Is preoperative parathyroid localization necessary for tertiary hyperparathyroidism?

Background: The role of preoperative parathyroid localization for tertiary hyperparathyroidism(tHPT) is unclear. We reviewed our experience regarding the feasibility of parathyroidectomy without preoperative localization. Methods: This is a retrospective study of renal allograft recipients who underwent parathyroidectomies (2001-2019). Patients with normal preoperative serum calcium and PTH levels or previous cervical operations were excluded. Patient demographics, laboratory results, radiology reports, pathology reports, and clinical notes were reviewed. Wilcoxon signed rank test, Mann-Whitney U test, Fisher's exact and Pearson chi-square analysis were used to compare patients with and without preoperative localization. Results: Of the 118 patients, 25 patients(21.1%) had preoperative localization. Of the 36 ectopic glands recovered, 31(86.1%) were found without preoperative localization. All 118 patients achieved normocalcemia at the time these data were collected. There were no differences in surgical cure rate, recurrence rate, temporary hoarseness, or postoperative symptomatic hypocalcemia between the two groups. Conclusions: We observed no differences in surgical cure rate, reoperation rate, or postoperative complications without preoperative localization. Under most circumstances, it is appropriate to perform parathyroidectomy for tHPT without localization.