Advanced secondary (renal) hyperparathyroidism (HPT) induced by uremia is one of the most serious complications for long-term hemodialysis patients. Parathyroidectomy (PTx) is indicated in patients with severely advanced renal HPT that is refractory to medical treatment, including calcitriol pulse therapy. The clinical effect of PTx is striking. However, skeletal deformity, vessel calcification, and remarkable reduction of bone content is irreversible. Therefore, it is important to perform PTx at the right time. Based on histopathological and pathophysiological investigations, nodular hyperplasia is monoclonal neoplasia with abnormal parathyroid hormone response to extracellular calcium and vitamin D. When parathyroid hyperplasia progresses to nodular hyperplasia, PTx should be required. Total PTx with forearm autograft is the preferred procedure for renal HPT, especially for patients who need to continue hemodialysis treatment after PTx. Removal of all parathyroid glands, including supernumerary glands, at the initial operation and proper choice of adequate parathyroid tissue for autograft are important to prevent persistent and recurrent HPT. In this series of 782 patients, the function of autografted parathyroid tissue is almost satisfactory and no retransplantation of cryopreserved parathyroid tissue was necessary; however, graft-dependent recurrent HPT was not negligible. In conclusion, total PTx with forearm autograft is very effective and adequate treatment for advanced renal HPT and parathyroid function can be controlled after PTx.