Intraoperative PTH Monitoring in Primary Hyperparathyroidism: A Risk‐Stratified Approach

Abstract Objective To evaluate whether routine intraoperative parathyroid hormone (ioPTH) monitoring is necessary in all cases of sporadic primary hyperparathyroidism (pHPT) in the era of advanced preoperative localization and to propose a conservative, risk‐stratified operative framework. Data Sources PubMed, Scopus, and Embase were searched for English‐language publications from January 2020 through January 2026, supplemented by key guidelines, consensus statements, and high‐impact reviews. Review Methods This narrative review synthesizes contemporary guidelines, imaging performance studies (ultrasound, sestamibi‐based techniques, four‐dimensional computed tomography 4D‐CT, and 18 F‐fluorocholine positron emission tomography FCH‐PET), observational cohorts comparing operative strategies, and decision‐analytic and cost‐effectiveness analyses. Evidence was prioritized by clinical relevance and methodological quality. Conclusions Focused parathyroidectomy, ioPTH‐guided surgery, and bilateral neck exploration all achieve high cure rates when appropriately applied. The incremental value of ioPTH is greatest in settings of elevated residual uncertainty, including discordant or nonlocalizing imaging, atypical biochemical profiles (including normocalcemic or discordant calcium–PTH presentations), familial or syndromic disease, reoperative necks, and unfavorable anatomy. In a narrowly defined subgroup with sporadic disease, favorable anatomy, and concordant high‐fidelity localization—particularly high‐quality, surgeon‐reviewed or surgeon‐performed ultrasound combined with 4D‐CT—the likelihood that routine ioPTH alters management appears low. Implications for Practice Selective omission of ioPTH may be reasonable in carefully selected patients within a conservative, risk‐stratified framework, with a low threshold for intraoperative escalation.