Subtotal Versus Total Parathyroidectomy for the Management of Tertiary Hyperparathyroidism: A Systematic Literature Review and Meta-Analysis of Optimal Surgical Modality.

Background: Surgery is the definitive treatment option for tertiary hyperparathyroidism (THPT), however, the optimal surgical approach remains unclear. We aimed to compare total parathyroidectomy (PTX) with auto-transplantation vs subtotal PTX for THPT through a systematic review and meta-analysis.Methods: PubMed, Embase, and Web of Science were searched for studies comparing outcomes of total vs subtotal PTX for THPT. A total of 28 studies (n = 1000 patients) met the inclusion criteria.Results: The mean age was 46.5 years and 53% were female. The proportion of females (59% vs 49%) was higher in the total PTX with auto-transplantation cohort (P = .008). Both procedures had similar preoperative calcium and PTH levels. Postoperative and 6-month calcium and PTH were also comparable between groups, except transiently higher post-operative PTH in the total PTX with auto-transplantation cohort (P = .03). Hypercalcemia cure rates were 98%-100% with no difference between surgical techniques (P = .67). Safety profiles were comparable and low.Conclusions: Total PTX with auto-transplantation and subtotal PTX yield similar efficacy and safety for THPT, with no significant differences in cure rates, recurrence, complications, or biochemical control.