6 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative (12 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePTH (pg/mL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e259.5\u0026thinsp;\u0026plusmn;\u0026thinsp;276.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3861.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1336.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative (Early)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57\u0026thinsp;\u0026plusmn;\u0026thinsp;44.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative (6 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u0026thinsp;\u0026plusmn;\u0026thinsp;28.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative (12 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.5\u0026thinsp;\u0026plusmn;\u0026thinsp;23.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecimen Weight (mg), n\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e480\u0026thinsp;\u0026plusmn;\u0026thinsp;147.5, 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e453.1\u0026thinsp;\u0026plusmn;\u0026thinsp;549.4, 16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecimen Volume (mm\u0026sup3;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e417.5\u0026thinsp;\u0026plusmn;\u0026thinsp;234.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e512.1\u0026thinsp;\u0026plusmn;\u0026thinsp;464.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital Stay (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFollow-up Period (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026thinsp;\u0026plusmn;\u0026thinsp;32.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe preoperative and postoperative trends of Ca, P, and PTH levels are displayed in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. At the final follow-up visits, all patients reported that they had no longer experienced any complaints as those in the preoperative period and reported a significant improvement in their overall well-being. Furthermore, no new bone fracture findings were observed, particularly in r-HPT cases.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study evaluated ten pediatric HPT patients, including six with pHPT and four with r-HPT. The mean age at diagnosis was 15 years for pHPT and 13 years for r-HPT. pHPT had an equal gender distribution, while all r-HPT cases were female. pHPT patients commonly presented with gastrointestinal, neuropsychiatric, and musculoskeletal symptoms, whereas r-HPT patients exhibited renal osteodystrophy. The diagnosis time was shorter for pHPT (10.8 months) than for r-HPT (96 months). Biochemical findings showed higher PTH and P levels in r-HPT. The US successfully localized all lesions, but S-mibi/S-CT had limited uptake in some cases. Surgical management included MIP for most pHPT cases and BNE for multiglandular pHPT and all r-HPT cases. No significant complications occurred except for one case of postoperative HBS. Long-term follow-up showed biochemical normalization and symptom improvement.\u003c/p\u003e\n\u003ch3\u003e4A. Demographics, Etiology, Clinical Presentation and Diagnosis\u003c/h3\u003e\n\u003cp\u003epHPT is rare in pediatric populations, with an incidence of 0.5\u0026ndash;5 per 100,000, compared to 20\u0026ndash;100 per 100,000 in adults [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Most reports indicate a female predominance, likely due to hormonal factors influencing parathyroid growth and function [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, this study identified an equal male-to-female ratio, differing from such reports. This variation may be due to a small sample size, regional genetic factors, or differences in healthcare-seeking behavior among male and female pediatric patients.\u003c/p\u003e \u003cp\u003eThe etiology of pHPT has been extensively discussed in the literature. It has been reported that 68\u0026ndash;81.5% of cases are sporadic, while 8.5\u0026ndash;12.8% are familial, and 5.8\u0026ndash;11.5% are associated with genetic or molecular abnormalities. These abnormalities are often linked to syndromes such as Multiple Endocrine Neoplasia (MEN-1, MEN-2A, MEN-4) or mutations in genes such as CASR, CDKN1A, CDKN1B, CDKN2C, and RET [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Consistent with prior studies emphasizing the sporadic nature of pediatric pHPT, this study found no familial or syndromic cases, and genetic screening did not reveal any molecular abnormalities. This further underscores that genetic testing remains valuable in pediatric pHPT workups, but its diagnostic yield may be low in sporadic cases.\u003c/p\u003e \u003cp\u003eThe literature indicates that about 80% of pHPT cases arise from single-gland involvement [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Multiglandular involvement is more commonly associated with syndromic or familial cases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In our cohort, 83.3% of cases involved a single gland, while 16.7% exhibited multiglandular involvement, similar to the literature.\u003c/p\u003e \u003cp\u003eClinical presentation in pHPT is primarily symptomatic, with 64\u0026ndash;96% of cases showing significant clinical findings. These symptoms commonly involve the musculoskeletal, gastrointestinal, neuropsychiatric, and urinary systems. Patients often present with muscle cramps, difficulty walking, bone deformities, bone fractures, nausea, vomiting, abdominal pain, gastroenteritis, headaches, fatigue, depression, or nephrolithiasis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In agreement with previous findings, all pHPT cases in this study were symptomatic, with musculoskeletal, neuropsychiatric, and gastrointestinal complaints being the most frequent. Notably, nephrolithiasis and nephrocalcinosis, reported in about 40% of pediatric cases, were absent in this cohort, possibly due to earlier diagnosis or genetic predisposition differences [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding r-HPT, CRF prevalence in adults is estimated at 40\u0026ndash;70 per million, but it is much rarer in children (0.5\u0026ndash;5 per million). Nevertheless, a significant proportion of pediatric CRF patients develop r-HPT (sHPT or tHPT), which, if untreated, can cause severe bone deformities and growth retardation [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Our study confirms this trend, with pediatric r-HPT patients presenting with bone deformities and leg pain as major clinical concerns.\u003c/p\u003e\n\u003ch3\u003e4C. Preoperative Imaging and Intraoperative Localization/Monitoring\u003c/h3\u003e\n\u003cp\u003eAccurate localization of parathyroid adenomas is critical for surgical planning in cases with pHPT. Preoperative imaging using a combination of US and S-mibi/S-CT has been reported to have a sensitivity of 82\u0026ndash;91.4% in localizing parathyroid lesions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The sensitivity is exceptionally high in cases of single-gland involvement, where detection rates range from 89\u0026ndash;94%, but it decreases in cases involving multiple glands or tiny lesions [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In one study, the US alone achieved 100% positive localization in their cohort. However, concordance with S-mibi was observed in only 93.8% of cases, and the authors concluded that S-mibi mainly improves specificity in suspected multiglandular disease and should be carefully evaluated in pediatric cases to minimize radiation exposure [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Multiglandular involvement in pHPT is reported in 7\u0026ndash;33% of cases, varying rates depending on imaging methods. Multiglandular disease rates were 5.7%, 11%, and 21% for positive findings on both, one, or neither imaging modality, respectively [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Careful attention is needed when operating on small or multiple affected glands. Surgical outcomes were comparable, even in imaging-negative cases. The US successfully localized all parathyroid lesions in this study, reinforcing its reliability. At the same time, S-mibi/S-CT failed to detect uptake in 33.3% of pHPT cases, supporting prior reports that the necessity of S-mibi/S-CT in single-gland involvement remains debatable. Li et al. reported that, despite advancements in diagnostic tools, the average time to diagnose pHPT cases remains 41 months [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In contrast, our cohort's mean duration from symptom onset to diagnosis was 10.8 months. Preoperative imaging is also essential in r-PHT to identify ectopic glands and minimize unnecessary dissections [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePreoperative imaging effectively guided surgical planning in all of our cases except for one with multiglandular involvement. Despite advances, 10\u0026ndash;20% of pHPT lesions were reported to remain unlocalized preoperatively, similar to our study, leading to intraoperative techniques like gamma-probe-guided localization and io-PTH [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Regarding io-PTH, both the American Association of Endocrine Surgeons (AAES) and the European Society of Endocrine Surgeons (ESES) endorse io-PTH, particularly in discordant imaging cases or reoperative PTX [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, its routine use remains debated due to cost and logistical challenges. While intraoperative PTH testing can be conducted rapidly using immunochemical devices installed in the operating theater, this approach is more expensive than central laboratory testing. The major drawback of central laboratory PTH testing is the delay in obtaining results, typically requiring 25\u0026ndash;30 minutes (19). For the case with multiglandular involvement, io-PTH and frozen section biopsy were performed to guide surgical decisions. Our approach reflects this controversy, as we opted against routine io-PTH use in all cases, prioritizing its application where necessary. Gamma-probe-guided localization techniques have proven safe and effective in reoperative PTX and sHPT [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Ayg\u0026uuml;n et al. noted no consensus regarding their routine use [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Consistent with this, gamma probes were not routinely employed in our cohort.\u003c/p\u003e\n\u003ch3\u003e4.D Management, Complications, and Outcomes of PTX in Pediatric HPT\u003c/h3\u003e\n\u003cp\u003eA multidisciplinary approach is essential in managing HPT, particularly in pediatric cases where surgical experience may be limited. Collaboration with endocrinology, radiology, nuclear medicine, and pathology departments is critical, and surgeries should be performed with the involvement of an experienced endocrine surgeon [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Our series evaluated all cases collaboratively with pediatric endocrinology, radiology, nuclear medicine, and pathology teams. Surgeries were conducted with the participation of an experienced endocrine surgeon. Although the small sample size is a limitation of our series, the outcomes align well with those reported in the literature.\u003c/p\u003e \u003cp\u003eIntraoperative neuromonitoring (NIM 3.0, Medtronic, Minneapolis, MN, USA) is widely used in PTX procedures to prevent nerve injury. Despite transient vocal cord paralysis in two cases in a previous study, no permanent paralysis was observed [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Similarly, intraoperative neuromonitoring was employed in all our surgeries, and no cases of transient or permanent laryngeal nerve injury were recorded.\u003c/p\u003e \u003cp\u003ePTX remains the gold standard for treating pHPT. Traditionally, BNE involved a large incision to explore all parathyroid glands. However, advancements in preoperative imaging, intraoperative gamma-probe technology, and io-PTH have facilitated a shift toward MIP for single-gland disease, allowing for a more targeted approach with a smaller incision [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. MIP is particularly effective for solitary parathyroid adenomas, though multiglandular disease or ectopic gland locations\u0026mdash;present in approximately 12% of cases\u0026mdash;may necessitate a broader surgical field [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Studies report MIP usage rates ranging from 40\u0026ndash;78%, with io-PTH playing a critical role, especially when ectopic glands are suspected [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In our cohort, the predominance of single-gland disease allowed for MIP in most cases, while multiglandular involvement required BNE, consistent with literature findings. Walsh et al. identified essential factors contributing to MIP success, including high-resolution US, S-mibi/S-CT, and io-PTH monitoring. More than a 50% reduction in PTH levels at 5\u0026ndash;30 minutes post-excision or normalization to \u0026lt;\u0026thinsp;65 pg/mL is considered adequate for confirming surgical success [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Our findings align with these criteria, as io-PTH monitoring was selectively applied in a multiglandular PTH case, aiding surgical decision-making.\u003c/p\u003e \u003cp\u003eA systematic review comparing MIP and BNE reported similar cure rates (97% vs. 98%) but found MIP to have a superior safety profile, with lower hypocalcemia (2.3% vs. 14%) and laryngeal nerve injury rates (0.3% vs. 0.9%) (1). Another study confirmed these benefits, highlighting MIP's association with shorter operative time (64 vs. 103 minutes), reduced pain, lower analgesic requirements, and improved cosmetic outcomes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A 2021 systematic review emphasized MIP's increasing adoption due to its high success rates and reduced complications, concluding that MIP offers a success rate comparable to BNE but provides additional advantages, including fewer postoperative complications, shorter hospital stays, and superior cosmetic outcomes. The review also reported that both the American Association of Endocrine Surgeons (AAES) and the European Society of Endocrine Surgeons (ESES) guidelines for io-PTH recommend its use, especially in cases where preoperative localization by US-mibi/S-CT is not compatible or re-operative parathyroidectomy (PTX) is required; the true benefit of io-PTH monitoring remains a subject of debate among endocrine surgeons [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, BNE remains the gold standard for multiglandular disease, MEN-1, or cases with negative preoperative imaging (19). Our findings support this distinction, as single-gland disease cases underwent MIP, while BNE was reserved for multiglandular involvement, ensuring optimal surgical outcomes.\u003c/p\u003e \u003cp\u003eHistopathological findings in pHPT generally confirm parathyroid adenomas, with some cases of hyperplasia. Lesion weights reported in the literature range from 130 to 2440 mg [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Our findings align with these reports, with all excised lesions confirmed as adenomas and an average lesion weight of 480\u0026thinsp;\u0026plusmn;\u0026thinsp;147.5 mg.\u003c/p\u003e \u003cp\u003eAlthough outpatient PTX has been deemed safe for pediatric pHPT patients [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], we opted for a more cautious approach. All patients in our study were hospitalized for an average of two days, consistent with the need for careful postoperative monitoring. Following PTX, studies report postoperative improvements in insomnia, dyspepsia, quality of life, neuropsychiatric symptoms, cardiovascular health, reduced nephrolithiasis and fracture risks, and increased bone mineral density [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Similarly, our patients reported complete resolution of symptoms and improved overall well-being postoperatively.\u003c/p\u003e \u003cp\u003eFor r-HPT, first-line treatment involves vitamin D and cinacalcet therapy [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. PTX is considered in 5\u0026ndash;25% of cases unresponsive to medical management, as uncontrolled r-HPT can cause severe osteodystrophy and vascular calcifications [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Indications for PTX in sHPT include severe hypercalcemia, progressive bone disease, and pruritus, while in tHPT, persistent hypercalcemia and kidney dysfunction post-transplant warrant surgical intervention [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. A study by Seong Hoon Kim et al. outlined PTX indications in sHPT as medical therapy resistance, symptomatic disease, and persistently elevated PTH, whereas in tHPT, indications include persistent hypercalcemia, nephrolithiasis and declining kidney graft function [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our findings align, as all r-HPT patients in our cohort met surgical indications, including persistently elevated PTH and clinical symptoms.\u003c/p\u003e \u003cp\u003eSurgical options for r-HPT include PTX with autotransplantation or subtotal PTX (removal of 3.5 glands). Total PTX without autotransplantation is not recommended in children due to high morbidity risks. Seong Hoon Kim et al.'s preferred surgical approach was subtotal PTX [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In our r-HPT cases, four glands were identified, and subtotal PTX with 3.5 gland excision was performed. Autotransplantation was not employed in any case. Unlike the reports advocating for autotransplantation in subtotal PTX, our findings indicate that avoiding it did not result in any postoperative complications or additional surgical interventions. Elijah Kakani et al. highlighted the critical role of PTX in managing inadequately controlled r-HPT cases but noted that evidence supporting its effect on reducing mortality is derived mainly from retrospective and observational data. They cautioned that PTX carries potential risks, including persistent or recurrent HPT and hypoparathyroidism, which necessitate careful long-term monitoring. Furthermore, they raised concerns that transitioning from a high-turnover to a low-turnover bone state post-PTX may predispose patients to vascular calcifications, complicating calcium homeostasis in CRF patients with mineral bone disease [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Our results support the efficacy of subtotal PTX in reducing PTH levels without leading to overt hypoparathyroidism, reinforcing the importance of preserving well-vascularized parathyroid tissue to mitigate post-PTX complications. None of our patients experienced new bone fractures, and significant clinical improvements in leg pain and mobility were observed.\u003c/p\u003e \u003cp\u003eNo significant complications occurred in our pHPT cohort. Long-term follow-up showed biochemical normalization and symptom improvement. On the other hand, one patient with tHPT developed postoperative HBS, a known complication due to high post-PTX osteoblastic activity. This condition was successfully managed with appropriate medical interventions, and the patient recovered without complications. Our results support prior findings that elevated PTH levels are a risk factor for HBS, emphasizing the importance of preoperative optimization. Curtis Hanba et al. reported that male patients, younger children, and those with pre-existing kidney disease had more prolonged and complex postoperative courses, including mental status changes, infections, and respiratory complications [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In contrast, all of our r-HPT patients were female, yet they still experienced extended hospital stays (11\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 days), primarily due to the need for fluid and electrolyte management during dialysis rather than postoperative complications.\u003c/p\u003e \u003cp\u003eA large-scale study comparing PTX outcomes in pHPT and r-HPT patients found no significant age differences between the two groups, although female predominance was noted in pHPT. It reported that r-HPT patients had longer operative times, higher estimated blood loss, and extended hospital stays compared to pHPT cases. The study also found that in pHPT, lesions were most frequently located in the right lower and left lower glands, whereas in r-HPT, the preserved gland was typically in the left upper position. Preoperative PTH levels were significantly higher in r-HPT patients (1242.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1075 pg/mL) than in pHPT patients (161.6\u0026thinsp;\u0026plusmn;\u0026thinsp;95.4 pg/mL). Postoperative PTH levels at 6 and 12 months were comparable between both groups. Preoperative calcium levels were higher in pHPT cases (10.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9 mg/dL vs. 9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 mg/dL), while postoperative calcium levels normalized immediately in pHPT patients but took longer in r-HPT patients, with hypocalcemia persisting for up to six months postoperatively [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Consistent with these findings, our study also observed significantly higher preoperative PTH levels in r-HPT patients compared to pHPT patients. However, unlike the reported delayed calcium normalization in r-HPT cases, our cohort maintained stable postoperative calcium levels within normal ranges at the 6- and 12-month follow-ups.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003ePediatric HPT poses notable diagnostic and therapeutic complexities, compounded by its rarity and the broad spectrum of clinical presentations. In this series, pHPT manifested equally in males and females\u0026mdash;diverging from the predominantly female trend reported elsewhere\u0026mdash;while r-HPT affected only females. Despite these differences, all children in both groups presented with significant biochemical derangements, including markedly elevated PTH levels, underscoring the urgency of early recognition and intervention. Surgical management tailored to disease type and gland involvement proved highly effective: MIP was optimal for single-gland pHPT, while BNE with subtotal parathyroidectomy was preferred for multiglandular disease and r-HPT. Meticulous preoperative imaging\u0026mdash;particularly ultrasound, which localized all lesions\u0026mdash;minimized the need for additional imaging methods in straightforward single-gland pHPT. Complications were minimal, with only one postoperative HBS in an r-HPT patient successfully managed medically. No recurrences were observed during long-term follow-up, signaling robust and durable outcomes.\u003c/p\u003e \u003cp\u003eThese findings reinforce the efficacy of targeted surgical approaches and highlight the pivotal roles of multidisciplinary collaboration and vigilant postoperative monitoring. Refining diagnostic algorithms, optimizing intraoperative techniques, and honing perioperative care will be essential to improve further outcomes and quality of life for pediatric HPT patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBNE\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBilateral neck exploration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCRF\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChronic renal failure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHBS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHungry bone syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHPT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHyperparathyroidism\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIo-PTH\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntraoperative parathyroid hormone monitoring\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMIP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinimally invasive parathyroidectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003epHPT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary hyperparathyroidism\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePTH\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eParathyroid hormone\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePTX\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eParathyroidectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003er-HPT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRenal hyperparathyroidism\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eS-CT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSingle-photon emission computed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003esHPT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSecondary hyperparathyroidism\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eS-mibi\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTc 99 sestamibi scintigraphy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003etHPT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTertiary hyperparathyroidism\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eUS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUltrasonography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eW/FNA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWashout/Fine needle aspiration biopsy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of interest/Competing interests\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo funding was received to assist with the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was approved by\u0026nbsp;Health Sciences University, Kanuni Sultan Suleyman Training and Education Hospital Ethics Committee (#2023.10.145)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants and parents included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author, upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026apos;s Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception and design: SO,SS,EHAK,ZKS,SY; data collection: EHAK,ZKS,SY,HYB,BEA; analysis and interpretation of results: SO,SS,SY,HYB,HK,BEA; draft manuscript preparation: SO,SS,HK; All authors reviewed the results and approved the final version of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to present our thanks to our mentors Dr. Mehmet Halil Serdar Sander, Dr Oyhan Demirali ve Dr Cemile Besik for his invaluable contribution to the follow-up and surgeries of the patients.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSingh Ospina NM, Rodriguez-Gutierrez R, Maraka S, Espinosa de Ycaza AE, Jasim S, Castaneda-Guarderas A, Gionfriddo MR, Al Nofal A, Brito JP, Erwin P, Richards M, Wermers R, Montori VM (2016) Outcomes of Parathyroidectomy in Patients with Primary Hyperparathyroidism: A Systematic Review and Meta-analysis. World J Surg 40:2359\u0026ndash;2377\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkorecki K, Green J, Brenner MM (2004) Chronic Renal Failure. Harrison's Principles of Medicine, 15 edn. The McGraw-Hill Companies, New York, pp 1551\u0026ndash;1562\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchreiner GE (1989) Uremia. Textbook of Nephrology, 2 edn. Williams \u0026amp; Wilkins, Baltimore, pp 540\u0026ndash;547\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDurkin ET, Nichol PF, Lund DP, Chen H, Sippel RS (2010) What is the optimal treatment for children with primary hyperparathyroidism? J Pediatr Surg 45:1142\u0026ndash;1146\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchlosser K, Schmitt CP, Bartholomaeus JE, Suchan KL, Buchler MW, Rothmund M, Weber T (2008) Parathyroidectomy for renal hyperparathyroidism in children and adolescents. 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J Endocrinol Invest 47:2157\u0026ndash;2176\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Salameh A, Haissaguerre M, Tresallet C, Kuczma P, Marciniak C, Cardot-Bauters C (2025) Chapter 6: Syndromic primary hyperparathyroidism. Ann Endocrinol (Paris) 86:101695\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRomanet P, Coppin L, Molin A, Santucci N, Le Bras M, Odou MF (2025) Chapter 5: The roles of genetics in primary hyperparathyroidism. Ann Endocrinol (Paris) 86:101694\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMigon J, Miciak M, Pupka D, Biernat S, Nowak L, Kaliszewski K (2025) Analysis of Clinical and Biochemical Parameters and the Effectiveness of Surgical Treatment in Patients with Primary Hyperparathyroidism: A Single-Center Study. 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Exp Clin Endocrinol Diabetes 120:229\u0026ndash;233\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim SH, Lee SY, Min EA, Hwang YM, Choi YS, Yi JW (2022) Single-Center Experience of Parathyroidectomy Using Intraoperative Parathyroid Hormone Monitoring. Med (Kaunas). ;58\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliva AR, Lobos PA, Moldes JM, Liberto DH (2021) Usefulness of combined ultrasonography and scintigraphy in the preoperative assessment of secondary or tertiary hyperparathyroidism. Cir Pediatr 34:63\u0026ndash;66\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMedas F, Cappellacci F, Canu GL, Noordzij JP, Erdas E, Calo PG (2021) The role of Rapid Intraoperative Parathyroid Hormone (ioPTH) assay in determining outcome of parathyroidectomy in primary hyperparathyroidism: A systematic review and meta-analysis. 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Int J Pediatr Otorhinolaryngol 91:94\u0026ndash;99\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hyperparathyroidism, Parathyroidectomy, Primary Hyperparathyroidism, Renal Hyperparathyroidism, Pediatric Surgery","lastPublishedDoi":"10.21203/rs.3.rs-6489091/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6489091/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eHyperparathyroidism (HPT) is a condition marked by excessive secretion of parathyroid hormone (PTH), leading to disturbances in calcium, phosphate, and vitamin D metabolism. HPT is classified into primary (pHPT), secondary (sHPT), and tertiary (tHPT) types, which can cause systemic complications. Parathyroidectomy (PTX) remains the cornerstone treatment for pHPT and refractory cases of sHPT and tHPT.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A retrospective review was conducted on 10 pediatric patients who underwent PTX for HPT at our clinic between 2016 and 2024. Demographic data, preoperative imaging, laboratory findings, surgical details, pathology reports, and postoperative outcomes were analyzed. Patients were categorized as having either pHPT (n\u0026thinsp;=\u0026thinsp;6) or renal HPT (r-HPT; n\u0026thinsp;=\u0026thinsp;4), which included one case of sHPT and three cases of tHPT.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean age of pHPT and r-HPT patients was 15 and 13 years, respectively. While 50% of pHPT patients were female, all r-HPT patients were female. Preoperative imaging localized parathyroid lesions using ultrasonography in all cases, but Sestamibi scintigraphy had a lower detection rate (66.7%). Minimally invasive parathyroidectomy was performed in single-gland pHPT cases, while bilateral neck exploration was used for multiglandular pHPT and all r-HPT cases. No intraoperative complications were observed. Postoperatively, all patients demonstrated normalized calcium, phosphate, and PTH levels with significant symptomatic improvement. Hungry bone syndrome developed in one r-HPT patient and was managed successfully. No recurrences were noted during an average follow-up of 39 months.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePTX is a safe and effective treatment for pediatric HPT, providing excellent biochemical and clinical outcomes. Multidisciplinary collaboration is crucial in managing pediatric cases, particularly those with complex renal HPT.\u003c/p\u003e","manuscriptTitle":"Parathyroidectomy in the Treatment of Childhood Hyperparathyroidism: A Single-Institution Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-23 10:43:54","doi":"10.21203/rs.3.rs-6489091/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"34ca12c0-2df4-4dce-8656-f232a223cbf1","owner":[],"postedDate":"April 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-10T09:53:49+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-23 10:43:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6489091","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6489091","identity":"rs-6489091","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}