Reasons for Parathyroid Gland Removal
Parathyroid glands should be removed in patients with primary hyperparathyroidism who have symptomatic disease or meet surgical criteria, and in patients with secondary hyperparathyroidism from chronic kidney disease who fail medical management with severe, refractory symptoms. 1
Primary Hyperparathyroidism (PHPT) - Indications for Surgery
Symptomatic Disease
Parathyroidectomy is definitively indicated when patients present with target organ damage or symptoms, even though this is less common in countries with routine screening: 1
- Skeletal manifestations: Bone demineralization, osteoporosis, pathological fractures, and skeletal deformities 1
- Renal complications: Nephrolithiasis (kidney stones) and nephrocalcinosis 1
- Neuromuscular symptoms: Muscle weakness and progressive articular pain 1
- Neuropsychiatric disorders: Neurocognitive dysfunction and psychological disturbances 1
Asymptomatic Disease
Surgery is typically indicated even in asymptomatic PHPT due to the potential negative effects of long-term hypercalcemia on cardiovascular health, bone density, and renal function. 1 This represents a shift in management philosophy, as most patients in developed countries with routine screening present asymptomatically. 1
Persistent or Recurrent PHPT
Parathyroidectomy is required when: 1
- Normocalcemia fails to occur within 6 months after initial surgery (persistent PHPT) 1
- Hypercalcemia recurs after a normocalcemic interval of 6 months or more (recurrent PHPT) 1
Critical caveat: Reoperations carry lower cure rates and higher complication rates than first-time surgery, making preoperative imaging mandatory in these cases. 1
Secondary Hyperparathyroidism (SHPT) - Indications for Surgery
Refractory Disease in Chronic Kidney Disease
Parathyroidectomy becomes necessary when medical therapy (phosphate binders, vitamin D analogs, calcimimetics) fails to control the disease: 1
Severe hyperparathyroidism with hypercalcemia that precludes further medical therapy with vitamin D sterols 1
PTH levels exceeding specific thresholds with symptoms: 1, 2
- At PTH >500-800 pg/mL: Progressive skeletal pain, intractable pruritus, and moderate hyperparathyroid bone disease 1, 2
- At PTH >800-1000 pg/mL: Severe symptoms including persistent hypercalcemia, progressive skeletal disease, pathological fractures, and calcium-phosphate products exceeding 70 mg²/dL² 1, 2
- At PTH >10 times upper normal limit: Severe hyperparathyroid bone disease with skeletal deformities 2
Specific clinical scenarios requiring surgery: 1
- Calciphylaxis with elevated PTH levels (>500 pg/mL), though not all calciphylaxis patients have high PTH 1
- Hyperphosphatemia that precludes medical therapy 1
- Intractable pruritus resistant to conventional therapies 2
- Progressive vascular calcification with cardiovascular complications 1
Tertiary Hyperparathyroidism (THPT)
Surgery is indicated when patients with long-standing SHPT develop autonomous PTH production that persists despite rising calcium levels, most commonly after kidney transplantation: 1
- Hypercalcemia threatening transplant graft function 2
- Persistent symptomatic hypercalcemia post-transplant (occurs in 1-5% of recipients) 2
Surgical Approach Selection
For PHPT with single adenoma (80% of cases): Minimally invasive parathyroidectomy (MIP) is preferred when preoperative imaging confidently localizes the adenoma, offering shorter operating times and faster recovery. 1, 3
For multigland disease or nonlocalizing imaging: Bilateral neck exploration is required. 1, 3
For SHPT: Surgical options include subtotal parathyroidectomy, total parathyroidectomy (TPTX), or total parathyroidectomy with autotransplantation (TPTX+AT). 1 Recent evidence suggests TPTX may have advantages in reducing recurrence rates, though concerns about temporary hypocalcemia exist. 1
Important pitfall: Avoid total parathyroidectomy in patients who may subsequently receive kidney transplant, as calcium control becomes problematic post-transplant. 1