4D CT-guided parathyroidectomy: improving operative efficiency in end-stage renal disease patients with medically refractory secondary hyperparathyroidism.

Abstract

Background: Parathyroidectomy for medically refractory secondary hyperparathyroidism in end-stage renal disease (ESRD) patients traditionally relies on experience-dependent surgical exploration due to limited preoperative localization capabilities. This study evaluates whether four-dimensional computed tomography (4D CT) provides significant improvements in surgical efficiency with measurable operative benefits.

Methods: This retrospective comparative study analyzed 103 ESRD patients undergoing total or subtotal parathyroidectomy between January 2023 and December 2024. Patients were stratified into two groups: 4D CT-guided focused parathyroidectomy (n = 45) versus conventional imaging-guided surgery using ultrasound ± SPECT/CT (n = 58). Primary endpoints included operative time and intraoperative frozen section requirements. Secondary endpoints assessed diagnostic accuracy and positive predictive value of imaging modalities, with postoperative outcomes evaluated to ensure therapeutic equivalence.

Results: The 4D CT group demonstrated significantly shorter operative times compared to conventional imaging (162.51 vs. 188.78 minutes, P = 0.014), representing a 13.9% reduction in surgical duration. Multiple frozen sections were required in 8.9% of 4D CT patients versus 31.0% of conventional patients (P = 0.013), demonstrating a 3.5-fold reduction in intraoperative histological confirmation needs. 4D CT showed superior diagnostic accuracy (75% vs. 33.33%) and positive predictive value (93.75% vs. 85.0%) compared to conventional imaging. Multivariate analysis identified 4D CT as the only independent predictor of reduced frozen section requirements (OR: 0.21, 95% CI, P = 0.009). Postoperative outcomes including biochemical control and complication rates were equivalent between groups, demonstrating that enhanced surgical efficiency did not compromise therapeutic effectiveness.

Conclusions: Four-dimensional CT significantly enhances surgical efficiency in ESRD patients with medically refractory secondary hyperparathyroidism through improved preoperative localization. These efficiency gains are achieved while maintaining therapeutic effectiveness.