Parathyroid Surgery for Primary Hyperparathyroidism in 2026.

Abstract

Primary hyperparathyroidism (PHPT) is the most common parathyroid disease and one of the most common endocrine disorders. It results from autonomous overproduction of parathyroid hormone, which in the classic form of the disease causes hypercalcaemia. The ready access to biochemical testing in high-income countries has moved the disease spectrum from a classic symptomatic presentation to a biochemical anomaly that is asymptomatic or minimally symptomatic. Untreated PHPT, however, remains associated with significant consequences. This review summarizes up-to-date concepts in the diagnosis, imaging, and surgical management of PHPT. The diagnosis of PHPT requires confirmation of hypercalcaemia with inappropriately elevated or unsuppressed parathyroid hormone levels, while excluding alternative causes. Parathyroidectomy remains the only definitive cure for PHPT, and the changing thresholds for intervention are discussed. Advances in pre-operative localization, including high-resolution ultrasonography, 99mTc-sestamibi (technetium-99m methoxyisobutylisonitrile), 4D-computed tomography, and fluorocholine positron emission tomography, have increased the number of patients with localised disease and therefore facilitated focused and minimally invasive surgical approaches. Intraoperative parathyroid hormone monitoring has also added a new dimension to intraoperative decision-making. However, the single biggest determinant of outcome in parathyroidectomy remains the practice volume and experience of the operating surgeon. It remains to be seen whether emerging technologies, including robotic surgery, thermal ablation, advanced molecular imaging, and artificial intelligence-assisted diagnosis and lesion localization, will further refine patient selection and improve treatment strategies in PHPT.