Primary Hyperparathyroidism

Parathyroidectomy is the definitive therapy for primary hyperparathyroidism . In the hands of the experienced parathyroid surgeon, the procedure is curative in more than 90% of individuals. Recent advances in parathyroid surgery augur for even greater success among surgeons who may not be bona fide parathyroid experts. 33 Nevertheless, the decision to operate on all patients with primary hyperparathyroidism is controversial. 42 First, the operation is not always successful, even when performed by an experienced surgeon. The parathyroid glands are notoriously variable in location and can elude even the most careful search. Second, there are potential complications of parathyroid surgery, such as damage to the recurrent laryngeal nerve , local bleeding, and, rarely, hypoparathyroidism . Third, the clinical spectrum of primary hyperparathyroidism has changed remarkably in the Western world such that most patients are now asymptomatic. 21 In these patients, hypercalcemia is discovered most often in the course of routine blood tests and not in response to a specific search for a set of symptoms. It is not clear which of these asymptomatic patients should undergo surgery. This article focuses on the difficult decision to operate or not to operate, especially in asymptomatic patients with primary hyperparathyroidism.