Abstract Background Primary hyperparathyroidism (pHPT) is increasingly recognized, and surgery remains the only curative treatment. While selective parathyroidectomy (SP) is preferred when imaging is concordant, bilateral neck exploration (BNE) is recommended when localisation studies are discordant or nonlocalising. Advanced imaging may be used selectively, but its added value is variable. Methods This multicenter retrospective cohort (2023–2024) examined therapeutic strategies and outcomes in pHPT patients undergoing surgery across four Portuguese endocrine surgery units. All included patients had biochemical confirmation of pHPT and at least two preoperative localization studies. Data collected included imaging results, surgical approach, and postoperative outcomes. Results Among 227 patients, ultrasound was performed in 100% and Sestamibi in 197 (86.8%). Imaging was concordant in 140 patients (61.7%). Among patients without concordant imaging, 63.2% underwent additional imaging, most commonly 4D-CT (40%). Nevertheless uni/bilateral exploration rates remained similar (∼18%) regardless of re-imaging. In patients with discordant or completely nonlocalising studies, 68% underwent additional imaging and 32% required BNE, compared with 13% in those with only one non-localizing test. Recurrent laryngeal nerve injury occurred in 3.3% of SP versus 17.6% of BNE (p 0.01). Persistence of pHPT following parathyroidectomy was similar following SP (4.6%) and unilateral/BNE (4%). Conclusion Additional imaging—although frequently used—rarely alters operative strategy. Surgical morbidity increases with the extent of exploration, although persistence rates were similar between focused parathyroidectomy and neck exploration, underscoring the importance of management in high-volume endocrine surgery centers.
Castro et al. (Fri,) studied this question.