Four-Gland Exploration Versus Four-Dimensional Computed Tomography in Patients with Nonlocalized Primary Hyperparathyroidism

  • Courtney E. Quinn
  • Tobias Carling
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


The surgical management of patients with primary hyperparathyroidism (PHPT) varies greatly among parathyroid surgeons, as well as across institutions. Four gland exploration, or bilateral neck exploration (BNE) has long been the “gold standard” operation for PHPT; it involves direct visualization of all parathyroid glands, with removal of enlarged parathyroid tissue, and has yielded excellent cure and complication rates, when performed by experienced surgeons. However, given that approximately 85% of patients with PHPT have single-gland disease, unilateral, minimally-invasive approaches have been advocated. The latter approaches require preoperative localization studies to identify the abnormal gland(s). While non-invasive imaging studies are routinely employed before index parathyroid surgery, negative, discordant or equivocal non-invasive localization studies are not uncommon, even in the unexplored patient. In this setting, an experienced parathyroid surgeon will still find and cure PHPT in the vast majority of patients. While bilateral neck exploration remains an excellent operation, controversy has developed in recent years, regarding the potential superiority of more focused, minimally invasive approaches. To address this issue, we evaluated the available literature for recommendations regarding the use of preoperative four-dimensional computed tomography (4DCT) versus direct, four gland exploration in patients with negative sestamibi and/or neck ultrasound studies. We summarize the available data and provide recommendations on how to surgically treat patients undergoing parathyroidectomy for PHPT.


Primary hyperparathyroidism Parathyroid adenoma 4D CT Four-gland exploration Bilateral neck exploration Sestamibi Neck ultrasound Non-invasive imaging Parathyroidectomy Minimally invasive parathyroidectomy 


  1. 1.
    Rodgers SE, Hunter GJ, Hamberg LM, Schellingerhout D, Doherty DB, Ayers GD, et al. Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography. Surgery. 2006;140(6):932–40. Discussion 40-1.CrossRefPubMedGoogle Scholar
  2. 2.
    Starker LF, Mahajan A, Bjorklund P, Sze G, Udelsman R, Carling T. 4D parathyroid CT as the initial localization study for patients with de novo primary hyperparathyroidism. Ann Surg Oncol. 2011;18(6):1723–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Cheung K, Wang TS, Farrokhyar F, Roman SA, Sosa JA. A meta-analysis of preoperative localization techniques for patients with primary hyperparathyroidism. Ann Surg Oncol. 2012;19(2):577–83.CrossRefPubMedGoogle Scholar
  4. 4.
    Suh YJ, Choi JY, Kim SJ, Chun IK, Yun TJ, Lee KE, et al. Comparison of 4D CT, ultrasonography, and 99mTc Sestamibi SPECT/CT in localizing single-gland primary hyperparathyroidism. Otolaryngol Head Neck Surg. 2014;18:1723–8.Google Scholar
  5. 5.
    Kukar M, Platz TA, Schaffner TJ, Elmarzouky R, Groman A, Kumar S, et al. The use of modified four-dimensional computed tomography in patients with primary hyperparathyroidism: an argument for the abandonment of routine sestamibi single-positron emission computed tomography (SPECT). Ann Surg Oncol. 2015;22(1):139–45.CrossRefPubMedGoogle Scholar
  6. 6.
    Wang TS, Cheung K, Farrokhyar F, Roman SA, Sosa JA. Would scan, but which scan? A cost-utility analysis to optimize preoperative imaging for primary hyperparathyroidism. Surgery. 2011;150(6):1286–94.CrossRefPubMedGoogle Scholar
  7. 7.
    Lubitz CC, Stephen AE, Hodin RA, Pandharipande P. Preoperative localization strategies for primary hyperparathyroidism: an economic analysis. Ann Surg Oncol. 2012;19(13):4202–9.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Miccoli P, Bendinelli C, Berti P, Vignali E, Pinchera A, Marcocci C. Video-assisted versus conventional parathyroidectomy in primary hyperparathyroidism: a prospective randomized study. Surgery. 1999;126(6):1117–21. Discussion 21-2.CrossRefPubMedGoogle Scholar
  9. 9.
    Miccoli P, Berti P, Materazzi G, Ambrosini CE, Fregoli L, Donatini G. Endoscopic bilateral neck exploration versus quick intraoperative parathormone assay (qPTHa) during endoscopic parathyroidectomy: a prospective randomized trial. Surg Endosc. 2008;22(2):398–400.CrossRefPubMedGoogle Scholar
  10. 10.
    Bergenfelz A, Lindblom P, Tibblin S, Westerdahl J. Unilateral versus bilateral neck exploration for primary hyperparathyroidism: a prospective randomized controlled trial. Ann Surg. 2002;236(5):543–51.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Westerdahl J, Bergenfelz A. Unilateral versus bilateral neck exploration for primary hyperparathyroidism: five-year follow-up of a randomized controlled trial. Ann Surg. 2007;246(6):976–80. Discussion 80-1.CrossRefPubMedGoogle Scholar
  12. 12.
    Bergenfelz A, Kanngiesser V, Zielke A, Nies C, Rothmund M. Conventional bilateral cervical exploration versus open minimally invasive parathyroidectomy under local anaesthesia for primary hyperparathyroidism. Br J Surg. 2005;92(2):190–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Slepavicius A, Beisa V, Janusonis V, Strupas K. Focused versus conventional parathyroidectomy for primary hyperparathyroidism: a prospective, randomized, blinded trial. Langenbeck’s Arch Surg. 2008;393(5):659–66.CrossRefGoogle Scholar
  14. 14.
    Aarum S, Nordenstrom J, Reihner E, Zedenius J, Jacobsson H, Danielsson R, et al. Operation for primary hyperparathyroidism: the new versus the old order. A randomised controlled trial of preoperative localisation. Scand J Surg. 2007;96(1):26–30.CrossRefPubMedGoogle Scholar
  15. 15.
    Sozio A, Schietroma M, Franchi L, Mazzotta C, Cappelli S, Amicucci G. Parathyroidectomy: bilateral exploration of the neck vs minimally invasive radioguided treatment. Minerva Chir. 2005;60(2):83–9.PubMedGoogle Scholar
  16. 16.
    Russell CF, Dolan SJ, Laird JD. Randomized clinical trial comparing scan-directed unilateral versus bilateral cervical exploration for primary hyperparathyroidism due to solitary adenoma. Br J Surg. 2006;93(4):418–21.CrossRefPubMedGoogle Scholar
  17. 17.
    Udelsman R, Lin Z, Donovan P. The superiority of minimally invasive parathyroidectomy based on 1650 consecutive patients with primary hyperparathyroidism. Ann Surg. 2011;253(3):585–91.CrossRefPubMedGoogle Scholar
  18. 18.
    Udelsman R, Akerstrom G, Biagini C, Duh QY, Miccoli P, Niederle B, et al. The surgical management of asymptomatic primary hyperparathyroidism: proceedings of the fourth international workshop. J Clin Endocrinol Metab. 2014;99(10):3595–606.CrossRefPubMedGoogle Scholar
  19. 19.
    Philippon M, Guerin C, Taieb D, Vaillant J, Morange I, Brue T, et al. Bilateral neck exploration in patients with primary hyperparathyroidism and discordant imaging results: a single-centre study. Eur J Endocrinol. 2014;170(5):719–25.CrossRefPubMedGoogle Scholar
  20. 20.
    Lubitz CC, Hunter GJ, Hamberg LM, Parangi S, Ruan D, Gawande A, et al. Accuracy of 4-dimensional computed tomography in poorly localized patients with primary hyperparathyroidism. Surgery. 2010;148(6):1129–37. Discussion 37-8.CrossRefPubMedGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Section of Endocrine Surgery, Department of SurgeryYale University School of MedicineNew HavenUSA

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