A novel optimized surgical strategy for secondary hyperparathyroidism: clean parathyroidectomy combined with autotransplantation and its clinical analysis.

Background: Recurrent disease due to ectopic parathyroid tissue remains a significant challenge following conventional total parathyroidectomy with autotransplantation (TPTX+AT) for refractory secondary hyperparathyroidism (SHPT). This retrospective cohort study aimed to evaluate the safety and medium-term efficacy of a standardized, extended surgical approach-clean parathyroidectomy with autotransplantation (CPTX+AT)-which systematically resects the central neck compartment to address this issue. We also clarified the exclusion criteria for kidney transplantation candidates and the application of intraoperative parathyroid hormone (ioPTH) measurement to optimize the surgical strategy. Methods: A total of 98 patients with uncontrolled SHPT who underwent CPTX+AT between April 2021 and June 2023 were enrolled as the Observation Group, and 80 patients who underwent TPTX+AT between January 2020 and March 2021 served as the Control Group. All patients were excluded from kidney transplantation waiting lists or had no definite kidney transplantation plan at surgery. Perioperative outcomes, biochemical parameters (iPTH, calcium, phosphorus, ALP), clinical symptom resolution, thyroid function, complications, recurrence rates (defined as iPTH >500 pg/mL on two consecutive measurements), and patient-centered hard outcomes (mortality, fracture, cardiovascular events) were analyzed. ioPTH was measured in all operations, and surgical strategies were adjusted according to ioPTH decline trends. Kaplan-Meier curves and log-rank tests were used to assess recurrence-free survival, with all patients followed until a uniform data-collection cut-off of 31 December 2024. Results: Postoperative biochemical parameters improved significantly in the Observation Group, with complete resolution of clinical symptoms by 3 months postoperatively. The overall complication rates were comparable between the groups (12.24% in the Observation Group vs. 12.50% in the Control Group, p > 0.05). Transient hypocalcemia occurred in 6.12% (6/98) of the Observation Group and 5.00% (4/80) of the Control Group; all patients received high-dose 1,25-dihydroxyvitamin D and calcium supplementation postoperatively, and no permanent hypoparathyroidism was observed in either group. During a median follow-up of 25.0 months (range 18-44) for the Observation Group and 47.0 months (range 45-59) for the Control Group, no recurrence was detected in the Observation Group (0/98), while the Control Group had a recurrence rate of 5.0% (4/80) (log-rank Conclusion: CPTX+AT is a safe, feasible, and promising medium-term strategy for uncontrolled SHPT in non-kidney transplantation candidates, achieving durable biochemical and symptomatic improvement with no recurrence detected during a median follow-up of 25 months. High-dose 1,25-dihydroxyvitamin D supplementation effectively reduces the risk of severe hypocalcemia, and ioPTH measurement is key to ensuring surgical success. CPTX+AT is particularly suitable for patients at high risk of recurrence due to ectopic parathyroid tissue.