Routine bilateral neck exploration and four-gland dissection remains unnecessary in modern parathyroid surgery

Area of Science:

• Endocrinology
• Surgical Oncology
• Minimally Invasive Surgery

Background:

• Minimally invasive parathyroidectomy (MIP) is increasingly preferred for primary hyperparathyroidism (pHPT) due to advances in imaging and intraoperative parathyroid hormone (ioPTH) assays.
• A recent recommendation suggests bilateral neck exploration (BNE) with four-gland dissection for all pHPT patients.
• This study compares long-term outcomes of MIP versus conventional BNE.

Purpose of the Study:

• To compare the long-term efficacy of MIP with BNE for treating pHPT.
• To evaluate the cure rates and recurrence rates of MIP.
• To assess the safety and benefits of MIP in the context of current surgical recommendations.

Main Methods:

• A 10-year review of patients with pHPT undergoing initial MIP with ioPTH assessment in a tertiary endocrine practice.
• Comparison of cure rates from MIP with published data for conventional BNE with four-gland dissection.
• Analysis of preoperative imaging, intraoperative findings, and long-term follow-up data.

Main Results:

• Of 212 patients with sufficient follow-up, MIP achieved an overall cure rate of 98.6% with <2% long-term recurrence.
• Preoperative imaging correctly localized the affected gland in 69.8% of cases, leading to successful single-gland surgery in 85.8% of these.
• Even without co-localizing imaging, 65.3% of patients were cured with unilateral surgery.

Conclusions:

• MIP, combined with ioPTH assay and preoperative localization, yields a 99% cure rate for pHPT, matching or exceeding BNE outcomes.
• Unilateral surgery eliminates risks of permanent hypoparathyroidism and vocal cord paralysis.
• Planned four-gland exploration is unnecessary for most pHPT patients, challenging recent recommendations.