What are the indications for parathyroidectomy (surgical removal of the parathyroid gland)?

Indications for Parathyroidectomy

Parathyroidectomy is indicated for patients with symptomatic hyperparathyroidism and should be considered for most asymptomatic patients with primary hyperparathyroidism, as it is more cost-effective than observation or pharmacologic therapy. 1

Primary Hyperparathyroidism

Definite Indications

• Symptomatic hyperparathyroidism (renal stones, bone disease, neurocognitive disorders) 2, 1
• Asymptomatic hyperparathyroidism with:
  • Impaired renal function (GFR < 60 mL/min/1.73 m²) 3
  • Serum calcium > 1 mg/dL above upper limit of normal 1
  • Bone mineral density T-score ≤ -2.5 at any site or previous fragility fracture 1
  • Age < 50 years 1
  • Nephrolithiasis or nephrocalcinosis 2, 1

Relative Indications

• Asymptomatic hyperparathyroidism with:
  • Cardiovascular manifestations (even mild PHPT is associated with cardiovascular dysfunction) 4, 5
  • Neuropsychological symptoms (anxiety, depression, cognitive impairment) 6
  • Reduced quality of life (significant improvements have been documented after surgery) 6

Secondary Hyperparathyroidism

Indications in End-Stage Renal Disease

• Refractory and/or symptomatic hypercalcemia (after excluding other causes) 2
• Refractory hyperphosphatemia 2
• Severe intractable pruritus 2
• Serum calcium x phosphorus product persistently exceeding 70-80 mg/dl 2
• Progressive extraskeletal calcifications 2
• Calciphylaxis 2, 3
• Persistent serum levels of intact PTH > 800 pg/mL despite medical therapy 7, 8

Tertiary Hyperparathyroidism

• Hypercalcemic hyperparathyroidism unresponsive to medical treatment 2, 8
• Persistent hyperparathyroidism after kidney transplantation with hypercalcemia 2, 9

Surgical Approaches

For Primary Hyperparathyroidism

• Minimally invasive parathyroidectomy (MIP) - preferred for single adenoma with confident preoperative localization 2, 7
• Bilateral neck exploration (BNE) - necessary for discordant/nonlocalizing imaging or suspected multigland disease 2, 7

For Secondary/Tertiary Hyperparathyroidism

• Subtotal parathyroidectomy 2, 3
• Total parathyroidectomy with autotransplantation 2, 3
• Total parathyroidectomy without autotransplantation (not recommended for patients who may receive kidney transplant) 2, 3

Preoperative Evaluation

• Biochemical confirmation: serum calcium, PTH, phosphorus 2
• 25-OH Vitamin D measurement to exclude hypovitaminosis D 8, 1
• Imaging for localization: ultrasound, 99mTc-sestamibi scintigraphy with SPECT/CT 2, 8
• Additional imaging for reoperative cases: CT scan, MRI 2, 3

Postoperative Management

• Monitor ionized calcium every 4-6 hours for first 48-72 hours, then twice daily until stable 3, 8
• Calcium supplementation: calcium carbonate 1-2g three times daily when oral intake is possible 3
• Calcitriol supplementation up to 2 μg/day 3
• Calcium gluconate infusion if ionized calcium falls below 0.9 mmol/L 3, 8

Common Pitfalls to Avoid

• Delaying surgery in symptomatic patients 5, 1
• Performing parathyroid biopsy preoperatively (should be avoided) 1
• Overlooking multigland disease (should be routinely considered) 1
• Performing parathyroidectomy for calciphylaxis without documented hyperparathyroidism 3
• Failing to autotransplant devascularized normal parathyroid tissue 1

Benefits of Parathyroidectomy

• Immediate normalization of hypercalcemia 9
• Significant improvement in bone mineral density 6, 9
• Improvement in cardiovascular function 4, 9
• Enhancement of neuropsychological symptoms and quality of life 6, 9
• Decreased fracture risk 4
• Improved survival in patients with severe secondary hyperparathyroidism 9

Parathyroidectomy remains the only definitive cure for hyperparathyroidism, with medical therapies like bisphosphonates and calcimimetics serving as alternatives only when surgery is contraindicated or refused 9, 5.