Utilization of preoperative imaging before parathyroid surgery: Clinical necessity or routine practice?

Preoperative imaging is widely advocated for and often routinely ordered for patients undergoing parathyroidectomy. Yet its actual benefit in contributing to surgical safety considering high rates of non-diagnostic imaging remain debated. This study aims to evaluate if imaging before parathyroidectomy contributes to improving post operative outcomes in hyperparathyroidism.

We conducted a retrospective cohort study of patients who underwent parathyroidectomy (PTx) for hyperparathyroidism between 2000 and 2023 at our institution. Patients with prior thyroid or parathyroid surgery were excluded. Data collected included demographics, clinical features, biochemical parameters, and outcomes. Localization status was determined by ultrasound, sestamibi, or 4D-CT. Patients without imaging were 1:1 propensity-matched to those with imaging by age, gender, preop calcium, and PTH. Assessed complications included transient and permanent hypocalcemia, hoarseness, and persistent hyperparathyroidism.

Of 2,287 eligible patients, 349 (15.3%) underwent PTx without preoperative imaging, while 1,938 (84.7%) had at least one imaging study. We matched 311 imaging-naive patients to counterparts with imaging. Among those imaged, 13.1% (n = 253) had negative localizing studies; 17.4% of these had undergone multiple imaging tests. Negative imaging was significantly associated with normocalcemic or normohormonal disease (OR 1.6, 95% CI 1.2 - 2.2, p = 0.003), double adenomas (OR 2.5, p < 0.001), and hyperplasia (OR 1.5, p = 0.06). Complication rates were similar between imaging and non-imaging groups as were cure rates based on normocalcemia at 6 months (94.5% vs 97.1%, p = 0.2).

Preoperative imaging is not essential for successful parathyroidectomy performed by experienced surgeons as outcomes remain comparable even without localization.