Parathyroidectomy is the Most Appropriate Next Step
For a patient with symptomatic primary hyperparathyroidism (PHPT) presenting with recurrent ureteric stones, bone pain, fatigue, hypercalcemia (3.50 mmol/L), and a 2 cm parathyroid adenoma, immediate surgical parathyroidectomy is the definitive and only curative treatment. 1
Rationale for Immediate Surgery
This patient has clear target organ damage requiring urgent surgical intervention:
- Recurrent nephrolithiasis (ureteric stones) represents definitive end-organ involvement that mandates parathyroidectomy 1
- Bone pain indicates ongoing skeletal demineralization from chronic PTH excess 1
- Symptomatic hypercalcemia with calcium of 3.50 mmol/L (14 mg/dL) is significantly elevated and causing systemic symptoms (fatigue) 2, 3
- A 2 cm parathyroid adenoma is substantial in size and represents single-gland disease amenable to minimally invasive surgery 1
Why Other Options Are Inappropriate
Bisphosphonates (Option A):
- Only indicated for skeletal protection in asymptomatic patients who are NOT surgical candidates or who refuse surgery 3
- Do not address the underlying PTH excess or prevent progression of kidney stones 3
- This patient has clear indications for surgery, making medical management inappropriate 1
Calcium mimetics/Calcimimetics (Option B):
- May lower serum calcium but do not cure the disease 3
- Reserved for patients with contraindications to surgery or those who refuse surgery 3
- Delaying surgery for medical management in symptomatic patients with clear target organ damage is not recommended 1
Increased calcium diet (Option C):
- Completely contraindicated in hypercalcemia 4
- Would worsen the patient's already elevated calcium levels 4
- Calcium supplementation is only used POST-operatively to prevent hungry bone syndrome 4, 5
Surgical Approach
Minimally invasive parathyroidectomy (MIP) with intraoperative PTH monitoring is the preferred approach:
- Single adenoma localization allows for focused surgical approach rather than bilateral neck exploration 1
- Intraoperative PTH monitoring confirms adequate removal of hyperfunctioning tissue (expect >50% drop in PTH within 10 minutes) 2, 6
- Preoperative imaging with 99Tc-Sestamibi scan facilitates surgical planning 4, 1
Post-Operative Management Considerations
Be prepared for hungry bone syndrome:
- Monitor ionized calcium every 4-6 hours for first 48-72 hours post-operatively 4
- If calcium falls below 0.9 mmol/L (3.6 mg/dL), initiate calcium gluconate infusion at 1-2 mg elemental calcium/kg/hour 4
- Transition to oral calcium carbonate 1-2 g three times daily plus calcitriol up to 2 μg/day when oral intake possible 4
- Severe cases can develop dramatic calcium drops requiring aggressive replacement 5
Common Pitfalls to Avoid
- Do not delay surgery for medical optimization in symptomatic patients with documented adenoma 1
- Do not use calcimimetics as they do not address the underlying adenoma and delay definitive cure 3
- Do not increase calcium intake pre-operatively as this worsens hypercalcemia 4
- Do not underestimate post-operative calcium monitoring needs, as hungry bone syndrome can be life-threatening 5
Answer: D. Parathyroidectomy