IOPTH Widely Used, Variation Persists

Most surgeons reported using intraoperative parathyroid hormone monitoring, but approaches to imaging and intraoperative criteria varied, particularly in secondary and tertiary disease

By
Kathryn Wighton
April 13, 2026
3 min

Conexiant

Overview

A survey of 523 North American surgeons revealed that 88% use intraoperative parathyroid hormone monitoring (IOPTH) during parathyroid surgery, with higher usage in primary hyperparathyroidism and among US surgeons. Despite strong adherence to guidelines in primary hyperparathyroidism, significant variation exists in imaging and intraoperative decision-making, particularly in secondary and tertiary hyperparathyroidism.

Background

Intraoperative parathyroid hormone monitoring (IOPTH) is a key adjunct in parathyroid surgery, aiding in real-time assessment of surgical success. While clinical guidelines strongly support its use in primary hyperparathyroidism, management of secondary and tertiary hyperparathyroidism, often related to renal disease, lacks standardized protocols. Imaging modalities and surgical approaches vary, reflecting the complexity of these conditions and differences in surgeon training and regional practices. Understanding current practice patterns can inform efforts to standardize care and improve outcomes.

Data Highlights

Parameter	Percentage/Value
Survey Response Rate	70.5% (523 surgeons)
IOPTH Use Overall	88% (376/426 surgeons)
IOPTH Use by Region	US: 98%, Canada: 69%, Other: 67%
IOPTH Use by Disease Type	Primary: 92%, Tertiary: 77%, Secondary: 76%
Use of Miami or Modified Miami Criteria (Primary HPTH)	64%
Surgeons Using ≥2 Postexcision Hormone Measurements	76%, commonly at 10 minutes
Surgeons Not Using Defined IOPTH Criteria	Secondary HPTH: 28%, Tertiary HPTH: 25%
Most Common Imaging Modality	Ultrasonography (45%-53% across disease types)
Common Intraoperative Adjuncts	IOPTH (44%), Frozen Section (39%)
Use of Autofluorescence	7%
Use of Radioguidance	4%
Minimally Invasive Parathyroidectomy in Image-Positive Primary HPTH	80%
Bilateral Neck Exploration for Multigland/Image-Negative Disease	93%
Subtotal Parathyroidectomy in Renal HPTH	Secondary with transplant: 74%, Secondary without transplant: 70%, Tertiary: 74%
Reported IOPTH Turnaround Time	16-30 minutes (most common), >30 minutes (27%)
IOPTH Prolongs Operative Time	87% of users

Key Findings

IOPTH is widely used during parathyroid surgery, especially in primary hyperparathyroidism and among US surgeons.
Significant variation exists in imaging modalities and intraoperative decision-making, particularly in secondary and tertiary hyperparathyroidism.
Most surgeons use ultrasonography as the primary imaging tool, followed by scintigraphy and 4D CT.
Minimally invasive parathyroidectomy guided by IOPTH is common in image-positive primary hyperparathyroidism, while bilateral neck exploration is reserved for multigland or image-negative cases.
Operational challenges include prolonged operative times and turnaround times for IOPTH results, often exceeding 30 minutes due to reliance on central laboratory testing.
There is less consensus on IOPTH criteria use in renal hyperparathyroidism, with a notable proportion of surgeons not using defined criteria.

Clinical Implications

Clinicians should recognize that while IOPTH is a standard tool in primary hyperparathyroidism surgery, variability in its use and imaging approaches persists in renal-related hyperparathyroidism. Awareness of operational delays with IOPTH testing may inform surgical planning. Efforts to standardize intraoperative criteria and imaging protocols, especially in secondary and tertiary hyperparathyroidism, could improve consistency and outcomes.

Conclusion

IOPTH is broadly adopted in parathyroid surgery with strong guideline adherence in primary hyperparathyroidism, yet practice heterogeneity remains, particularly in renal hyperparathyroidism. Addressing these variations may enhance surgical decision-making and patient care.