Indications for Parathyroidectomy
Parathyroidectomy is indicated for patients with primary hyperparathyroidism who are symptomatic or meet specific criteria for asymptomatic disease, and for patients with secondary hyperparathyroidism who have failed medical management and exhibit severe complications. 1, 2
Primary Hyperparathyroidism
Symptomatic Primary Hyperparathyroidism
Parathyroidectomy is the definitive treatment for all symptomatic patients with primary hyperparathyroidism 2. Symptoms and complications include:
- Renal stones
- Osteoporosis/bone disease
- Neuropsychiatric symptoms
- Hypercalcemic crisis
Asymptomatic Primary Hyperparathyroidism
For asymptomatic primary hyperparathyroidism, parathyroidectomy should be considered when any of the following criteria are met 2:
- Serum calcium >1 mg/dL above upper limit of normal
- Bone mineral density T-score ≤-2.5 at any site or previous fragility fracture
- Age <50 years
- Creatinine clearance <60 mL/min
- 24-hour urinary calcium >400 mg/day
- Nephrolithiasis or nephrocalcinosis (by imaging)
- Significant cardiovascular manifestations
Parathyroidectomy is also indicated for patients with primary hyperparathyroidism who cannot undergo regular follow-up or when medical surveillance is not feasible 3.
Secondary Hyperparathyroidism
For patients with chronic kidney disease and secondary hyperparathyroidism, parathyroidectomy is indicated when 4, 1:
- Failed medical management (dietary phosphorus restriction, phosphorus-binding agents, vitamin D metabolites/analogues, and calcimimetics like cinacalcet)
- Refractory and/or symptomatic hypercalcemia (after excluding other causes)
- Refractory hyperphosphatemia
- Severe intractable pruritus
- Serum calcium × phosphorus product persistently exceeding 70-80 mg²/dL²
- Progressive extraskeletal calcifications
- Calciphylaxis
- PTH levels >800 pg/mL despite optimized medical therapy
Tertiary Hyperparathyroidism
Parathyroidectomy should be considered for renal transplant candidates with 4:
- Persistent hyperparathyroidism despite medical management
- Severe complications of hyperparathyroidism
- Hypercalcemia that persists after renal transplantation
Surgical Approaches
The choice of surgical approach depends on the type of hyperparathyroidism and patient factors 4, 5:
For primary hyperparathyroidism: Focused, image-guided surgery (minimally invasive parathyroidectomy) is appropriate for single adenomas, while bilateral neck exploration is recommended for suspected multigland disease 2
For secondary hyperparathyroidism: Options include 4:
- Subtotal parathyroidectomy (removal of 3.5 glands)
- Total parathyroidectomy (TPTX)
- Total parathyroidectomy with autotransplantation (TPTX+AT)
Benefits of Parathyroidectomy
Evidence shows that parathyroidectomy provides significant benefits 6, 2:
- Increased bone mineral density (particularly at femoral neck and total hip)
- Improved quality of life scores (social functioning, emotional role function)
- Reduced anxiety and phobia
- Normalization of calcium and PTH levels
- Cost-effectiveness compared to observation or pharmacologic therapy
Preoperative Considerations
Before proceeding with parathyroidectomy 2:
- Measure 25-hydroxyvitamin D levels and supplement if deficient
- Perform cervical ultrasonography or other high-resolution imaging for operative planning
- Avoid preoperative parathyroid biopsy
- Consider the possibility of multigland disease
- Assess for clinically relevant thyroid disease
Special Considerations
- Parathyroidectomy is more successful when performed by high-volume surgeons 2
- For minimally invasive parathyroidectomy, intraoperative PTH monitoring is recommended 2
- Devascularized normal parathyroid tissue should be autotransplanted 2
- Familial hyperparathyroidism, reoperative parathyroidectomy, and parathyroid carcinoma require special expertise 2
Parathyroidectomy remains the only curative intervention for hyperparathyroidism, with medical therapies like bisphosphonates and calcimimetics serving as alternatives only for patients who cannot undergo surgery 7.