Algorithmic Surgical Management of Primary Hyperparathyroidism and Its Variants: A Scoping Review

Primary hyperparathyroidism (PHPT) has varied presentations whose successful surgical management demands integration of the expanding literature within a comprehensive decision-making framework. Our objective is to compare the workup and management of variant (i.e., normocalcemic hyperparathyroidism (NCPHPT) and normohormonal hyperparathyroidism (NHPHPT)) to classic hyperparathyroidism (CPHPT), taking into account localization studies, surgical considerations, utility of intraoperative parathyroid hormone (IOPTH), and surveillance to identify gaps in knowledge that limit management outcomes of variant PHPT presentations.

A comprehensive search of PubMed and Google Scholar was conducted from June 11, 2024, to March 17, 2025, using MeSH terms and free-text queries focused on imaging, surgery, and outcomes in PHPT and reported using PRISMA ScR guidelines.

Peer-reviewed studies addressing surgical management of PHPT in adults, published in English, were included. Two reviewers independently screened all titles, abstracts, and full texts using previously developed inclusion criteria recorded in a shared spreadsheet. Twenty-seven studies were included. Data were synthesized into a flow diagram to identify areas in need of further guidance.

Imaging accuracy was highest with 4DCT and PET scans in both classic and variant PHPT, particularly in the setting of multiglandular disease. Not obtaining ≥ 50% IOPTH drop and/or levels below 40 pg/mL are risk factors for persistence or recurrence.

PHPT has varied presentations that demand nuanced approaches. Our review highlights knowledge gaps that, if addressed, will improve the care of patients with variant PHPT. Further prospective validation of this algorithmic summary is warranted to improve long-term impact and patient outcomes.