Objective: The aim of this study was to investigate long-term outcomes after focused parathyroidectomy (FPTX) and open 4-gland parathyroid exploration (OPTX) for primary hyperparathyroidism (pHPT).
Background: Concerns about increased long-term recurrence rates after FPTX in conjunction with decreased operative times for OPTX have led some groups to abandon FPTX in favor of routine 4-gland exploration.
Methods: This is a multicenter retrospective cohort study of patients undergoing parathyroidectomy for pHPT from 1990 to 2013. The patient cohort was divided into 2 groups, FPTX and OPTX, based on intention-to-treat analysis. The primary outcome measure was the persistence of pHPT. Secondary outcome measures were differences in the long-term recurrence rate of persisting pHPT and surgical complications.
Results: A total of 4569 patients (3585 females) were included. The overall persistence and recurrence rates were 2.2% and 0.9%, respectively, after a median follow-up of 6.5 years. There were 2531 FPTX cases and 2038 OPTX cases. The initial persistence rate was higher for FPTX than for OPTX (2.7% vs 1.7%, P = 0.036); however, the long-term recurrence rate was not different (5-year 0.6% vs 0.4%, log-rank P = 0.08). Complications were more common in OPTX than in FPTX (7.6% vs 3.6%, P < 0.001).
Conclusions: FPTX was associated with fewer operative complications and an equivalent rate of long-term recurrence than with OPTX. Although initial persistence rates were higher after FPTX than after OPTX, most were readily resolved with subsequent early reoperation. FPTX should not be abandoned in patients with positive preoperative localization.