Primary hyperparathyroidism: should surgery be performed on all patients? Current evidence and residual uncertainties

Primary hyperparathyroidism (pHPT) is the third most common endocrine disease and is characterized by hypercalcaemia and elevated or inappropriately 'normal' levels of the parathyroid hormone (PTH). The main target organs of PTH are the skeletal system and the kidneys. Before the 1970s, pHPT was a rarely detected disease associated with notable morbidity and premature mortality. Introduction of biochemical screening, allowing for a wide range of indications, has contributed to the detection of the full spectrum of the disease. A new entity with an isolated elevation of PTH, normocalcaemic HP, has emerged and is currently being explored. The highest incidence of pHPT, 3-5%, is observed amongst women, and the prevalence increases with age. The female-to-male ratio is 3-4 : 1 except in younger patients where distribution is equal and known hereditary causes account for approximately 10% of the cases. In the last few decades, it has become evident that fewer patients than previously believed are truly asymptomatic. The cause of pHPT is often a benign tumour, a parathyroid adenoma, and the only definite treatment is parathyroidectomy (PTX). No medical treatment, single or combined, can achieve a curing of pHPT. Recent data indicate that PTX, despite being proven to be cost-effective compared to conservative treatment, is underutilized, especially in elderly pHPT patients. The decision of PTX should always be based on a safe diagnosis, and the potential benefits of curative treatment should not be outweighed by the risks of surgery or anaesthesia.