Rationale for a New Approach to the Surgical Treatment of Primary Hyperparathyroidism Patients Based on the Analyzed Dynamics of Laboratory Bone Turnover Markers

Introduction. In order to improve the efficacy of treatment for primary hyperparathyroidism, it is important to make a science-based choice of the surgical intervention method. Aim . To justify a new approach to the surgical treatment of primary hyperparathyroidism patients relying on the analyzed dynamics of laboratory bone turnover markers. Materials and methods . The dynamics of laboratory bone turnover markers were compared in primary hyperparathyroidism patients ( n = 394). The patients were divided into four groups: 1) parathyroidectomy through central mini-access with bilateral exploration of the parathyroid glands and the use of confocal laser microscopy ( n = 97); 2) parathyroidectomy through mini-access with unilateral exploration ( n = 150); 3) parathyroidectomy through mini-access without ipsilateral exploration (local anesthesia) ( n = 72); 4) parathyroidectomy through the Kocher access on the neck ( n = 75). Results and discussion . In Group 1 patients, the target intraoperative levels of intact parathyroid hormone (iPTH) were reached in 100% of cases ( n = 97): normalization in 84.6% of cases ( n = 82) or a decrease of 50% or more from preoperative values in 15.4% of cases ( n = 15). With the use of the other approaches (Groups 2, 3, and 4), iPTH normalization was observed in 61.3 % of cases ( n = 182); a decrease of 50% or more in iPTH occurred in 25.6% of cases ( n = 76); in 13.1% of cases ( n = 39), the target iPTH levels of were not reached. Only in Group 1, complete normalization of ionized calcium and iPTH was observed three months after the surgery. In Groups 2, 3, and 4, ionized calcium levels of over 1.35 mmol/L were observed in several cases, and iPTH levels of over 68.3 pg/mL were noted in 30.3% of patients ( n = 90). Conclusion. A new approach is proposed for the surgical treatment of primary hyperparathyroidism patients with the use of confocal laser microscopy, which provides a means to increase treatment efficacy, allows target iPTH levels to be reached in 100% of cases, and achieves normalization of ionized calcium. This approach also justifies the permissibility of omitting the mandatory intraoperative iPTH testing, ensuring a decrease in the length of the surgical procedure without reducing its radicality.