Intraoperative Identification of Parathyroid Glands During Thyroidectomy with Near-Infrared Autofluorescence and Its Impact on Postoperative Hypoparathyroidism and Hypocalcemia Rates: A Systematic Review

Background: Near-infrared autofluorescence (NIRAF) imaging has been widely used to identify parathyroid glands, but its impact on postoperative hypoparathyroidism and hypocalcemia remains controversial. This systematic review aims to evaluate the impact of NIRAF on postoperative hypoparathyroidism and hypocalcemia rates compared to conventional thyroid surgery. Methods: This study was conducted in accordance with PRISMA 2020 guidelines. We conducted a systematic search across PubMed, Scopus, and Google Scholar from January 2011 to April 2026. Studies comparing postoperative calcium and parathyroid hormone (PTH) levels, hypoparathyroidism and hypocalcemia rates, parathyroid gland identification rates, and inadvertent parathyroid gland resection rates between NIRAF and conventional surgery were included. Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool for randomized controlled studies and the ROBINS-I tool for non-randomized studies (cohort, case–control, before-and-after, and retrospective analyses). We performed a narrative synthesis of the results following the Synthesis Without Meta-analysis (SWiM) reporting guidelines, due to profound diagnostic and threshold heterogeneity across studies. Results: Seventeen studies, including a total of 5163 patients (control = 3397, NIRAF = 1766), with a sample size-weighted mean age of 51.19 years, met the selection criteria and were included in the systematic review. The most common surgical procedure was total thyroidectomy without central neck dissection (ten out of seventeen studies, 58.8%). Regarding the NIRAF device, Fluobeam was the most used among the included studies (64.71%). Across 16 studies evaluating postoperative hypocalcemia, point estimates consistently favored the NIRAF intervention across varying sample sizes, showing a clear directional trend toward reducing transient postoperative hypocalcemia, even when small-sample studies lacked the power to reach statistical significance. Regarding postoperative hypoparathyroidism, the synthesis showed that NIRAF’s clinical utility depends directly on the extent of surgical dissection, providing a major protective effect size when central neck dissection is performed. Conclusions: This systematic review indicates that NIRAF provides protective effects against transient postoperative hypocalcemia and temporary hypoparathyroidism, especially when central neck dissection is performed. NIRAF also significantly increases per-gland parathyroid identification rates and reduces incidental parathyroidectomy. According to this review, NIRAF exerts no significant effects on permanent hypoparathyroidism or permanent hypocalcemia rates. Broad clinical generalization remains limited by the profound heterogeneity in diagnostic thresholds and metrics across the literature.