[What is new in surgery for primary hyperparathyroidism?]

Primary hyperparathyroidism is being increasingly recognized because of the widespread availability of biological screening, thus explaining that one third of the patients are nowadays asymptomatic at diagnosis. Initially based on the hypercalcemia-hypophosphoremia syndrome, its diagnosis is now depending upon biological measurements of AMPc, intact (1-84) parathyroid hormone and dynamic tests such as the oral calcium-loading test. A controversial issue is the use of sophisticated imaging methods (ultrasonography, computed tomography, thallium-technetium scanning, magnetic resonance imaging and more infrequently venous catheterization with blood sampling) to localize the abnormal parathyroid glands, which are clearly inferior to surgery with a 95% success rate. The lesions include single adenoma in 80%, multiple adenomas in 5%, cancer in 1% and hyperplasia in 14% of the cases. Moreover, among the majority of seemingly sporadic hyperparathyroidism, about 10% of the cases appear to be part of a multiple endocrine neoplasia which is frequently misdiagnosed or lately recognized. The questions remain (as to) whether the surgical strategy should be revisited and whether intraoperative histopathological examination of the removed abnormal gland is still needed to ensure excellence in the management of hyperparathyroidism. However, since its initial description in the early 80s, the concept of unilateral cervical exploration directed by an accurate localization study and intraoperative measurements of intact hormone could become in the future the standard approach for surgical treatment in more than half of the patients.