Unilateral surgery for hyperparathyroidism: indications, limits, and late results--new philosophy or expensive selection without improvement of surgical results?

We assessed the "late" results after unilateral parathyroidectomy (PTX) performed for selected indications. From October 1998 throughout March 2001 we operated on 454 patients for hyperparathyroidism (HPT). A positive unifocal (99m)tc-MIBI scan was required for the unilateral approach to be used. Intact parathormone (PTH) measurements were done intraoperatively. Postoperative calcium and PTH serum levels of unilaterally operated patients were checked. Follow-up has been 16.2 months (range 6-40 months). Of the 454 patients, 336 (74.0%) were not eligible for the unilateral approach; and 125 (27.5%) of the 454 patients had renal HPT. Among the 329 patients with primary HPT, 125 (38.0%) were excluded for well established reasons, and in 77 other cases (23.5%) preoperative imaging results did not allow the unilateral approach. Altogether, 126 patients (38.3%) with primary HPT were selected for the unilateral approach. Of the 126 unilateral operations, 8 (6.3%) had to be converted to a bilateral procedure. Among the 118 patients with a unilateral approach, 3 patients have been reoperated for overlooked contralateral disease, and 13 dropped out of the study. A total of 102 postoperative calcium and PTH serum late levels are known: 90 (88.2%) patients had normal levels; 10 (9.8%) had a high PTH level, and 2 (1.9%) had high ionized calcium levels. The failure rate in selected cases was 4.2% (5/118) (three were reoperated, and two had a supranormal postoperative ionized Ca level). Even with stringent indications, the late results of unilateral surgery (95.8% cure rate) barely matched those of conventional bilateral surgery (97.6% cure rate). The economic impact of such a surgical strategy should be clarified.