October 2009

New Minimally Invasive Surgery for Hyperparathyroidism

Wen T. Shen, M.D.
Endocrine Surgeon
UCSF Medical Center

One in 500 women and one in 2,000 men suffer from primary hyperparathyroidism (HPT), with the peak incidence at 60 years of age. Benign tumors of the parathyroid gland are the major cause of primary HPT, resulting in elevated calcium levels. Research has shown that 25 to 50 percent of untreated patients progress to severe, potentially life-threatening disease.

A 2002 study found that patients with primary HPT were 2.5 times more likely to develop acute myocardial infarction compared to cohorts of the same age. A risk of hypertension and stroke was also observed, even in patients with mildly elevated calcium levels. Other risks include left ventricle hypertrophy (LVH), osteoporosis and neurocognitive impairment.

While primary HPT traditionally caused a host of classic, debilitating symptoms, many patients today are considered "asymptomatic" due to earlier screening and detection. In many instances, patients and doctors attribute symptoms, such as fatigue, weakness and memory loss to old age, rather than to primary HPT. As a result, these patients often fail to get referred to surgery, although they are still at risk for life-threatening complications.

Further, many patients are thought to be "too old" or not good surgical candidates due to age. However, up to 80 percent of patients who are referred for surgery are asymptomatic at the time of surgery and up to 80 percent of these patients report "feeling better" after surgery.

The National Institutes of Health (NIH) guidelines call for referring asymptomatic patients for surgery if:

  • Serum calcium levels > 1 mg/dL over upper limit of normal
  • Urinary calcium > 400 mg/24 hours
  • More than 30 percent decrease in CR clearance
  • T-score < -2.5 standard deviations
  • Age < 50 years
  • Poor follow-up

Surgery at UCSF

Surgery is the only curative therapy for this condition, with a 95 percent success rate. While the gold standard for first-time operation is still bilateral neck exploration with identification of the four parathyroid adenomas, improved pre-operative imaging and availability of PTH assay allows for focused, minimally invasive parathyroidectomy.

Surgeons at UCSF Medical Center use ultrasound and Sestamibi scan to create a detailed, pre-operative road map of the parathyroid adenomas, with a sensitivity of 96 percent. In 80 to 85 percent of the cases, only one gland is enlarged. The key is localizing the gland preoperatively.

Using this new, focused approach, the enlarged gland is then removed through one 2.5-centimeter incision with the use of intraoperative PTH monitoring.

Patients undergoing minimally invasive parathyroidectomy enjoy the same biochemical and symptomatic benefits of the standard bilateral operation with less morbidity and an excellent cosmetic outcome.

Other Resources

For more information, contact the Physician Referral Service at UCSF Medical Center:

Phone (888) 689-UCSF or (888) 689-8273
Email referral.center@ucsfmedctr.org