Current approach in cases of persistence and recurrence of primary hyperparathyroidism

Primary hyperparathyroidism (pHPT) is now diagnosed much earlier and is often asymptomatic. Biochemically mild pHPT is characterized by small parathyroid adenomas (NSDA) and the results of localization diagnostics as well as surgical treatment are poorer. The frequency of redo surgery is 3-14% in large registries. The planning of a reoperation is no different from the basic principles for the first intervention. Diagnosis and differential diagnoses must be checked. This is followed by a review of the first operation and the associated histology as well as imaging and the course of parathyroid hormone (PTH) values. The next step is to check whether the reoperation is necessary. Most patients still have comprehensible indications that correspond to the guidelines and also ex-post. In contrast to the first intervention, there is always a need to attempt to localize the NSDA. The first procedure is a surgically performed ultrasound. Other localization options are MIBI-SPECT scintigraphy, 4D-CT and FEC-PET-CT, with the latter having the highest sensitivity. There is a clear relationship between higher case numbers and better surgical outcomes. Personal experience is decisive and in terms of predicting success this is even more important than the results of localization procedures. The goal of maximizing the outcome and minimizing morbidity justifies what is from the perspective of those affected probably the most important requirement for the future: no redo surgery for HPT outside of a high-volume center.