Management of Persistence and Recurrence Post Parathyroidectomy in Patients With Presumed Non‐Familial Primary Hyperparathyroidism—Lessons Learned From 10 Years of Practice

BACKGROUND: Persistent and recurrent primary hyperparathyroidism (pHPT) are important postoperative outcomes and have contributed to a shift towards more extensive initial surgery in some centres. This study aimed to describe the management strategies and outcomes of these cases over a 10-year period across two referral centres. METHODS: A retrospective cohort study of patients undergoing parathyroidectomy for primary hyperparathyroidism at two public referral centres between 2013 and 2022. Demographic, clinical, biochemical, imaging and outcome data were collected. Persistent disease was defined as pHPT diagnosed within 6 months of surgery, while recurrence was defined as disease diagnosed more than 6 months after initial biochemical cure. RESULTS: Of 484 patients who underwent parathyroidectomy for pHPT, 15 (3.1%) had persistence and 3 (0.6%) developed recurrence (median follow-up 14 months). Fourteen patients underwent reoperation, with cure achieved in 11 (median follow-up 16 months), resulting in an overall cure rate of 98.6%. Reasons for non-cure after all surgery in the remaining 7 patients included multigland disease (n = 3), previously unrecognised familial syndrome (n = 2), missing fourth gland (n = 1), and patient declined further surgery (n = 1). Among the 11 patients cured following reoperation, the index procedure was bilateral neck exploration (BNE) in 3 and unilateral neck exploration (UNE) in 8. Cure was achieved following excision of additional adenoma(s), guided by preoperative localisation imaging in 10 patients or completion BNE in 1. No recurrent laryngeal nerve injury or postoperative haematoma occurred. CONCLUSION: Unilateral neck exploration remains an appropriate strategy for selected patients with pHPT. With adequate preoperative localisation, abandoning this approach for routine bilateral neck exploration may prevent repeat surgery in only 1.9% of patients.