Role of Intraoperative Parathormone monitoring in Parathyroidectomy for Primary Hyperparathyroidism, A narrative review

Abstract

Intraoperative parathyroid hormone (ioPTH) has emerged as a valuable tool in improving the success of minimal invasive parathyroidectomy which has become the standard management in Primary Hyperparathyroidism. It appears a very attractive tool with a significant academic advantage to confirm the removal of parathyroid adenoma during surgery. Despite having such an advantage no direct Randomized studies comparing MIP (minimal invasive parathyroidectomy) with ioPTH and MIP without ioPTH have been performed nor much detailed systematic reviews and meta-analyses are available in the literature on this topic.

Objective: we performed this review to evaluate the role of ioPTH in surgeries for Primary Hyperparathyroidism due to parathyroid adenoma.

Data Source: A systematic search of databases PubMed, Scopus, Embase and Google Scholar using keywords Intraoperative Parathormone monitoring, primary Hyperparathyroidism was performed to identify all studies assessing the role of ioPTH during parathyroidectomy. All studies including randomized clinical trials and observational studies with a retrospective or prospective design from 2019 to 2024 were analysed.

Results: A total of 15 studies involving more than 1500 patients with Primary Hyperparathyroidism were included for analysis. All studies demonstrated the effectiveness of ioPTH in improving the success rate of focused Parathyroidectomy to around 99% compared to 97% without the use of ioPTH. The benefit was however more in cases with discordant preoperative imaging studies Ultrasonography and Sestamibi scan and in cases where the preoperative localization of parathyroid adenoma was equivocal (66%). The benefit of ioPTH comes with an increased duration of surgery noted in many studies with a statistically significant difference (0.0001).

Conclusion: The use of ioPTH is associated with higher cure rates for patients with primary hyperparathyroidism undergoing MIP. However, ioPTH monitoring is most useful as an adjunct to preoperative imaging when imaging results are equivocal allowing for more focused/unilateral operations to be performed. When ultrasonography and MIBI are used for preoperative localisation and the results are concordant, the additional benefit of ioPTH is marginal, especially given the longer duration of surgery.