Introduction and objective:

Once the diagnosis of primary hyperparathyroidism (pHPT) is made, the only curative treatment available is parathyroidectomy. This can be achieved by a bilateral neck exploration or through a minimally invasive parathyroidectomy, in which the only neck compartment explored is the one suspected of having the parathyroid gland causing the pHPT. The results of both techniques are equivalent. However, there is a growing tendency to choose MIP when imaging studies correctly localize the affected gland. When imaging studies are negative or discordant, surgical management causes some controversies.

Method:

We performed a systematic review of original articles, guidelines and scientific societies documents related to the management of primary hyperparathyroidism with contradictory or negative preoperative localization. We found 211 studies, and selected 2 systematic reviews, 20 original articles and 4 guidelines.

Discussion:

Guidelines recommend performing a BNE when preoperative localization fails. In the reviewed literature we observed a growing tendency of requesting further imaging studies to perform a MIP, although the majority of surgeons follow the guidelines. MIP + intraoperative PTH monitoring has been reported to have similar success rates as BNE. Some techniques like 18F-Fluorocloline or 11C-coline PET-TC, radioguided surgery with intraoperative gamma camera and intraoperative PTH monitoring, are especially useful in the preoperative workup and as support during surgery when localizing imaging tests result negative.

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