Parathyroidectomy for Primary Hyperparathyroidism
Parathyroidectomy should be performed in middle-aged to elderly patients with primary hyperparathyroidism who present with symptomatic disease including kidney stones, osteoporosis, or neuropsychiatric symptoms, as surgery is the only curative treatment and is strongly recommended for all symptomatic patients. 1, 2
Clear Indications for Surgery
The following are definitive indications for parathyroidectomy in primary hyperparathyroidism:
- Nephrolithiasis or nephrocalcinosis - This is an absolute indication for surgery 1
- Osteoporosis documented on DEXA scan - Bone disease warrants surgical intervention 2
- Neuropsychiatric symptoms - Including neurocognitive disorders, even with mild hypercalcemia (as low as 10.4 mg/dL), as these symptoms can be severe and improve dramatically post-surgery 1, 3
- Impaired renal function (GFR < 60 mL/min/1.73 m²) - This is an indication even in otherwise asymptomatic patients 1, 4, 2
- Age younger than 50 years - Surgery is advised regardless of symptom severity 5
- Significant hypercalcemia - Elevated calcium levels meeting guideline thresholds 5
Superiority of Surgery Over Medical Management
Parathyroidectomy achieves a 99% cure rate at 6-24 months, compared to 0% cure with observation or medical therapy alone. 6 Recent meta-analysis demonstrates that:
- Surgery results in normalization of calcium and PTH levels, whereas medical management shows increasing PTH levels over time (from 83.84 to 106.14 pg/mL) 7
- Patients managed medically maintain persistently elevated calcium (10.46 vs 9.39 mg/dL post-treatment) and have significantly lower bone mineral density at all sites 7
- Medical management with calcimimetics (cinacalcet) can lower calcium and PTH but does not cure the disease and has unknown effects on fracture risk 5
Preoperative Localization
Before surgery, obtain imaging for adenoma localization:
- 99mTc-sestamibi scintigraphy with SPECT/CT has the highest sensitivity and is the preferred initial imaging modality 4, 8
- 18F-fluorocholine PET/CT is the most sensitive method available, particularly valuable for multigland disease or when other imaging is non-localizing 8
- Cervical ultrasound should be performed as first-line imaging 8
- 4D-CT is an alternative to sestamibi scanning 8
Surgical Approach Selection
Minimally invasive parathyroidectomy (MIP) is preferred when preoperative imaging confidently localizes a single adenoma, offering shorter operative times and faster recovery 1, 2
- Bilateral neck exploration is necessary when imaging is discordant, non-localizing, or multigland disease is suspected 1
- Intraoperative PTH monitoring should be used with MIP to confirm adequate resection 2
Critical Postoperative Management
Intensive calcium monitoring is essential to prevent complications:
- Measure ionized calcium every 4-6 hours for the first 48-72 hours, then twice daily until stable 1, 4
- If ionized calcium falls below 0.9 mmol/L (3.6 mg/dL), immediately initiate calcium gluconate infusion at 1-2 mg elemental calcium/kg/hour 9, 4
- Once oral intake is tolerated, provide calcium carbonate 1-2 g three times daily plus calcitriol up to 2 μg/day 9, 4
- Gradually reduce calcium infusion as levels stabilize in the normal range 9
Important Caveats
Psychiatric symptoms alone, even severe psychosis, are not traditionally listed as surgical indications in guidelines, but case evidence demonstrates dramatic improvement post-surgery even with mild hypercalcemia 3. Consider surgery in these patients as psychiatric symptoms may be the only salient manifestation of PHPT 3.
The evidence for medical management is weak - while observation may be reasonable in truly asymptomatic patients with very mild disease, any symptomatic patient (kidney stones, bone disease, neuropsychiatric symptoms) should proceed to surgery as this is curative and prevents disease progression 1, 2, 7.