Indications for Parathyroidectomy in Primary Hyperparathyroidism
Parathyroidectomy is indicated for all symptomatic patients with primary hyperparathyroidism and should be considered for most asymptomatic patients as it is more cost-effective than observation or pharmacologic therapy. 1
Indications for Elective Parathyroidectomy
Primary Hyperparathyroidism
- Symptomatic patients: All patients with symptoms related to hypercalcemia (kidney stones, bone disease, neurocognitive disorders, muscle weakness) should undergo parathyroidectomy 2, 1
- Asymptomatic patients with any of the following criteria:
- Serum calcium >0.25 mmol/L (1 mg/dL) above the upper limit of normal 2, 1
- Age <50 years 2, 1
- Osteoporosis (T-score ≤-2.5 at any site) or previous fragility fracture 1
- Impaired kidney function (GFR <60 mL/min/1.73m²) 2
- Kidney stones or nephrocalcinosis (even if asymptomatic) 2, 1
- Hypercalciuria (>400 mg/day) 2, 1
Secondary Hyperparathyroidism
- Refractory hyperparathyroidism despite optimal medical management 2
- Persistent serum levels of intact PTH >800 pg/mL (88.0 pmol/L) 2
- Hypercalcemia and/or hyperphosphatemia that are unresponsive to medical therapy 2
- Progressive extraskeletal calcifications with persistently elevated calcium-phosphorus product >70-80 mg/dL 2
- Severe intractable pruritus 2
- Calciphylaxis with elevated PTH levels (>500 pg/mL) 2
Indications for Urgent Parathyroidectomy
- Hypercalcemic crisis (severe symptomatic hypercalcemia with altered mental status, dehydration, or cardiac arrhythmias) 2
- Calciphylaxis with elevated PTH levels 2
- Severe, symptomatic hypercalcemia unresponsive to medical management 2
- Acute kidney injury due to hypercalcemia 2
Surgical Approaches
For Primary Hyperparathyroidism
Minimally invasive parathyroidectomy (MIP): Appropriate for single adenoma with positive preoperative localization 2, 1
Bilateral neck exploration (BNE): Appropriate for non-localized disease or suspected multigland disease 2, 1
For Secondary Hyperparathyroidism
- Subtotal parathyroidectomy: Removal of 3.5 glands 2
- Total parathyroidectomy with autotransplantation: Complete removal with reimplantation of parathyroid tissue (usually in the forearm) 2
- Total parathyroidectomy without autotransplantation: May be considered but not preferred for patients who might receive kidney transplants 2
Postoperative Considerations
- Monitor for hypocalcemia in the immediate postoperative period 2
- Measure ionized calcium every 4-6 hours for the first 48-72 hours after surgery 2
- Calcium supplementation may be necessary postoperatively 2, 1
- Follow-up to assess for cure (eucalcemia at >6 months) 1
Clinical Outcomes After Parathyroidectomy
- Normalization of serum calcium concentrations 3
- Increase in bone mineral density (8-12% increase in lumbar spine and 6-14% increase in femoral neck over 1-10 years) 3
- Prevention of recurrent kidney stones in symptomatic patients 3
- Improvement in cardiovascular and neuropsychiatric manifestations (though clinical significance remains to be fully determined) 4
Common Pitfalls and Considerations
- Parathyroid imaging is not usually required preoperatively for first-time surgery but is recommended prior to re-exploration 2
- Preoperative parathyroid biopsy should be avoided 1
- Consider the possibility of multigland disease in all cases 1
- Surgeons who perform a high volume of operations (>40 PTX per year) have better outcomes with fewer complications (<3%) 1, 5
- Total parathyroidectomy without autotransplantation is not recommended for patients who may subsequently receive a kidney transplant 2
- For reimplantation, use a portion of the smallest parathyroid gland (less likely to have severe nodular hyperplasia) 2
Parathyroidectomy remains the only definitive treatment for primary hyperparathyroidism, with medical therapy (bisphosphonates, calcimimetics) reserved for those who cannot or do not want to undergo surgery 6, 4.